Complaint Investigation Report

Allegation: Resident sustained multiple pressure injuries while in care.

The details of the complaint alleged resident # 1 (R1) sustained multiple pressure injuries while in care at this facility. As reported on the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. Specifically, the complaint focused on an incident that occurred on 12/14/21 when (R1) was hospitalized at Harbor UCLA Medical Center Hospital. Indicated on the (SOC-341) (R1) presented multiple wounds described in various stages from unstageable to wound healing in Stage 3. In medical records, a total of (15) wounds were identified. The Department reached out to the complainant for further comments but was not available.

The Admissions Agreement indicated (R1) was admitted at Carson Senior Assisted Living (CSAL) on 04/19/21. (R1) was medically assessed according to (R1’s) Physician’s Report dated 04/19/21 as ambulatory in fair physical health status. (R1’s) capacity for self-care required assistance with activities of daily (ADL) however did not require continuous bed care and a history of skin breakdown. According to service records (R1) was admitted on 04/20/21 by St. Paul Home Health Services (SPHHS). Home health services included services 2 or 3 visits weekly by a licensed registered nurse who attended to (R1’s) medical health condition that included a wound care order. The medical records for (R1) presented between 04/19/21 to 12/14/21, (R1) transitioned between hospitals, skilled nursing homes, and Carson Senior Assisted Living (CSAL). As a result of these transitions, (R1’s) wound care orders remained consistent with St. Paul Home Health Services. Each time (R1) was readmitted back at (CSAL), (SPHHS) was reinstated.

In accordance to a Medical Body Assessment and Body Documentation for (R1), wound assessment and care was conducted on 09/24/21, 10/14/21, 11/23/21, 11/24/21, 12/04/21 by (CSAL) (SPHHS) and Omni Wound Physicians (OWP). The West Coast Wound Company conducted an additional wound assessment and wound treatment plan on 12/02/21. No wounds were classified as stage 3 or stage 4 in any of the assessments.