Complaint Investigation Report

physical health status: “history of skin condition or breakdown- YES “buttocks.” Ambulatory status: non-ambulatory.

On 5/05/2021 LPA Brown interviewed Administrator, Miki Lamm; she indicated that R1 was on home health with Torrance Memorial Home Health, the request was made on 11/20/19. First pressure injury was observed on 11/21/19 which was located on residents left heel. On 11/27/19 resident was admitted to Torrance Memorial Hospital due to shortness of breath. LPA Cardenas conducted resident file review and there is no available evidence that Home Health was treating R1’s pressure injuries. There isn’t documentation of a Home Health care plan with a start date for pressure injuries. LPA Cardenas interviewed Lamm, and according to the administrator the resident’s Physician “did not want to place the resident on home health .”

Per Medical records from Torrance Memorial Medical Center Hospital Progress Note from 10/21/19; Reason for visit: RESPIRATORY INFECTIONS & INFLAMATION W MCC & MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS. Diagnosis Pneumonia. Pressure Ulcer present on admission, Other: BUTTOCK/SACRUM/ COCCYX, Stage I; Wound Care Consultation 10/21/19; discharged 10/22/19. Resident given patient education materials, prescriptions, and follow up with your Physician within two weeks of discharge.

Facility Staff#7 (S7) stated to TMMC that, Patient was supposed to be on service with Dynamic Home Health upon discharge from Torrance Memorial Medical Center on 10/22/19. However, Dynamic Home Health only came out once and then patient was discharged due to insurance problems. Since 10/22/19, S7 states that no Home Health has been coming out to manage wounds. Patient is being followed by Primary Care Provider (PCP).

On 11/28/19 Resident was admitting into the hospital diagnosis is Respiratory Infections & Inflammation. Also present were Pressure Ulcer of Left heel - Stage 3; Pressure Ulcer of Right heel – Unspecified Stage; Pressure Ulcer of Sacral Region – Stage 2.