Complaint·March 1, 2024

The resident was evaluated in the Emergency Department and later admitted for further evaluation. Records reflect that hospital staff placed a staple on a laceration on the back of R1’s head. Records also reflect that R1 was admitted for treatment of an open area on the right shoulder and right hip. A review of R1’s facility communication report indicates that on 02/07/2024, R1 presented to facility nursing with redness to the groin area. On 02/14/2024, records reflect a facility caregiver observed “redness to right hip and shoulder. Notified MT. MT checked vitals. Vitals normal – redness on body.” R1’s records noted that on 02/15/2024, R1 refused shower. R1 was admitted to the facility on 10/26/2023. Per R1’s LIC602A Physician’s Report, dated 10/10/2023, R1’s primary diagnosis was Dementia, HTN, CKD, and Diabetes. R1’s secondary diagnosis was senile debility and a high risk for falls. R1’s physical health indicated they did not require assistance other than a regular low sugar diet. R1’s mental condition showed inappropriate and aggressive behavior, suicidal, at risk if allowed direct access to personal grooming and unable to leave the facility unassisted. R1’s records noted they were unable to bathe them self and needed supervision. R1’s records noted they were non-ambulatory based upon their mental condition. Interviews with facility managers and supervisors revealed that R1 was very independent and at times refused bathing assistance. Management and supervisory staff acknowledged that R1’s plan of care included bathing assistance. Management interviews stated that when care staff provide bathing assistance, they are able to evaluate residents for skin breakdown or wounds. Interviews revealed that it was common knowledge R1 regularly refused bathing assistance. Management and supervisory staff did not arrange for R1 to be reevaluated so their plan of care could be updated. Management acknowledged that if staff followed R1’s plan of care, pertaining to bathing assistance, they could have discovered R1’s skin condition sooner. It was also noted by supervisory interviews that there was a delay by care staff in notifying supervision of R1’s wounds. LPA obtained R1’s hospital records which noted that the admitting diagnosis were shoulder abscess, hip abscess, and cellulitis. An interview with an outside source indicates R1 remained at the hospital for treatment and was transferred to a rehabilitation facility on 2/23/24. The source told LPA that R1 is currently receiving treatment for Methicillin-resistant Staphylococcus aureus (MRSA) and will likely return to the facility after they recover. The Department has investigated the above-mentioned allegation and has found that based upon evidence gathered during record review and interviews, there is sufficient evidence to corroborate the allegation. The Preponderance of Evidence standard was met. Therefore, the allegation is deemed substantiated. A deficiency is cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with Ms. Lopez and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. Ms. Lopez’ signature below confirms receipt of the documents.