Complaint·November 1, 2022

Regarding the allegation: Staff are not meeting the resident's incontinence needs It was alleged that staff were double diapering Resident #1 (R1). Staff interviews confirmed that staff would place two pull-ups on R1 because of R1’s bowel and bladder incontinence. During the initial visit on 7/29/2022, the LPA was informed that R1 had on two pull-ups; at the time of observation, staff reiterated that they did so due to R1’s incontinence. At the time of observation, a home health representative was providing care to R1, and the home health representative informed staff that R1 only needed one pull-up, required frequent changing, and educated staff on the concern of skin breakdown if R1 sits in a moist pull-up for an extended period of time. An interview with a home health representative communicated that R1 was at higher risk for skin breakdown with the usage of two pull-ups and required frequent changing. Besides the observed dates of 7/29/2022, a review of home health notes indicated that R1 was observed wearing two pull ups on the following dates: 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. Based on the information obtained from interviews, observations, and records review, there is sufficient evidence to support the claim that staff are not meeting the resident's incontinence needs. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff are not changing residents bandage timely It was alleged that staff were not changing R1’s bandage on their left leg in a timely fashion. Records and interview indicated that R1 developed a blood blister on the left leg on approximately 7/7/2022. A review of home health records documented an order for the dressing on the wound to be changed every 2-3 days, or as needed, if the wound dressing becomes soiled. Records indicated that during a home health visit on 7/12/2022, R1’s bandage on the left leg was changed. Home health had educated the staff on the care for the left leg wound and communicated that the bandage would need to be changed every 2-3 days or if the bandage became soiled. Home health returned to the facility on 7/21/2022 and observed that the dressing in place on the left leg wound was dated 7/12/2022. Staff informed the home health representative that they had not changed the dressing as they assumed that the home health nurse was going to do so. As a result, the wound dressing had not been changed for nine (9) days. At the time of observation on 7/21/2022, the wound dressing was soiled. Thereafter, nursing visits from home health were increased to ensure the bandage was changed regularly. Staff interviews confirmed that at that time, home health nurses were changing the bandage on R1’s left leg wound every other day. Based on information obtained from interviews and record review, there is sufficient evidence to support the claim that staff did not change R1’s bandage timely. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff are not following physician’s orders It was alleged that staff were not following the physician’s orders from home health related to wound care. Records review indicated that R1 developed a stage 2 pressure injury on the buttocks on approximately 5/12/2022. Interview with home health staff revealed that it was suspected that the wound developed due to poor incontinence care, not repositioning R1 timely, and utilizing two pull-ups on R1. At that time, staff were instructed to keep R1 dry, to change R1 frequently, and to apply barrier cream. Staff interviews confirmed that they provide barrier cream to R1’s buttocks timely, ensure that R1 is repositioned, and ensure that R1 is dry. A review of home health notes indicated that R1 was observed wearing two-pull ups on 5/31/2022, 6/7/2022, 7/5/2022, and 7/21/2022. During the visit conducted on 7/29/2022, LPA observed that R1 had on two pull-ups. Staff claimed that they used two pull-ups due to R1’s incontinence, yet according to home health, wearing two pull-ups can also aid in skin breakdown. A review of home health notes regarding R1’s wound on the buttocks indicated that on the following dates, the barrier cream was observed to be applied either incorrectly or minimally: 5/31/2022, 7/25/2022, 7/27/2022, and 7/29/2022. Lastly, whereas there was an order to change R1s’ bandage on the left leg wound every 2-3 days or as needed if soiled, staff did not change R1’s between 7/12/2022 – 7/21/2022, as staff assumed that the home health nurse would change the wound dressing. Based on the information obtained from interviews and record review, there is sufficient evidence to support the claim that staff are not following physician’s orders. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained.