complaint·March 27, 2024

Investigator Bendana conducted interviews on 07/11/2023, at approximately 1:47 p.m., with Staff #1 (S1), Staff #2 (S2), Resident #2 (R2), and attempted to interview Resident #1 (R1) but R1 did not respond to questions or acknowledge the investigator; on 08/16/2023, from approximately 10:58 a.m. to 11:14 a.m., with the hospice nurse and R1’s resident representative; on 08/21/2023, at approximately 3:01 p.m., with the administrator; on 08/22/2023, at approximately 11:36 a.m., with the wound care specialist certified nurse; on 09/01/2023, at approximately 1:14 p.m., re-interviewed the administrator; and on 09/05/2023, at approximately 3:49 p.m., attempted to re-interview S1. In addition, the investigator reviewed R1’s medical records, photos of R1’s pressure injuries and bruises, and facility file documents related to R1. R1’s Physician Report, dated 02/27/2023, listed R1’s primary diagnosis as Alzheimer/Dementia. R1 needed assistance with all activities of daily living, needed routine check for skin breakdown, was considered non-ambulatory, and needed assistance transferring to and from bed. R1’s Appraisal Needs and Services Plan, dated 02/15/2023, documented R1 needed assistance with all activities of daily living, needed assistance when ambulating, and was a fall risk. A review of the text messages sent between the administrator and R1’s resident representative revealed that on 05/12/2023, at 12:42 p.m., the administrator notified R1’s resident representative that R1 had a rash on the left shoulder and hip and needed to be seen by a doctor. R1’s resident representative took R1 to the primary care physician on 05/15/2023 where R1 was assessed. During the visit, the nurse practitioner addressed a pressure injury of R1’s buttocks at stage 2, unspecified laterality. R1 was prescribed Doxycycline Hyclate and Mupirocin ointment. The orders included pressure setting on bed at the facility and move positions every two (2) hours to prevent damage to the skin. R1 was referred to the Tarzana Wound Care Center for further evaluation. On 05/22/2023, at 2:00 p.m., the wound care center noted multiple pressure injuries including right and left hip unstageable pressure injuries; left scapula deep tissue pressure injury; and right and left buttock stage 2 pressure injuries. R1 was also noted to have bruising on the right forehead and bilateral knees, the right knee worse than the left. R1 was referred to the Adventist Health Simi Valley Emergency Room for further evaluation. A review of the Adventist Health Simi Valley medical records revealed that on 05/22/2023, R1 was seen in the Emergency Room with the chief complaint of open wound in the coccyx, left buttock, and left shoulder since 05/12/2023. R1 was admitted to the hospital for further management and a wound care specialist consultation. (Continue to LIC9099C) It was noted that R1 had several areas of bruising to the lower extremities that suggests R1 had fallen relatively recently. The evaluation noted “evidence of ecchymosis (bruising) of the right knee consistent with a recent fall, there is also a deep wound to the right hip that may be related to the same injury”. Imaging was conducted and there was no evidence of fractures. The assessment included R1 had pressure ulcers, noting R1’s right hip wound appeared to be relatively deep and may be partially gangrenous. R1 was diagnosed with unspecified open wound of lower back and pelvis, stage 1 pressure ulcer of sacral region, unstageable pressure ulcer of left and right hip, and pressure induced deep tissue damage of right and left upper back. On 05/24/2023, R1 was discharged to hospice care. On the allegation “Neglect/Lack of Supervision - Resident sustained pressure injuries while in care”. The Department’s investigation provided sufficient evidence to substantiate the allegation. The interviews and medical records noted R1 had unstageable pressure injuries. The staff reported they repositioned R1 twice a day, in the morning and in the evening. Due to R1’s condition, R1 needed to be repositioned more than twice a day. The administrator and the staff were aware the pressure injuries were “progressively” worsening. The staff failed to reposition R1 every two (2) hours as instructed in the discharge notes. The staff failed to provide care according to the after-visit care plan. The facility neglected R1 causing pressure injuries to develop and progressively worsen. Therefore, the allegation “Neglect/Lack of Supervision - Resident sustained pressure injuries while in care” is deemed substantiated at this time. On the allegation “Neglect/Lack of Supervision - Resident sustained unexplained bruises due to staff negligence”. The Department’s investigation provided sufficient evidence to substantiate the allegation. During R1’s evaluation at the hospital, it was noted that R1 had several areas of bruising to the lower extremities that suggests R1 had fallen relatively recently. Based on R1’s facility file documents, R1 was a known fall risk. When initially questioned if R1 had any falls at the facility, the administrator and staff denied any falls. The administrator was later informed by S1 that R1 had slipped in the bathroom. Therefore, the allegation “Neglect/Lack of Supervision - Resident sustained unexplained bruises due to staff negligence” is deemed substantiated at this time. A $500 immediate civil penalty is assessed today. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.