Inspector’s narrative
What the inspector wrote
On the allegation "
Staff neglect resulted in resident sustaining a wound requiring hospitalization"; it is the concern of the Reporting Party (RP) that on 09/18/24, Resident 1 (R1) was admitted to St. John’s Regional Medical Center, with a gluteal abscess that was so deep, muscle and fat was able to be seen. RP believes R1 was neglected by facility staff due to their condition and R1 was possibly “never turned” by staff. To investigate the allegation the LPA conducted a file review and interviews.
According to medical and home health records reviewed, R1 was initially admitted to Camarillo Health Care Center (CHCC) on 07/21/2024 for “encounter for surgical aftercare following surgery on the genitourinary system”. On 08/19/2024, R1 was discharged and admitted to the A Peace of Home facility. The discharge paperwork from CHCC did not indicate a pressure injury. However, home health records reviewed indicated that on 08/22/2024, R1’s Patient Information Report notated R1 had a left foot unstageable pressure ulcer and a coccyx stage 3 pressure ulcer: measurements at 6.65 CM X 6.5 CM and that all wounds were acquired prior to board and care transfer. Facility staff able to assist with providing wound care 1 time a week or as needed, with home health twice weekly for a total of 3 times a week. On 08/26/2024, a home health nurse cleansed sacral wound with normal saline and there were no signs or symptoms of infection. New wound orders called in for left heel wound. On 08/29/2024, R1 received wound care, pressure relieving measures with skin management for prevention of skin breakdown, no new skin concerns noted at visit. Diet was noted as a concern for board and care as it was reported R1 eats 15% of total daily solids. R1 and care staff were instructed on the importance of appropriate measures to prevent skin injury/breakdown including routine inspection of skin, turning schedule/offloading, keeping skin clean and dry especially over bony prominences, encourage adequate nutrition and hydration and leave blisters intact. On 09/01/2024, a home health nurse noted that R1 was diagnosed with UTI on Friday August 30
th
, 2024, R1 did not fully engage in conversation due to increased tiredness, and heart rate range between 110 to 113 throughout visit. Nursing interventions were listed as the following: R1 and caregivers educated on repositioning every 2 hours to help heal pressure injuries and prevent further skin breakdown, educated on increasing protein intake as tolerated if not contraindicated to help with the healing process, and educated on signs and symptoms of infection. On 09/04/2024, a case conference note indicated bedbound, wound care, pressure ulcers, cervical spine issues, recently diagnosed with UTI, on antibiotic as skilled reason for home health services, and that R1 is being seen by mobile wound specialist, waiting to have pet scan and recently had MRI. On 09/05/2024, a home health nurse noted that they called the office of Dr. West and gave report that R1 had not been eating or drinking well for 4 days and a feeding tube was being requested. Report will continue on LIC9099-C, 3rd page.
Additionally, on 09/06/2025, a home health nurse noted that they were informed by R1’s case manager that R1 was admitted to St. Johns Regional on 09/04/2024 with Dx sepsis, UTI, an abscess, and R1 was on O2. On 09/08/2024, it was noted that R1 was scheduled for drainage procedure later in the day.
On 09/13/2024, it was noted R1 was now at USC-Keck Hospital and home health nurse spoke with R1’s nurse at USC. On 09/19/2024, it was noted that R1 was transferred back to St. Johns Regional on 09/18/2024 as R1 was more stable. On 09/25/2024, it was noted a home health nurse spoke with R1’s case manager at St. John’s Regional and it was stated R1 needed a higher level of care as they still had a wound vac in place and wound was not looking good, and it was recommended for R1 to go to SNF instead of Board and care.
The Administrator stated that R1 had what appeared to be an "unstageable pressure ulcer” upon admission and that when they did the pre-assessment at CHCC, R1 refused to be seen and went based on photos that were shown to him and the information that was provided. The Administrator revealed that the nurse involved with R1’s care at CHCC let him know he had a diabetic ulcer on their heel, as well as an excoriation on their sacrum, coccyx region, and based on the information that was shared they agreed R1 would be a good fit for the facility. However, upon admission, R1’s wounds were more severe and not as described. The Administrator notified R1’s POA that R1’s wounds were more severe than they thought, they were more of a pressure ulcer and R1 needed a higher level of care, however R1 refused to go the hospital and wanted the home care aspect and nursing visits as opposed to hospitalization. The Administrator further revealed that during R1’s stay at the facility after home health diagnosed the wound as a pressure ulcer, they emphasized to R1’s POA that the facility might not be the appropriate place for R1, and they needed to get treatment at a wound center or the hospital, it did need the clinician care, higher frequency care as it was a pressure injury and the POA eventually was able to convinced R1 to go to the hospital. Staff interviews revealed that staff did not get wound treatment training by a home health nurse. Staff either received training on basic treatment to care for R1’s wound by the Administrator or did not get any training on how to treat the wound, even though R1’s dressing would get changed either by the nurse or sometimes by the staff. Staff further revealed that they would reposition R1 every 2 to 3 hours.
Based on record review and interviews conducted, there is sufficient evidence to support the allegation occurred. The Administrator admitted and retained R1 with a prohibitive health condition (who needed a higher level of care) in direct violation of regulations.
Report will continue on LIC9099-C, 4th page.
R1 had a rapid progression of a pre-existing Stage 3 pressure ulcer to a severe gluteal abscess and sepsis within 2 weeks. Despite HH visits and staff claiming repositioning R1 every 2 hours, R1’s condition deteriorated rapidly between 08/19/2024 and 09/04/2024. A UTI was diagnosed on 08/30/2024, which, coupled with the existing pressure ulcer, required a higher level of care. Additionally, the care staff should not be changing R1’s dressings as they are not skilled professionals. Furthermore, file review did not provide information or documentation to support which caregivers were provided with training on R1’s wound care. Therefore, the allegation “Staff neglect resulted in resident sustaining a wound requiring hospitalization” is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regu
lations, the following deficiencies are cited (refer to LIC 9099-D). An immediate $500 civil penalty was issued today. Administrator Michelle Perey
was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).
Exit interview conducted, copy of this report issued.
