Inspector’s narrative
What the inspector wrote
Hospital records dated August 14, 2022, revealed directly prior to R1’s admission to the facility they lived alone at their own place of residence and R1 sustained a fall while on a walk, resulting in a hospital admission. Hospital records revealed R1 sustained no injuries from the fall however revealed other health conditions, including the following diagnosis: Major Depressive Disorder, Diabetes Mellitus II with Chronic Kidney Disease at stage 3A and Dyslipidemia, Hypertension, Hypoglycemia, severe sepsis with acute organ dysfunction, generalized weakness, depression with Suicidal Ideation (SI), and general self-neglect. R1 also had a history of Brain Cancer, severe sepsis with organ dysfunction and a non-traumatic Kidney injury.
Additional review of hospital records and an interview with Outside Source 1 (OS1) revealed an agreement that upon R1’s hospital discharge on August 19, 2022, they would be relocated to a Board and Care Facility. Further review of R1’s hospital records dated their day of discharge, August 19, 2022, revealed R1 had a skin assessment and was educated on skin care precautions including but not limited to; position change, screening for skin injury risk, such as pressure or moisture associated skin damage, keeping areas clean and dry, redistribution of pressure, floating heels off bed to avoid pressure on Achilles Tendon, encouraged ambulation, and to maintain hand hygiene and skin mucous membrane.
On that same day, August 19, 2022, R1 was discharged from the hospital and transported to the facility. On August 22, 2022, R1 was assessed by a Home Health Agency (HHA) with services starting on August 30, 2022. A review of HHA records dated August 30, 2022, revealed they were assigned to, but not limited to, assist with the treatment of R1’s Diabetes and maintenance of R1’s Foley Catheter, provide Physical Therapy, educate staff on infection prevention and control, fall-risk prevention, how to monitor for pressure injuries on lower extremities, provide understanding and intervention for Diabetic foot care, instruction of pressure injury care per physician’s orders, signs and symptoms of a pressure injury and when to notify the physician. The HHA records dated August 30, 2022, also notated that R1 presented an unstageable pressure injury to their left heel. HHA records dated September 27, 2022, revealed R1 had developed a new pressure injury to their left ear, facility staff was educated on how to care for the pressure injuries during non-HHA nursing days.
An interview conducted with R1 revealed when Staff 1 (S1) assisted R1 around September 1, 2022, in the shower they advised R1 that they observed skin peeling off R1’s left heel. R1 revealed they saw S1 a couple times a week and S1 changed and showered them. R1 also revealed facility staff had left them in soiled depends for approximately 2 hours on at least one occasion. An interview conducted with the Licensee revealed on approximately September 1, 2022, they were giving R1 a shower and saw something on R1’s heel, and that it was hot and red. The Licensee’s statement contradicts R1’s recollection of who was showering them on or about September 1, 2022. The Licensee revealed they did not conduct a re-appraisal however called and notified R1’s Responsible Party (RP) and then alleged that HHA staff did not conduct full body checks, they would only check R1’s medication, assisted with showers and leave, and they never provided any trainings or instructions regarding the care of R1’s pressure injury to their heel. The Licensee admitted to never asking HHA staff questions regarding R1’s injury and stated they took their word that it was nothing serious. The Licensee made these statements just after informing the Department they are a Registered Nurse (RN) themselves. The Licensee also revealed they never discussed or reported R1’s prohibited health condition because they never knew what stage the pressure injury was. Additionally, they could not provide any facility records regarding R1’s care plan, claiming the HHA took all R1’s paperwork. The Licensee also revealed on September 30, 2022, R1’s pressure injury was observed to be malodourous, and they had concern that R1’s foot was becoming gangrenous. An additional interview with Outside Source 2 (OS2) revealed the wound was unstageable due to it being covered by black eschar (dead skin). An interview conducted with facility Staff 2 (S2) revealed knowledge of R1’s pressure injury, S2 believed it was a Stage I or Stage II and revealed they never provided any wound care, or sought medical attention, and stated the care for R1’s pressure injury was provided by the HHA. An interview conducted with Staff 3 (S3) revealed they had worked at the facility for approximately 3 years, S3 also revealed knowledge of R1’s injury and that it was only treated by the HHA, also stating they were never provided instructions on how to care for R1’s injury.
This is an amended version of the original report dated 2/27/2024.
A review of HHA records revealed on September 26, 2022, they had just been approved to start caring for R1’s pressure injuries. HHA records also revealed providing facility staff education on proper Diabetic foot care and how to monitor for the presence of skin lesions. The records also included documentation of several other dates HHA staff provided facility staff education on how to care for R1’s foot. An interview with OS2 revealed that facility staff were provided verbal education/instructions on how to care for R1’s pressure injury located on their left heel. OS2 revealed having facility staff repeat back how they were to care for R1’s foot per their instructions.
A review of additional hospital records revealed on October 1, 2022, R1 was admitted to the hospital after sustaining a fall at the facility resulting in no bodily injury. During hospitalization R1 told hospital staff they felt generally weaker than usual over the past two days and collapsed while trying to use the restroom. Hospital records also revealed R1 was notified by medical staff that their pressure injury on their left heel was so severe R1 faced an amputation or possible death. On October 2, 2022, R1 heel was lanced and drained and R1 was given a urine test and culture test of their heel and both tests returned positive for Multi Drug Resistant (MDR) Escherichia (E) Coli, a bacterium that is difficult to treat with standard anti-biotics and posed an increased mortality rate and significant public health concern. On October 4, 2022, the eschar (dead skin) was removed from the wound, on October 6, 2022, R1 was diagnosed with Osteomyelitis (a serious bone infection) of the left foot, and on the following day, October 7, 2022, R1 underwent an amputation of their left limb from below the knee. R1 was released to Post Acute agency for continued care post amputation and released back to the facility on November 4, 2022. A review of Post Acute Agency records revealed they strongly recommended R1 to relocate to a new facility but R1 and their RP strongly disagreed and were adamant R1 return to their prior placement. In addition, at the time of release the Post Acute Agency staff informed the Licensee R1 was COVID-19 positive and the Licensee agreed to follow CDC guidelines.
A facility records review regarding an additional resident, Resident 2 (R2) revealed they were admitted to the facility on October 7, 2022, and had a diagnosis of Renal Cancer, Dementia, and Diabetes. At the time of admission R2 was receiving Hospice Services that would come to the facility 2-3 times a week to clean R2’s pressure injuries. Interviews with outside sources revealed instructing facility staff to prop R2 on their side to relieve pressure and they needed to reposition them every 2 hours. An interview with R2 revealed facility staff would reposition them, however they stopped, or gave up, and ended up buying them an air mattress. R2 also revealed they were notified by their servicing Hospice agency they had a Stage IV pressure injury.
This is an amended version of the original report dated 2/27/2024
Additionally, during the interview with R2 they revealed facility staff would change their Depends once per day, and on occasion again at night. An interview with OS1 revealed they had found R2 sitting in soaked Depends on several occasions and had found fecal matter in R2’s wound. An interview conducted with Staff 4 (S4) revealed R2 was repositioned every two (2) hours and staff used props on their back and hip area to relieve pressure but R2 would roll over to being flat on their back, at the time of the interview R2 had already passed away.
It regard to the allegation that facility staff did not treat residents with dignity/respect, an interview with OS1 revealed the Licensee was disrespectful towards R2 and they would have loud arguments. An interview conducted with R2 corroborated being yelled at by the Licensee but felt the rest of staff were nice. R2 revealed the Licensee did not like their criticism and would become angry and yell at them, they also revealed being left in bed all day and felt ignored. [See LIC 811 for Confidential Names]
Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being 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 Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) were provided. Licensee signature below confirms receipt of the documents.
This is an amended version of the original report dated 2/27/2024.
It was also alleged facility staff was not giving medications as prescribed and an unskilled staff member was administering insulin injections to residents in care. An interview with an Outside Source 1 (OS1) revealed residents in care would report they did not receive their medications. The interview also revealed that during the Month of May of 2022, one of the facility owners was in the hospital, and the other co-owner’s whereabouts was unknown and during that time an individual, known to be a relative of the facility owner, who did not speak English, came to the facility, and OS1 observed them administer the residents in care their insulin injections. Interviews conducted with Residents 1 (R1) and Resident 3 (R3), both having a diagnosis of Diabetes, revealed no corroborating information or evidence of either an unknown individual administering insulin or missing administration of medications.
It was alleged staff were not meeting the residents’ personal hygiene needs and the facility did not provide adequate amount of food for residents’ daily diet. An interview with OS1 revealed R3 complained about how often staff were assisting with grooming, more specifically assistance with hair washing. An interview conducted with R3 revealed being showered twice a week and likes living at the facility. Other resident interviews revealed no complaints regarding hygiene needs. An interview conducted with Resident 2 (R2) revealed they get enough food, additionally an interview conducted with R1 revealed they are never left feeling hungry.
Based on the Department’s investigation the above-mentioned allegations were determined to be unsubstantiated. An unsubstantiated finding means the allegations may have happened or could be valid although there was not a preponderance of evidence to prove that the alleged violations occurred.
LPA conducted an exit interview with LIcensee Chhina and was provided a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) and signature on this report acknowledges receipt of the documents.
