complaint·September 12, 2023

The Licensee observed redness to R1’s back in May of 2020 and began treating R1 with an ointment. This treatment by the licensee was conducted prior to consultation with the doctor and prior to contacting hospice. Interviews conducted with multiple facility staff, corroborated the Licensee was tending to the wounds using an ointment. The licensee reported facility staff used and treated the red areas with ointment (skin barrier cream or A&D ointment) for an estimated time period of two weeks. Between May of 2020 and June 6, 2020, the pressure injuries were not diagnosed by a physician or appropriately skilled professional. Neither did R1 receive care for the pressure injuries from a physician or appropriately skilled professional. The licensee reported acting in good faith but confirmed she is not a physician nor a skilled professional able to treat the pressure injuries. R1 was not admitted to hospice until June 6, 2020. Per R1’s hospice admission paperwork R1 was “bed bound” and had a history of reoccurring pressure injuries to their sacral area (space between coccyx and spine). At the time of R1’s hospice admission, they were assessed and noted to have “six (6) to seven (7)” pressure injuries ranging from stage II to unstageable. This was noted on the admission paperwork dated June 6, 2020. The pressure injuries were observed to be on R1’s shoulder, arm, back, and sacral area. As a result of the confirmed pressure injuries, facility staff were instructed by hospice staff, to turn R1 every 2 hours. Based interviews and record reviews, the allegation of Staff neglect resulted in a resident sustaining multiple pressure injuries 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. Based on the findings of the investigation deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the LIC 9099D. 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, and a copy of this report, 9099C, 9099D, immediate civil penalty assessment and appeal rights were provided to Licensee Nora Clemons.