Complaint Investigation Report

The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris on 05/26/2020. Investigator Ferris conducted interviews with staff, residents and witnesses on 07/14/2020, 07/20/2020, 07/26/2020, and 08/05/2020. Investigator Ferris obtained copies of R1’s medical records from Northridge Hospital Medical Center on 06/24/2020; from Kaiser Permanente Panorama City on 06/18/2020; from Physician’s Preferred Hospice Care on 07/14/2020; from Omni Wound Physicians on 07/29/2020; and Astoria Nursing and Rehabilitation Center on 07/30/2020.

On 07/15/2019, R1 was admitted to Astoria Skilled Nursing Facility due to multiple falls and non-compliance with medication regimen and home safety recommendations. R1 lived in own home prior to being admitted and refused to transition out of home or hire caregivers. A report for self-neglect was filed for R1 in January 2019 and again on 07/15/2019. R1 was discharged on 08/19/19 with diagnosis of right heel deep tissue injury and admitted to the Granada Golden Years facility.

Information in the Hospice records indicated R1’s start of hospice care was 08/30/2019 and end of care date was 10/04/2019, the day R1 was admitted to the hospital. Hospice nurses provided wound care to R1 every 3 to 4 days. It was also noted that R1’s family were in communication with the hospice agency and aware R1 was receiving hospice services.

Information reviewed in the OMNI Wound Physicians report indicated on 09/11/2019, R1 was treated for chronic wound to bilateral posterior heels as R1 was unable to move both lower extremities; left heel, pressure ulcer stage 3-chronic; pressure ulcer stage 4-chronic. A bilateral vascular study of the lower extremity arteries was performed for signs and risk faction of peripheral vascular disease (PVD). The study indicated non-compressible arteries on both extremities. High complexity, treatment course is prolonged due to sustained inflammation vascular factors-immobility. Staging care due to poor wound progression. R1 was seen again on 09/17/2019 where left buttock pressure ulcer stage 3 was added to the diagnoses and treatment plan. R1 was seen again by the wound care nurse on 09/24/2019 and 10/01/2019.