Complaint Investigation Report

The investigation findings revealed that R1 had been living at this facility since April 07, 2024. Upon R1’s admission to the facility, R1 was noted to have stage 2 pressure injuries near the buttocks in which both staff and the administrator acknowledge. Because of this condition, R1’s responsible party admitted R1 to A1 Palliative and Hospice on 04/09/2024. Approximately mid-April 2024, the LVN from A1 Hospice agency ordered wound specialist for R1 who visited R1 only once at the facility. Although interview with a witness revealed that A1 Palliative and Hospice Care were responsible for providing wound care to R1; and due to staff shortage the agency was unable to provide sufficient wound care to R1, it was facility’s responsibility to contact the resident primary care doctor for alternative medical attention.

On 05/12/2024, due to a medical emergency, R1 was admitted to Northridge Hospital where it was discovered that R1 had developed stage 3 through unstageable pressure wounds. Prior to re-admitting R1 back to the facility on 05/15/2024, facility staff failed to do a reassessment for R1. Therefore, the Administrator failed to get R1 on proper medical attention or assist with obtaining a wound specialist to address these issues. Subsequently on 05/19/2024, R1 was re-admitted to the hospital and review of hospital records revealed that R1 beside having stage 3/unstageable pressure wound injuries she/he developed maggots in their wounds. Based on the interviews conducted and supporting documents provided regarding R1’s pressure injuries, the facility retained R1 knowing his/her pressure injuries were worsening and failed to seek medical attention in a timely manner. There is sufficient evidence to support the allegation of Neglect/Lack of Care and Supervision; there for the finding(s) are substantiated.