Complaint Investigation Report

Allegation #1: Resident sustained a severe infection while in care.

Allegation #2: Staff do not assist resident with incontinence care.

The details for the complaint alleged client #1 (C1) sustained a severe infection while in care by staff at this facility. It was reported on 11/03/21, (C1) was taken to Harbor UCLA Medical Center Hospital due to a severe rash on the posterior. On 11/12/21, (C1) was later transferred to Torrance Memorial Hospital for MRSA and E. coli infection. The complainant reported (C1) is left in diapers for prolonged periods at night and during the day.

Harbor UCLA Medical records (dated 04/14/22) revealed (C1) was assessed with raw, skin peeling/slothing off and no active bleeding/drainage in the buttocks. On 11/04/21 hospital’s wound care consultants completed a complete skin assessment with (C1) noted to have Incontinence Associated Dermatitis (IAD) extending to the bilateral buttock and exposed dermis. On 11/05/21 (C1’s) history and physical indicated skin superficial skin loss/breakdown along posteromedial and scrotal area. Finding favored to represent cellulitis. On 11/05/21, (C1’s) history and physical findings are favored to represent cellulitis. Blood culture growth revealed Methicillin resistant Staphylococcus Aureus (MRSA).

On 03/24/22, 03/25/22, and 04/13/22, the Department interviewed by phone (4) medical professionals and (1) service coordinator. (3) out of the (5) witnesses #1-#3 (W1-W3) confirmed that(C1) was being treated for cellulitis or some type of bacterial infection.

On 04/13/23 between 3:00 pm – 4:00 pm, the Department interviewed by phone (3) facility staff. (3) out of (3) staff #1-#3 confirmed (C1) wore adult pull-up diapers and was unable to wipe oneself. (S1-S3) acknowledged that (C1) had some types of rash and routine body checks were conducted. (S1-S3) reported (C1) was changed every (2) hours or as needed.

On 04/13/22, between 3:00pm – 4:00pm, the Department reviewed client #1-#2 (C1-C2) service records and attempted to interview (C1-C2) by phone and were unable to hold a conversation as a result of their disability.

(Evaluation Report Continues on LIC 9099-C)