complaint·June 13, 2024

On 2/26/2023, R1 was sent to Santa Barbara Cottage Hospital after developing aphasia and was found to have cellulitis on their right second toe, which had to be amputated. R1 was diagnosed with having a stroke and was discharged from the hospital to a Skilled Nursing Facility (SNF). R1 saw a podiatrist and was diagnosed with a foot fungus as well. Facility nurse visited R1 at the SNF and observed R1 appeared to be declining. R1 did not return to the facility until 4/17/23. R1 returned to the facility on home health because R1 was not participating in physical therapy. Central Coast Home Health regularly visited R1 and did not consider the wound to be a pressure injury. The facility nurse contacted the SNF, who also stated the wound was not a pressure injury and was healing. LPA interviewed the case manager nurse from the hospital, who disclosed based on hospital records, when R1 was seen in the hospital on 2/27/2023, R1 did not have black necrotic tissue or the wound that was observed 5/9/2023. Case manager nurse indicated the wound developed between 3/29/2023 and 4/11/2023, when R1 was at the SNF. Facility nurse stated after R1 returned to the facility, they asked for hospice to be considered for R1, and also asked for a swallowing evaluation. Facility nurse also asked for palliative care as a bridge between home health and hospice. On 5/9/2023, a home health nurse visited R1 at the facility. Home health nurse observed R1’s right great toe and observed an unstageable necrotic (black) wound to the right great toe. On 5/9/2023, home health nurse notified facility nurse of the unstageable necrotic wound. Facility nurse stated she was unaware of the necrotic toe until 5/9/2023. R1’s PCP was in the building at the time of discovery, and PCP’s nurse observed R1’s toe. PCP believed the tissue could be a basal cell carcinoma. R1 was taken to Goleta Valley Cottage Hospital and was diagnosed with osteomyelitis. Additionally, hospital notes indicate on 5/10/2023, R1 was found to have MRSA and E.coli, and the skin of the bone reached the toe and caused osteomyelitis. Hospital notes indicate R1’s course of treatment was IV antibiotics. Facility nurse stated home health was brought in for wound care and was supposed to communicate with the facility staff or herself if there was anything concerning. Facility nurse stated they questioned how the condition of R1’s great toe could have been missed if home health was providing wound care for the amputated second toe on the same foot. However, facility nurse stated when R1 was first brought back from the hospital, there was a bandage on the toe, so the condition was not visible. Please continue to 9099-C, Pg 3. Based on interview with facility nurse and R1’s physician’s report and care plan, the facility showered R1. After R1 returned to the facility, they obtained a Hoyer lift to assist with showers, but R1 began refusing showers. Eventually R1 received bed baths due to refusing showers and refusing to use the Hoyer lift. LPA interviewed staff who assisted R1 between 4/17/2023 and 5/9/2023 about R1’s care needs and the condition of R1’s right great toe. Staff interviewed indicated R1’s feet were always wrapped in compression socks and/or had bandages covering the toes, so they did not look at R1’s feet. Staff interviewed indicated the Home Health nurses would check R1’s feet, and that task was not assigned to facility staff. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore, the allegation is deemed Unsubstantiated at this time.