Complaint·December 11, 2024

RSD reported they instructed facility staff to clean the wound, put antibiotic ointment and bandage it. RSD reported the facility contacted R1's physician's office at San Diego PACE and requested home health services for wound care while the facility's licensed vocational nurses treated the wound and changed the dressing on a daily basis. RSD reported Mismo Dermatology assessed R1 on 11/19/2024. LPA contacted Mismo Dermatology who reported a Physician's Assistant (PA) was at the facility when staff requested they assess R1's wound. Mismo Dermatology reported the PA assessed the wound and determined it was too late for R1 to receive stitches. RSD reported R1's Responsible Person (RP) was notified of the wound and declined emergency services for R1. LPA conducted an interview with R1's RP who reported they were notified of the wound but RSD minimized the severity of the wound and reiterated the wound could be managed by facility staff. R1's RP reported facility staff never offered them the option to send R1 to the hospital. R1's RP reported when R1's family observed the wound in person, they were concerned with the severity of the wound and contacted San Diego PACE who requested to see R1 in their office. On 11/20/2024, R1's RP transported R1 to San Diego PACE to address the wound. LPA reviewed R1’s Medical Visit Summary from San Diego PACE noting on 11/20/2024 R1 visited their physician, at San Diego PACE's request, and was observed with an uncovered open wound measuring 6 centimeters by 2 centimeters with no discharge, edges with eschar tissue, no erythema around the wound, and subcutaneous tissue exposed. The MVS noted the wound required stitches and R1 was referred to the emergency department following their doctor’s visit. Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Hill along with a Confidential Names list (LIC 811) and Appeal Rights.