complaint·September 20, 2021

On November 17, 2020, during an in person visit with the hospice nurse, it was reported that the pressure injury on the coccyx had transitioned to a stage 3 and the pressure injury on the left hip became unstageable with necrotic tissue present. R1 had also developed a Deep Tissue Injury (DTI) on the left ankle. Based upon interviews, facility staff failed to notify the hospice nurses when R1’s condition worsened and deviated from the physician’s order for the treatment of the pressure injuries by not using the proper dressing, not repositioning R1, and not keeping the pressure injuries covered with a dressing as ordered by the doctor. Based on Department interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D. The licensee was also advised that civil penalties may be assessed in accordance with Health and Safety Code §1569.49. An exit interview was conducted where this report and appeal rights were discussed and provided to Ms. Rodriguez..