Complaint Investigation Report

The investigation revealed the following:

Allegation: Resident sustained multiple pressure injuries due to staff neglect (investigated by IB)

It is alleged that the facility’s neglect caused the resident R1, tosustain a fever, diarrhea, pressure ulcers in his heels/ coccyx, and sepsis while in care at the facility. This allegation was investigated by Investigations Branch (IB) investigator D. Seng which revealed the following:

Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility’s neglect led R1 to sustain to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. R1 was placed at the facility from 04/01/2025 to 05/05/2025. Per my interview with the facility staff, R1 was repositioned at least once every two hours. He/she was on home health and received two visits weekly via his Neo Gen Registered Nurse, who was directly responsible for his/her wound care. RN stated that R1 sustained stage two pressure ulcers to his/her right and left buttocks on 04/02/2025 and these wounds never progressed to a stage three or above at any time while R1 was at the facility. RN added that R1 was discharged to Kaiser on 05/05/2025 and his/her pressure ulcers only became worse during his/her stay at Kaiser.

R1’s PCP stated that the facility would not have any way to know if he/she was septic unless there were

laboratory tests conducted. PCP added that they was in communication with R1 and had a phone encounter with him/her on 04/23/2025. W2 and R1’s PCP added that it was difficult to prevent sepsis or the pressure ulcer on his/her coccyx due to R1’s gunshot wounds, his/her lack of mobility, and his/her catheter. The staff stated that they would contact R1’s PCP/ Wound Care Nurse/ R1’s family immediately when there was a change of condition. Based on the evidence and interviews conducted, the allegation of Neglect/ Lack of Supervision was unsubstantiated.