complaint·December 12, 2023

Continues from LIC9099... Based on medical records dated 7/29/23 at 3:48:46pm responsible party contacted home health, which is indicated in the report that facility was aware of pressure injury. However, the facility did not seek timely medical from 7/29/23 until 8/7/23 when R1 met with their primary care physician through a virtual appointment and was diagnosed with a stage 2 pressure ulcer on their right heel. On 08/09/2023, R1 was assessed by hospice care staff and was diagnosed with a stage 2 pressure ulcer on their right heel. The Department obtained R1’s care plan dated 5/3/23 indicating that R1 needs assistance with daily activities including toileting, showering, and dressing. LPA conducted interviews with staff who informed LPA that they verbally notified responsible parties including home health agency about the blister that popped up from R1’s foot supposedly due to their socks that were assumed that were too tight. Facility failed to seek medical treatment when they noticed that the blister popped up to stage 2 pressure injury. Based on the information obtained by the Department during this investigation and confidential interviews conducted with witnesses, staff did not contact R1’s physician to seek timely medical attention after concerns about R1’s pressure injury. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The Department will be reviewing to determine if additional civil penalties are wanted. Regarding allegation about staff did not properly report an incident involving a resident. Per reporting party, staff did not notify R1’s responsible parties including the Department about R1’s pressure injury. Based on records review, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Administrator could not provide proof that incidents were reported to CCL. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given. Continued from LIC9099A... LPA conducted interviews with staff who informed LPA that they noticed the blister that popped up from R1’s foot supposedly due to their socks that were probably too tight. Based on the information obtained by the Department during this investigation, facility staff were assisting R1 and there were no concerns raised regarding R1’s sustaining a pressure injury due to neglect of facility staff. Based on LPA’s confidential interviews conducted with witnesses, there is no supporting evidence to prove that staff neglect resulted in a resident sustaining a pressure injury. A finding that the complaint allegations staff neglect resulted in a resident sustaining a pressure injury is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation of staff was sleeping during hours of care and supervision. Per reporting party, on one occasion facility staff was observed asleep while R1 was watching the TV in bed. Based on Records review of facility schedule for the month of August 2023 indicates that caregivers who previously worked night shift will stay later in the morning to assist R1 with their care needs. On 11/9/23 LPA conducted interviews with facility staff and residents in care. Interviews revealed that R1 was receiving a higher level of care due to their aggressive and combative behavior, resuming services to one-on-one care. The caregiver who was their main companion will call another caregiver to help them to assist R1 with daily activities such toileting, showering, etc. However, there is no indication or supporting evidence that at any given time any facility staff was observed sleeping during business hours. A finding that the complaint allegation staff was sleeping during hours of care and supervision is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation is about staff is unable to communicate effectively. Per reporting party, the occasion when they observed staff sleeping during business hours, they attempted to talk to the caregiver, but the caregiver did not speak English. On 11/9/23 LPA conducted interviews with facility staff and residents in care. Per Administrator, staff are divided into groups of residents that will assist with care and supervision. Staff performances are based on family input of staff personalities. Administrator told LPA that there had been incidents where caregivers don’t communicate properly using the English level necessary to communicate with residents, then they will re-assign them to a different section. LPA was able to determine through interviews with facility staff and residents in care, that staff are able to communicate effectively in English when assisting residents in care. A finding that the complaint allegation staff is unable to communicate effectively is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.