Complaint Investigation Report

Allegation #1 : Resident sustained a pressure injury while in care.

This complaint alleges that R1 sustained a pressure injury while in care : the investigation revealed that Resident #1 formed a Stage III pressure injury on its coccyx beginning 08/23/21; and it quickly progressed to Stage IV by 09/02/21. Resident #1 had been receiving hospice care since 03/03/21 for an unrelated issue. Facility staff were instructed to reposition Resident #1 every two (2) hours due to the resident’s status of Bedridden. The wound worsened over the next week – while the resident continued to reside in the facility – with no new hospice care plan or wound training. The facility was directed to reposition Resident #1 every two (2) hours; but according to Witness #1 (Hospice Care Nurse), the reposition chart was not being followed; and, it had missing initials in spaces where the resident was supposed to be turned and its pressure injury was listed as Stage IV by 09/02/21. Resident #1’s health was in decline and the facility continued to retain Resident #1 with a prohibited health condition until its passing on 09/03/21.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”