Complaint·September 12, 2023

Per the SNF Discharge Summary dated 08/31/2020, R1 was discharged back to the facility on 08/31/2020 with instructions to assist R1 in setting up Home Health. Home Health was needed for the following services: physical therapy, occupational therapy, Registered Nurse (RN) and Home Health Aide (HHA). Per an interview with the Assistant Living Coordinator Kevin Villacorte, the facility did not assist R1 with obtaining home health services as instructed. R1 was discharged from the facility on 09/23/2020 for needing a higher level of care, according to staff interviews. R1 was transferred to a SNF on 09/23/2020. Per the Skin Assessment dated 09/30/2020, completed upon R1’s admission to the SNF, R1 was noted to have an unstageable pressure injury on their coccyx area. It is noted that “the coccyx pressure injury had so much slough” (according to Oxford English Dictionary, slough is defined as “a layer or mass of dead tissue or flesh formed on the surface of a wound, sore, …”) “ and eschar” (according to Oxford English Dictionary, eschar is defined as “a brown or black dry slough, resulting from the destruction of a living part, …”) , “that it could not be staged until it was opened and examined.” Hospital nurse assessed the pressure injury and reported it was estimated that the time for the pressure injury to reach the unstageable stage “was approximately weeks”. Interview with Licensed Vocational Nurse (LVN) working at the facility revealed, she was aware of the beginning stages of a pressure ulcer on R1’s coccyx area. She provided instructions to caregivers to monitor R1, rotate R1 every two hours and to provide a cream. LVN further revealed R1 was not receiving wound care. Staff interview revealed if a resident develops redness, they do not call the hospital or SNF. It is the facility’s policy that if a pressure injury is not healing, they will then send the resident out for treatment. The investigation did not reveal that R1 was sent out for treatment between 08/31/2020 and 09/23/2020. Interviews with 4 facility staff revealed, staff either denied seeing any redness or denied seeing anything worse than redness on R1. Therefore, based on interviews and record reviews, the allegation of Resident sustained pressure injuries while in care due to neglect is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, 9099D, appeal rights, and LIC421IM was given to Administrator Macriselda Espiritu Santo. Not all relevant parties could be interviewed during the course of the investigation. There is insufficient evidence to corroborate or refute the allegation of Staff left resident in soiled adult brief, therefore the allegation is UNSUBSTANTIATED at this time. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, was given to Administrator Macriselda Espiritu Santo.