Complaint Investigation Report

The review of the records revealed the following: R1 was hospitalized on 03/23/2021. Upon admission, R1 was diagnosed with septic shock and acute organ dysfunction and diagnosed with unstageable pressure injury on coccyx, an unstageable pressure injury on left and right heels, deep tissue pressure injury on ischium, a stage III pressure injury (vs trauma) on the leg, deep tissue pressure injuries on the left and right hips, and a deep tissue pressure injury on the left lateral posterior back. Hospital records also documented that R1 was bed bound since sustaining a hip fracture 02/17/2021.

Interviews conducted by Investigator Real revealed the following: Administrator and staff were not aware of R1 having pressure injuries prior to hospitalization; however, when interviewed the administrator recalled seeing some “bedsores” on R1’s back. According to the administrator, the pressure injuries were initially open but improved over time and closed. Administrator did not provide approximate time the pressure injuries were observed, or documentation related to the care of the pressure injuries. Additionally, Staff 1 (S1) recalled seeing an injury on R1’s buttocks but did not recall if it was open or closed. R1 received home health services from 02/26/2021 to 03/08/2021 however the services did not include wound care. Home health care staff did not identify pressure injuries.

Information obtained during the course of the investigation revealed that R1 developed pressure injuries on or after 03/08/2021. R1 did not receive care for the pressure injuries from a physician or skilled medical professional until being hospitalized on 03/23/2021, therefore the allegation of neglect/lack of care and supervision is substantiated.

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 Discussed / A Copy of the Report Issued.