complaint·September 22, 2022

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegation. R1 was sent out via 911 on 07/20/22 from facility. Arriving at the ER, R1 presented with two sacral pressure injuries, stage ll and Unstageable. It has been alleged that, although prohibited by Title Twenty-Two regulations, facility retained R1 with Unstageable pressure injury. An investigation ensued by this Department which included review of photographs; statements taken from witnesses and staff; review of medical and other documents. The following determinations are made: When seen in a medical setting on 7/10, R1 had no noted pressure injuries; During the 3 days proceeding 7/20, staff and witness report R1 had only a small red area on skin in sacral area; Hearsay statements from medical practitioner suggest the injury was several weeks old by 7/20; Opinion expressed by one of the ER physicians reports that it is difficult to gage age of injury in R1 due to R1's fragile and severely malnourished state. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegation is true. Therefore, the allegation is UNSUBSTANTIATED. Report left. No citations issued.