complaint·September 12, 2023

On 01/03/2020, the doctor gave orders to keep the foot elevated in order to release pressure and asked to see photographs. Per the Acting Executive Director, a photo was not sent as they believed it would be a HIPPA violation. Additional interviews revealed, Staff # 3 (S3) revealed that they would change and adjust R1’s socks but would not check R1’s heels. S3 observed red stains in R1’s bedding but did not check to see where it was coming from. S3 assumed R1 had an ingrown toenail. R1 was known to pick their skin and S3 assumed the blood could have been from that as well. Investigation did not reveal that facility staff followed the doctor’s request to evaluate or stage the pressure injury/wound. Investigation revealed that between 01/02/2020 through 01/07/2020, R1 was reported to not receive any treatment for the wound on their left heel other than having their foot elevated and the area cleaned by facility staff. Per S2, staff are responsible for conducting skin integrity checks during resident showers. R1 received showers twice a week until they were admitted to hospice on January 7, 2020. However, staff did not report seeing any skin integrity issues until 01/02/2020. This resulted in nine (9) care staff receiving written warnings for not being aware of the wound. On 01/07/2020, hospice services were initiated, and the nurse assessed the wound. At this time the wound was described as an "unstageable decubitus ulcer to the right heel" that was about 6 cm (2.36 inches) by 6 cm (2.36 inches) and it was covered by necrotic tissue. S1 was present during the assessment and stated that "the wound looked the same as it did on 01/02/2020”. There is sufficient evidence to show neglect by facility staff, to provide proper care and supervision of R1. Therefore, the allegation 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 Executive Director Marguerite Crockem.