Follow-up·April 28, 2023

On April 28, 2023, Licensing Program Analyst (LPA) KaSandra Lopez met with Administrator Elizabeth Whittington for a Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(f). On September 2, 2020, the Department received a complaint alleging, “Resident #1 (R1) sustained multiple pressure injuries while in care,” and, “Facility staff did not seek medical attention for Resident #1 (R1).” It was alleged due to facility staff neglect and lack of supervision, R1 sustained multiple pressure injuries, and that facility staff failed to seek timely medical attention for R1. To investigate, the Department conducted visits to this facility on September 2, 2020, December 17, 2020, November 4, 2021, March 15, 2022, and March 18, 2022. Interviews were conducted with R1’s family, R1’s hospice agency staff and facility staff. R1’s facility and hospice records were also obtained and reviewed. The investigation revealed R1 was admitted to this facility on June 1, 2020. R1 was ambulatory and able to articulate their needs, despite having suffered a prior stroke and showing signs and symptoms of dementia. R1’s medical history included depression, frequent urinary tract infections, heart disease, stroke, and dysphagia. The licensee’s narrative charting record for R1 indicated on July 25, 2020, R1 was found by a caregiver sitting on the floor in the middle of their living room. R1 was noted as becoming weaker and in need of total assistance with toileting and feeding. On August 2, 2020, R1’s physician was contacted to obtain authorization for medical assistance as R1 “seemed a lot weaker,” and appeared in need of “a lot” more assistance. On August 15, 2020, R1’s representative visited R1 in this facility and bandaged R1’s legs due to R1’s itching and scratching, which caused bleeding. Band-aids were also placed on R1’s arms; however, R1 took them off twice, and R1’s representative was notified. Prior to August 15,2020, facility staff did not inform R1’s representative that R1 had not been ambulating on their own over a few weeks. Report continued on LIC 809-C. On August 20, 2020, R1 was assessed and admitted to TLC Hospice Care due to Alzheimer’s disease and a rapid decline in health. During the hospice assessment, R1 was observed to have a large stage 1 area on the coccyx with multiple scabs, and stage 2 areas within; a large skin tear to R1’s left lower leg; and, multiple open sores to both forearms. The assessment also noted since admission to this facility, R1 had rapidly declined, required support with all activities of daily living, and was in severe discomfort and significant pain. Information gathered further revealed it was not until hospice care initiated on August 20, 2020, that R1’s pressure injuries and wounds were diagnosed, treated and reported to R1’s representative. On August 22, 2020, the hospice nurse indicated R1 had moderate pain of a “6” in a Pain Scale as follows: [pain scale is to provide a standardized means of measuring pain intensity and severity, Pain Free 0, Mild Pain = 1-3, Moderate pain = 4-6, Severe Pain = 7-10…disabling or unable to carry out normal daily activity - https://connect.mayoclinic.org/]… ” On August, 24, 2020, the hospice nurse noted R1 was in severe pain, which was rated as a “9,” requiring pain medication (morphine). The licensee’s Residential Care Director (RCD) stated they were never made aware of R1’s pressure injury nor scattered skin tears, until R1 was accepted into hospice care. The RCD admitted the facility staff’s lack of documentation and communication, but also failing to provide appropriate supervision and care, attributed to neglecting R1’s change of condition and pressure injury/wound care needs going unmet. A review documentation obtained also reflects R1 did not receive the care and supervision necessary to address R1’s nutritional status (weight loss of 20 pounds in two months). Based on the records reviewed, interviews conducted, and photographic evidence of R1’s wounds/pressure injuries, facility staff neglect/lack of supervision and care was determined to have attributed to R1 sustaining pressure injuries. On March 18, 2022, licensing staff substantiated allegations, “Resident #1 (R1) sustained multiple pressure injuries while in care,” and, “Facility staff did not seek medical attention for Resident #1 (R1).” The licensee was cited for violating Health and Safety Code §1569.312, Basic Services Requirements, and for violating California Code of Regulations (CCR) Title 22, Section 87466 Observation of the Resident. On March 18, 2022, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. Report continued on LIC809-C. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injury while under the care of this facility. Welfare and Institutions Code §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee’s failure to properly evaluate and provide R1 with appropriate care and medical treatment. Based on the documentation reviewed, R1 did not receive the care and supervision necessary to address R1’s nutritional status (weight loss of 20 pounds in two months), and prevent or minimize the risk for skin integrity issues, causing R1 to develop wounds and a stage 2 pressure injury, contributing to R1’s severe pain (9/10). These deficiencies were a substantial factor in causing R1’s extreme pain/serious bodily injury, as indicated by the hospice nurse. Today, April 28, 2023, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on March 18, 2022, the amount of the civil penalty issued is reduced to $9,500. A copy of the LIC 421D was given to the Elizabeth Whittington and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Elizabeth Whittngton signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.