Complaint Investigation Report

On 11/26/2020, Client #1's PCP referred Home Health nurse to go to facility to check on Client #1. On 1/08/2021, facility staff reported to Administrator that Client #1 had a pressure sore on his left shoulder. Administrator admitted that PCP was not contacted, and facility only implemented first aid care for Client #1.

On 2/13/21, Client #1’s PCP conducted an onsite medical check on Client #1, and found a pressure sore on Client #1’s left hip and left deltoid. Administrator, did not contact PCP prior to the visit regarding pressure sores.

On 3/4/21, Administrator reported to the regional center that there were two stage III pressure sores on Client #1’s middle back and left shoulder. On 3/9/21, Client #1 was taken to a skilled nursing facility for treatment and was diagnosed with four stage III pressure sores on left shoulder, middle back, and left and right hips. Administrator admitted to failing to implement medical care in a timely manner, when staff notified him of Client #’1s pressure sores.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to California Code of Regulations, Title 22 Division 6, Chapter 1.

Immediate Civil Penalty will be issued in the amount of $500.00

"The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f), or 1548 (e) or (f), 1568.0822(e) or (f)."

An exit interview was conducted with Ms.De La Rosa. A copy of the report and appeal rights were provided.