complaint·January 24, 2022

Primary Care Physician (PCP) was contacted about the “ulcers,” there is no documentation on file to support that the PCP was notified nor that R1 was receiving any treatment for the “ulcers.” Furthermore, according to PCP interview, no contact was made by S1. In addition, PCP reported that R1 had history of pressure ulcers and needed two-persons to assist in transferring R1 in and out of bed. After the fall in March 2020, R1 needed incontinent care to be provided by staff at night (NOC) shift and needed to be repositioned. However, staff reported that they did not consistently reposition R1 nor change R1 incontinent care product during the NOC shift. On or around 4/8/2020, the PCP was sent a photo of R1’s ulcers. Following receipt of the photo, PCP requested emergency medical services be sought. On 4/8/2020, 911 Emergency services were called and R1 was sent to the hospital. Medical records revealed that there were four pressure injuries; (1) a 5cm Stage III pressure injuries to R1’s right lower buttock and (2) Stage III pressure injury to upper posterior thigh and (3) 1-2cm Stage II pressure injuries on right buttock and (4) Stage II pressure injuries on left buttock. Based on sufficient evidence to corroborate neglect caused by the facility staff to the resident, the allegation is substantiated. Due to immediate health and safety risk posed to resident in care, an Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that an enhanced civil penalty may be assessed based on Health and Safety Code 1569.49(f). In regards to allegation #2, Department staff interviewed R1’s primary care physician who stated, “I have never had contact in my life with facility staff.” R1’s primary care physician stated that the office only learned of R1’s pressure ulcer when a photo of the pressure ulcer was sent to the office from R1’s phone. In addition, there was no documentation provided by the facility which indicated that R1's primary care physician was aware of R1's pressure injury. Based on interviews and records review, there was sufficient evidence to corroborate the allegation; therefore, the allegation is substantiated. In regards to allegation #3, Department staff reviewed residents' Medication Administration Records (MAR) at 0930 hours. During the review, Department staff reported that one resident's MAR was marked as completed in advance by facility staff at 2000 hours. Department staff questioned the Administrator about the discrepancy, to which the Administrator stated that the MAR was marked as completed in advance because they were unaware if they would be present later. Based on the Administrator's statement and review of MAR, there was sufficient evidence to corroborate the allegation; therefore, the allegation is substantiated. Based on the evidence gathered during the course of the investigation, the three allegations as stated above are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report (LIC 9099, 9099C, & 9099D) and appeal rights were discussed and a copy was provided to Ramas at the conclusion of the visit. An exit interview was conducted where this report(LIC 9099 & 9099C) were discussed and a copy was provided to Ramas at the conclusion of the visit.