Inspector’s narrative
What the inspector wrote
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physician. The front desk for the office was closed due to it being a Saturday, and according to S1, they left a message for the Physician requesting a return call to discuss R1’s pressure injury.
Three different staff members observed R1’s pressure injury, and they all provided different descriptions of it. Although a body check form is required when a pressure injury is discovered on a resident, there was not one done.
Staff 2 (S2) said they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation, or information provided by other staff that R1’s pressure injury was monitored. In addition, no one from Mesaview called the Physician’s office on Monday, May 13, 2024, to follow up about R1’s pressure injury. R1 was transported from the facility to the medical office on May 14, 2024, for a follow-up appointment referencing their May 6, 2024, COVID-19 diagnoses. During the visit, the medical office staff discovered R1’s right ankle pressure injury, and the sock they were wearing was stuck to their skin due to the fluid oozing from the pressure injury.
R1 was evaluated by the medical office’s staff, who diagnosed R1’s pressure injury as an unstageable pressure injury due to the injury being covered with slough and being unable to see the depth of the wound. R1 was transported to the Hospital where they were admitted and administered antibiotics to treat their pressure injury.
On May 17, 2024, it was alleged that a resident developed a pressure injury, and staff did not seek medical attention for the resident in a timely manner. S2 was interviewed and stated they discovered R1’s pressure injury on May 11, 2024, in the early morning while changing R1. S2 described the pressure injury as being a circle about the size of a quarter, with redness and an outer red ring around the pressure injury. S2 stated on May 11, 2024, that they reported R1’s pressure injury to the medical office by leaving a message. On Monday, May 13, 2024, Mesaview staff did not receive a call from the medical office related to R1’s pressure injury, and no one from Mesaview called the office to follow up about R1’s pressure injury.
Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s
pressure injury as a “boil, a little red and a little wet.” During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury.
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OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment.
Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s
pressure injury as a “boil, a little red and a little wet.”
During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury. OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment.
OS1 said the first stage of the pressure injury would have been redness, which should have been immediately reported. The staff should have monitored the area closely and rotated the patient to prevent the pressure injury from worsening. By the time R1 was examined at the medical office on May 14, 2024, their pressure injury was open, oozing, and stuck to their sock from the fluid covering the pressure injury. Although S1 stated they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation or information provided by other staff that R1’s pressure injury was monitored.
OS1 said they found no record of Mesaview staff calling the medical office on May 11, 2024, or any other time to report R1’s pressure injury. OS1 confirmed the clinic’s front office is closed during the weekend; however, Mesaview is also provided with a 24-hour emergency number for these calls so the staff can respond to them immediately.
The Department investigated the above allegations, and the preponderance of the evidence standard was met. Therefore, the above allegations are substantiated.
Pursuant to the California Code of Regulations, Title 22, Division 6 deficiencies were cited on the attached 9099-D. An immediate civil penalty of $1000 was assessed during today's visit for the facility's neglect.lack of care and supervision resulting in a resident's pressure injury and hospitalization. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.
An exit interview was conducted with the Assistant Manager, Ileana Castro, and a plan of correction was jointly developed. A copy of these reports, along with Licensee/Appeal Rights (LIC 9058 03/22), was provided after the visit.
