complaint·May 18, 2022

no knowledge of the staging of the wound, were aware the injury was progressing. It was also reported the resident was not being rotated properly and was observed to be found in an extremely soiled diaper, on several different occasions. Medical records show R1 was diagnosed with an infected Necrotic Stage IV Decubitus Ulcer of Sacrococcygeal Area; the ulcer extends to the level of the bone. This posed an immediate risk to R1's health, safety and personal rights. This allegation is deemed SUBSTANTIATED at this time. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). This report was reviewed with ED, Mandy Taylor; a copy of the report and Appeal Rights were provided via email. July 16, 2020, a physician authorized treatment to the injury by home health agency. However, when home health staff visited the facility on same day, to evaluate R1, they were denied entry by a facility staff member. On July 23, 2020, home health staff visited facility again and assessed the pressure injury to be a Stage III. From time period from at least July 8, 2020 to July 26, 2020, it was found that R1 was not provided the care and services needed to meet R1 needs. Review of facility records revealed that R1 utilized a wheelchair for ambulation and needed assistance with incontinent care. According to R1 care plan, R1 had “impaired skin integrity” and “ resident needs to be changed every 2 hours to prevent skin breakdown which meets the need for every 2 hour status checks.” Staff interviews revealed that R1 remained in bed majority of the time and was not rotated while in bed. Interviews also revealed that R1 was observed in soiled incontinence briefs on several different occasions. Investigation also revealed that facility staff was unable to obtain documentation that illustrated correspondence between the facility and home health agency to support that a plan of care for treatment of the pressure injury was in place and/or being followed. Furthermore, interviews confirmed that R1 had history of pressure ulcers and was recently discharged from home health treatment on May 21, 2020 following the healing of a previous ulcer. Based upon investigation, the preponderance of the evidence standard has been met, therefore the allegation that staff neglect resulted in resident #1 (R1) sustaining an infected pressure injury (ulcer) is substantiated. Evidence supports that R1 had a pressure injury and facility staff neglected to insure care and services was provided and/or was received to meet R1 needs. An immediate civil penalty of $500 is assessed. The Executive Director was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f). An exit interview was conducted; this report was reviewed with Heldoorn and a copy was provided, along with LIC 811, LIC 421IM and Appeal Rights.