complaint·November 8, 2023

Staff neglect resulted in resident developing worsening pressure injuries. Interviews and records review indicated that over a nine-day period (9/16/2023 - 9/25/2023), facility staff failed to seek medical care intervention, until a Nurse Practitioner came to the facility on 9/25/2023. During the nurse visit to R1 on 9/25/2023, the nurse examined and described R1’s wound as unstageable. Interviews and documentation indicated Nurse Practitioner instructed Administrator on getting Home Health and Hospice involved, which Administrator verbalized understanding. Due to R1’s insurance not taking effect in California, the facility waited a couple more days before sending R1 to the Emergency room on 9/28/23. Facility staff did not contact 911 as soon as the wounds were noticed, nor did they get immediate care for R1 as soon as the wounds were observed. The Nurse Practitioner felt R1’s pressure wounds required immediate medical attention and advised the facility to get Home Health out as soon as possible. Since R1 was documented as being frail with limited ability to move on their own, facility staff should have observed R1’s pressure wounds worsening and contacted a doctor or the Emergency room as soon as possible, but facility failed to do that. It has been concluded that facility staff did not seek timely medical attention for R1. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited on the attached 9099-D page. Exit interview conducted. Appeal Rights and copy of this report has been provided to facility.