Complaint Investigation Report

Records (MARs) and interviewed the Current House Manager / Angelito Bajita.

The investigation revealed the following;

Allegations: Resident sustained pressure injuries while in care, Facility retained a resident with a prohibited health condition, Facility did not provide resident prompt medical treatment, and Facility did not maintain accurate resident’s records.

During the course of this investigation, DS obtained and reviewed R1's medical records and facility file and conducted interviews with investigatory leads. The outcome of the investigation revealed that R1 was admitted to Los Angeles Community Hospital (LACH) on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. R1 was also observed thin and frail. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) (prepared by RN Maria Aguilar), show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries. Staff were not aware of the six pressure injuries R1 had developed during his stay at Cogswell Garden Home. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for lack of documentation and failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. Based on the information gathered by DS, there is sufficient evidence to support the above allegations to be true.

(See LIC 9099C for additional information)