Complaint Investigation Report

The investigation revealed the following: Regarding allegations: Resident developed a pressure injury due to staff neglect, Facility staff did not seek timely medical attention to resident in care, and Staff did not notice a change in resident conditions. It is alleged R1 was diagnosed with unstageable wounds that developed at the facility for which R1 needed immediate hospitalization and facility staff did not notice the wound. On 10/31/23, R1 was visited at the facility by an occupational therapist. The occupational therapist had been providing services for movement and during the therapy noted the wound on the left heel. Occupational therapist informed facility staff and R1’s representative. R1’s representative contacted a wound specialist to evaluate R1. On 11/1/23, wound care doctor visited R1 at the facility and observed a 2cmx2.3cm sore on the left heel which was noted as “unstageable due to the presence of eschar covering the entire wound with no blood or drainage”. Wound care doctor recommended that R1 be taken to an “acute hospital for further evaluation”. R1 was taken to the hospital where the wound on the left heel was unstageable, measured at 3cmx3cm, and according to the physician the wound is at least Stage III, since it would take weeks to months for a wound to grow black eschar over the wound.

Interviews with staff revealed facility’s caregivers, med-tech, memory care director, and wellness director were aware of R1’s change in condition. Staff stated to have notified R1’s representative after they had noticed redness in the left heel. Although staff did not provide a clear date of when it was noted, staff stated the wound was observed for about 2 weeks. Staff also stated to not be trained to take care of wounds or prevention of wounds. Documents reviewed revealed, on 9/2/23, R1 complained of leg pain and contacted R1’s representative. A house doctor visited R1 and no signs of wound were noted during that visit. Based on the documents reviewed and interviews conducted, the facility staff were aware that R1 had developed the wound on the left heel while providing assistance with showers and assistance with activities of daily living. Staff noticed the wound, reported it to management, and R1’s representative. However, facility staff failed to obtain medical attention for R1 for at least 2 weeks, resulting in R1 obtaining an unstageable wound which measured 3cmx3cm.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.