Complaint Investigation Report

The investigation revealed the following: S1 indicated R1 had some redness in April 2019 after being hospitalized for an unrelated issue. Facility records also indicate R1 has a history of skin integrity issues. Licensee indicated R1 developed a pressure injury in May 2019 after being hospitalized. In August 2019, facility staff observed R1’s wound became larger. S1 admitted cleaning the wound prior to a medical professional treating it.

On 8/12/19, Physician’s Assistant from Ideal Health visited the facility to conduct a routine wellness check on R1. Physician’s Assistant only observed the skin that was visible and did not check R1’s buttocks because staff did not report any issues with wounds at that time. On 8/13/19, facility staff notified the facility nurse consultant of R1’s wound. However, wound care was not ordered until 8/22/19, when R1’s physician submitted an order to Purity Home Health Services to provide wound care to R1’s sacrum and buttocks area. On 8/22/19, a home health nurse assessed R1’s wounds. The sacral pressure injury was determined to be a Stage IV. On 8/29/19, Purity Home Health Services provided the first wound treatment. The nurse noted the sacrum pressure injury and it’s dressing to be “very dirty with feces”. Facility staff were instructed to reposition R1 every 2 hours. Purity treated the wounds on 8/29/19 and 8/31/19.

On 9/3/19, Omni Wound Physicians began treating R1’s wounds. The pressure injuries were now a Stage IV on the sacral area, a Stage III on the right buttocks and a Stage III on the left buttocks. Omni recommended R1 be evaluated at the hospital. Medical records from Southern California Hospital at Hollywood indicate R1 was admitted to the hospital on 9/5/19 because of a Stage IV pressure injury on the sacral area and acute metabolic encephalopathy. The chief complaint was being lethargic. R1 was admitted to the intensive care unit for septic shock among other conditions. R1 had multiple infections including a UTI and pneumonia.

Facility staff argue home health nurses never left documentation describing the condition of the wound and never notified staff the wounds had worsened. Despite facility staff continuing to provide assistance with R1’s diaper changes.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. Administrator, Antoinette Richardson refused to find. A copy of the report and appeal rights were provided. The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(d); if the department determines the injury of the resident is due to severe neglect.