Complaint Investigation Report

On 9/23/20, client was diagnosed with two Stage 3 wounds. On 10/5/20, Department of Developmental Services (DDS) and regional center approved the support letters for treatment of client’s wounds at the facility. From 9/18/20 – 9/23/20 client did not obtain care for the wounds because there was no official diagnosis and there was no treatment plan. Therefore, facility delayed medical treatment to client for 5 days. Based on the information obtained, the allegation is substantiated.

Allegation: Staff did not meet client's needs. C1 had ongoing issues with his/her bladder and constant urination. The use of a Purewick system, which is a urine collection system that works outside the body and helps keep the skin dry, was discussed with the facility. There were financial barriers and there was an insurance process to go through. The facility never obtained the Purewick system which could have assisted C1’s skin to repair quicker. Also, C1 had a broken wheelchair for months which facility never had repaired. This caused C1 to spend the majority of time in bed. Facility staff reported that COVID-19 caused the delay in obtaining these items. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided.