Complaint Investigation Report

The Department has investigated the above allegations. Based on the Department's observations, interviews conducted, and records review, facility failed to provide adequate care to C1 resulting in a stage 4 pressure wound. C1 requires assistance with toileting needs and risk for pressure ulcer. C1 was admitted at the facility on 06/08/2021 with stage two pressure sore, on November 25, 2021 C1 was sent out to the hospital and was diagnosed with stage 4 pressure wound. Documents review and Administrator claims that C1 refused wound care, however based on Medication Administrator Record (MAR) on November 2021 , licensed staff signed MAR every day that wound care is being performed to C1, there is only one documentation from progress note dated 11/5/2021 that C1 refused wound care from licensed staff.

Allegation: Resident wound care logs are incomplete

Based on interview and records review, facility did not properly document severity of wound, facility also did not properly identify the wound to be pressure injury.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

A formal meeting will be scheduled at a later time.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099 D.

Exit interview conducted and a copy of Appeal Rights provided to Melizza Cortez.