Complaint Investigation Report

197608267-11-5-2021-31-AS-EMIR-C9SL8B-20211217073138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 21731 VENTURA BLVD., STE. 250

This is an official report of an unannounced visit/investigation of a complaint received in our office on

07/14/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20200714171154

Resident has multiple unstageable pressure injuries

Licensing Program Analyst (LPA) Pitz initiated a complaint investigation visit on this day for the purpose of delivering the Investigation Branch’s (IB’s) findings on the above allegations.

Allegation #1, that “Resident has multiple unstageable pressure injuries”, has been substantiated based on the records reviewed and the credible nature of the reporting party. During the course of the investigation, it was revealed that former Resident #1 (R1) indeed sustained several pressure injuries during their stay at the facility. Per medical documents obtained during the investigation, it was indicated that upon admission to Northridge Hospital Medical Center on 7/5/20 R1 had sustained two “unstageable” pressure injuries on their back, as well as an unstageable pressure injury on their right heel and sacrum. While residing at the facility, R1 was receiving home health services for wound care prior to being hospitalized but was not on hospice. The reporting party, a credible source, stated that the wound “could have been preventable if resident was regularly turned and cared for appropriately.”

An exit interview was conducted with the Administrator, and a hard copy of the report and appeal rights was delivered.