complaint·June 24, 2022

...Continued from LIC 9099... Information obtained revealed R1 was admitted to the facility on 12/02/21 as non-ambulatory, requiring continuous bed care in assisting with repositioning, and required assistance of another person with activities of daily living (ADL’s) including bathing, dressing, and toileting. Record review of R1’s Resident Appraisal stated R1 was unable to move lower extremities, needed help with transfers, legs were swollen, and noted R1 to have a sore on their heel. Before admission to the facility, on 11/27/2021, R1 was assessed by DaranCare Home Health. During the assessment, R1 was noted to have a Stage 3 pressure injury on the left heel, with measurements of 2cm x 3cm x 0.2cm; and a Stage 2 pressure injury on right lateral malleolus, with measurement of 1cm x 1cm x 0.2cm. On 11/23/2021, three (3) facilities were contacted on behalf of R1 by their social worker and two (2) declined resident due to needs and services R1 required. However, Anita’s Care Villa accepted R1. Additionally, R1’s Admissions Agreement signed on 11/24/2022 states under Basic Services, facility will provide assistance with personal activities of daily living including dressing, eating, toileting, bathing, grooming, mobility tasks, and other personal care needs. According to R1’s medical records, R1 was scheduled for wound care for pressure injuries from 11/08/2021 to 01/06/2022 from DaranCare Home Health. Interviews conducted with facility staff and medical records review, confirmed that R1 was admitted to the facility with at least two (2) pressure injuries and both Staff and Administrator were aware of R1 having pressure injuries. Yet, R1 was still admitted to the facility. On 1/03/2022, R1 was reassessed again after 90 days and was noted to have new wounds. On 1/03/2021, R1 was noted to have an Unstageable pressure injury on the right lateral malleolus, with measurements of 3.5cm x 2.5cm x 0.5cm; a Stage 3 pressure injury on the right hip, with measurements of 0.75cm x 1.75cm x 0.2cm; and a Stage 3 pressure injury on the right buttock, with measurements of 1.5cm x 1.5cm x 0cm. Administrator stated that R1’s repositioning requirement every 2 hours by Home Health was a different level of care. Additionally, staff stated they were turning R1 every 2 hours while in bed, and the new pressure injuries were from R1 sitting on their wheelchair all day. However, facility did not have any records indicating how often they were repositioning R1. Moreover, Home Health nurse stated that new wounds are due to pressure from lying and not sitting. ...Continued on LIC 9099C... ...Continued from LIC 9099C... Furthermore, nurse notes revealed that nurse was continuously providing education to the caregivers on the importance of turning and repositioning R1 every 2 hours. Although R1 was receiving appropriate wound care from Home Health for the stage 3 and unstageable pressure injuries while at the facility by DaranCare Home Health, a stage 3 and unstageable pressure injuries are considered a Prohibited Health Condition. There were no records indicating that an exception request was submitted in order for R1 to be admitted or to remain at the facility. Based on the information and documentation obtained and reviewed, the allegations of “resident developed pressure injuries while in care” is deemed Substantiated at this time. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Exit interview. Appeal Rights discussed. Copy of the report sent to the Administrator via email.