Complaint Investigation Report

one (1) pressure injury to coccyx area was observed. Facility staff failed to notice change in C1’s condition.

IB’s investigation revealed the following: Per Slatic review of facility records: Unusual Incident Report (UIR) on 3/16/21 House manager contacted the facility RN to report that C1 was refusing meals and was lethargic. C1 primary care physician was unavailable, therefore C1 was taken to Little Company of Mary Medical Center -Torrance Emergency Room for an evaluation. Physician’s Report dated 2/1/2021 lists C1’s primary diagnoses as Profound intellectual disability, Parkinson’s disease, and diabetes. Secondary diagnoses include psychosis and generalized muscle weakness. C1 is not able to transfer independently to and from bed. Per most recent Individual Program Plan (IPP) is dated 12/3/20, C1 requires total assistance with Activities of Daily Living (ADL) skills such as dressing, bathing, hygiene, toileting, and grooming. The IPP nursing report dated 1/15/20 does not document any information about skin integrity issues. Per Body check chart for the period of 2/16/21 through 3/16/21 show that C1 was checked three times per day; no injuries or concerns were noted during this period.

Per Slatic review of the Little Company of Mary Medical Center -Torrance medical records: On 3/16/21 at 1243 hours C1 was brought Little Company of Mary Medical Center in a wheelchair due to decreased oral intake and weakness. At 1302 hours C1 was admitted to the Emergency Department. The initial exam found a Stage III decubitus pressure injury the size of a silver dollar on coccyx area. On 3/17/21 at 0229 hours, the notes indicate pressure injury was upgraded to a stage IV located on the coccyx area. On 3/22/21 at 1120 hours the pressure injury was listed as unstageable. C1 was noted to be bedbound, with Parkinson’s disease, dementia, with “functional quadriplegia”.

Per Slatic interviews; On 6/17/21 Slatic interviewed facility registered nurse, he contends that C1 did not leave the facility with a Stage 3 or Stage 4 pressure wound. On 6/24/21 Slatic interviewed caregiver S2 who denies observing skin breakdown. On 6/28/21 Slatic interviewed caregiver S3 who denies observing skin breakdown. On 3/22/21 LPA Jones interviewed Adriana Galeano who stated that staff conduct body checks 3 times a day and a pressure injury was never observed.

Based on interviews and records reviewed, the preponderance of evidence standard has been met. Hospital records dated 3/16/21 to 3/22/21 confirmed the initial diagnosis of a stage III pressure injury on the coccyx area during the admission. Pressure injury on the coccyx was later upgraded to a stage IV upon