Complaint·September 29, 2023

R1 was admitted to the facility in 2019. R1 was considered non-ambulatory and used a wheelchair for mobility. R1 was paralyzed on right side of body and had limited mobility. Physician assessment in facility records indicates that R1 was incontinent and needed staff assistance with toileting needs, including changing of incontinent briefs. In addition, R1 needed care and assistance with activities of daily living such as bathing, dressing, and eating. R1 did not have a history of skin breakdown, according to assessment. Per investigation, R1 did require two people for transfer. Per staff interviews, something described as a “small scratch” was observed on R1’s sacral area on March 31, 2022, several days prior to being admitted to the hospital. According to facility documentation, the area was described on April 1, 2022, as “red (irritation).” Facility staff did not seek medical assistance regarding these observations. Rather, facility staff treated the “scratch” with “diaper cream” and Neosporin. In addition, facility staff reported that R1 would spend most of the day in a recliner or wheelchair. Investigation revealed that on April 3, 2022, R1 was admitted to the hospital due to vomiting. Upon admission, medical records show that R1 was diagnosed with an unstageable pressure injury to sacral area, with a Stage 1 pressure injury to mid upper back and abrasions to right hand and right knee. Facility records nor staff interviews revealed observations of pressure injuries as diagnosed. Based on the Department investigation, it is concluded that there is sufficient evidence to substantiate allegation of staff neglect of R1. It was evident that R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff failed to provide the services needed by R1 to meet R1 needs. *** Continuation in LIC9099C *** As a result, R1 sustained an unstageable pressure injury to sacral area while in care. 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 immediate Civil Penalty in the amount of $500.00 was assessed. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f). Regarding allegation #2, Staff did not notify resident's authorized person of a change in health condition, LPA Brown determined that there was corroborating evidence that staff did not notify R1’s authorized person, the Inland Regional Center (IRC), of a change in health condition. Interview with Staff 1 (S1) indicated that Staff 2 and Staff 3 did not report a change in health condition specifically R1’s pressure injury to S1. In addition, an interview with IRC Consumer Services Coordinator revealed that staff did not notify them of R1’s change in health condition, and specifically indicated that no pressure injury was reported to them, and they only found out of the reported change of health condition from the hospital . Based on the information and interviews gathered the allegation Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury (Allegation #1) and Staff did not notify resident's authorized person of a change in health condition (Allegation #2), 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. Please see LIC9099D for deficiencies cited. An exit interview was conducted where this report (LIC9099), LIC9099D, LIC421IM and Appeal Rights were discussed, and a copy was provided to Licensee/Administrator Mary Mateas and staff Steven Mateas at the conclusion of the visit. Evidence shows that the facility staff called American Medical Response (911) on April 3 for R1’s complaint of Nausea and Vomiting. Staff interviews revealed that R1 was not exhibiting any unusual behavior or complaining of pain. Moreover, it was reported that facility staff monitored R1’s blood pressure and oxygen levels until emergency services arrived. There is insufficient evidence to prove that Staff did not seek medical attention for resident in a timely manner. The evidence also demonstrates that the facility acted appropriately by calling AMR when R1 complaint of nausea/vomiting and monitored R1’s blood pressure and oxygen levels. Therefore, based on the evidence obtained during the Department's investigation, the allegation of Staff did not seek medical attention for resident in a timely manner is unsubstantiated at this time. Although the allegation Staff did not seek medical attention for resident in a timely manner may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report (LIC9099) was discussed and provided to Licensee/Administrator Mary Mateas and staff Steven Mateas.