Complaint Investigation Report

During the investigation process, management, numerous staff persons, a physician and a nurse were interviewed regarding the resident’s condition. The resident (Resident 1) was not interviewed, as she has since passed away. It was reported that the resident developed several pressure injuries while in care.

The following information was provided regarding the resident: On 07/11/22 the resident was seen by her physician, and it was noted that the resident had a skin breakdown in her groin area and topical cream was prescribed. On 07/14/22 the first notation of a breakdown was on the resident’s “bottom.” It was stated in the care notes that the “resident has a sore on her bottom that is getting bad, we are going to rotate her while in bed and please apply cream after toileting.” On 07/17/22 it was documented that the resident had an “open” wound on her coccyx and blisters on her heel. The resident was not seen by the physician until 07/29/22 and at that time, the physician opened the resident to Home Health for wound care. The resident did not get professional medical care from the physician or a home health nurse for numerous days for several pressure injuries.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.