Complaint Investigation Report

Record review showed staff did not change R1’s diaper or reposition R1 overnight. Interview with staff indicated that staff conduct diaper changes every 2-3 hours. However, staff stated that R1 was heavy to lift and would yell when staff tried to reposition R1. On hospice’s initial visit on 3/12/2022, R1 was found wearing two diapers and laying on top of chux pads. R1’s wound was already at a stage 4 when hospice began treating R1. W3 stated that a wound can develop from a stage 1 to a stage 4 within a couple hours if the resident is not repositioned, remains in the same position for hours, and their diapers are not changed.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Health and Safety Code, are being cited on the attached LIC9099D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be schedule at a later time.

Exit interview conducted with Arnold. A copy of this report, civil penalty, and appeal rights provided.