Facility Evaluation Report

Licensing Program Analysts (LPAs) Teresa Camara, Ashley Smith and Salia Walker initiated a Case Management – Incident visit today. Administrator Kathy Adedigba (Adedigba) was not available so LPAs met with back-up administrator Isaac Adeleke (Adeleke).

On 07/09/21, this facility submitted a Special Incident Report (SIR) noting staff found a pressure injury on the upper buttocks of client #1 (C1) while assisting C1 with showering. C1 was taken to an urgent care and then to the hospital where C1 was admitted. C1 was discharged from the hospital on 07/12/21 and set up with home health services for wound treatment.

On 08/14/21, this facility submitted an SIR noting on 08/12/21 they spoke with the home health agency as C1’s wound was smelling badly, but home health said that was not unusual. Staff took C1 back to the urgent care on 08/13/21, and they were instructed to take C1 to the hospital. C1 was admitted to the hospital for wound treatment and discharged on 08/20/21 with further home health wound care.

On 09/01/21, this facility submitted an SIR on 08/30/21, noting that C1 went to urgent care for a visit and learned C1’s wound progressed to a Stage 3. On 08/31/21, they took C1 back to the hospital. Abedigba notified the hospital physician that C1 cannot return to the facility as a Stage 3 pressure injury is a prohibited health condition. C1 was admitted to the hospital for wound care and discharged to a skilled nursing facility.

On 09/02/21, Adedigba submitted a copy of home health paperwork dated 08/04/21 which noted C1 had a Stage 3 wound on 07/27/21. During today's visit, a file review conducted at 12:30 p.m. revealed a note from a physician dated 08/13/21, which indicated C1 had a Stage 3 pressure injury that was not improving. This facility did not submit an exception for C1 to be retained with the stage 3 pressure injury.

Based on the investigation, there is sufficient evidence to support that C1 remained in the facility for several weeks with a prohibited health condition. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report issued.