Complaint Investigation Report

Allegation: Staff fail to change resident’s diaper frequently and when wet

Based on interviews and records reviews, R1 was being treated for wound care by a home health nurse at the facility from 5/18/20 to 8/7/20. On 7/11/20, HHN observed a new red wound at the left buttock and on 7/24/20 instructed staff to change R1 promptly after each episode of incontinence to prevent deterioration of the wounds. On 8/5/20, HHN observed that R1s wound was not progressing due to continuing urine contamination. The preponderance of evidence has been met. Therefore, the allegation is substantiated.

Allegation: Staff fail to reposition resident several times a day using proper technique

Based on interviews and record reviews, HHN notified staff to reposition R1 every 2 hours while in bed and keep R1 clean and dry at all times for wound to heal on 06/24/20 and 07/06/20. On 06/26/2020 HHN brought in Occupational Therapist (OT) to train staff on proper resident repositioning techniques. On HHN’s routine wound care visit dated 07/11/20, a new wound on the left buttock which was observed to be red and reported this to staff. HHN again instructed staff to reposition R1 every 2 hours in bed and encourage R1 to hydrate and eat food. Upon review, it was found that this direction was not added to the care plan. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.