Complaint Investigation Report

LPA obtained records of Home Health and of the Staff Daily Log. Documents revealed that Staff didn't reposition R1 every 2 hours as instructed resulting in an unstageable pressure injury. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not seek timely medical attention for a resident.

It was alleged that staff did not seek timely medical attention for R1. On 09/10/23 R1 was taken to the hospital by a family member and was diagnosed with UTI, sepsis, and pressure injuries. S1 denied the allegation. Interview with S1 revealed that facility staff didn’t know the stage of the wound. S1 stated that there was a miscommunication between home health and facility staff. Interview with S2 revealed that they were unaware of R1's medical condition and that resident's medical conditions are being supervised by S1. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not adequately bathe a resident

It was alleged that staff did not adequately bathe R1. Interviews with 4 out of 4 staff denied the allegation. Records review indicated that R1 had received a one time shower since their admission at the facility. S2 stated that facility staff failed to document daily showers and thus S2 conducted an in-service training to address the issue. Based on information obtained the allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted, appeal rights given and copy of this report signed and delivered.