complaint·December 7, 2023

On 02/03/2023, two new stage II pressure injuries were diagnosed. On 02/10/2023, a possible abscess formation was found, and the resident was sent to the hospital. Hospital records show one of the pressure injuries was a stage IV. Records from the home health care agency indicate staff were trained on proper positioning of R1 and perform pressure relief and instructed to reposition R1 ever hour if possible. Staff were educated to perform frequent positional changes at night. Home Health Agency was treating R1 twice a week. A home health care nurse stated R1 was incontinent, and the nurse would find R1 frequently saturated and times where it was obvious R1 was not changed during the night. Interviews and medical records indicate R1 suffered a traumatic event and voiced that they were feeling sadness, no appetite, and felt less willing to move around. A note was found next to R1’s bed that stated R1 was to be in bed except during meals and the nurse stated they did not agree with the note and stated R1 was still able to sit up and staff were instructed to get R1 out of bed. There was a referral for mental health treatment but there are no notes indicating how long the resident was under mental health care or what staff were to do for the resident’s mental health. Interviews with staff did not mention ways staff were to monitor the resident for any changes. Home health nurse suggested R1 go to a wound care clinic once a week because the pressure injuries were not healing, and it was denied by the facility with no explanation. Based on the above, the needs of R1 were not met by the facility. As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations and California Health and Safety Code. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The Administrator was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights