Complaint Investigation Report

Regarding the allegation, “Staff did not address resident's change of condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Allegation: Staff did not prevent resident from developing a pressure injury.

It is being alleged that staff does not move or adjust Resident #1. Record review of R1’s Physician’s Report (07/03/25) revealed R1’s primary diagnosis necrotizing fasciitis, uses a wheelchair, and does not require continuous bed care. Record review of email correspondence (10/08/25-10/09/25) revealed S1 seeking home health or wound care services for R1. S1 indicated noticing redness on R1’s skin and would like a nurse to assess and provide preventative assistance. Review of Los Angeles Community Hospital (11/06/25) revealed R1 has a skin rash in sacral area and the plan was to consult a wound specialist. Review of Harbor UCLA Hospital Record (11/10/25) revealed R1 did not have rashes or lesions. Review of Los Angeles Community Hospital (11/13/25; updated 11/21/25) revealed R1 had a stage two pressure ulcer of sacral region. S2 indicated that upon admissions, R1 had a sore on R1’s back. It was cleaned, bandaged, and no longer there. S3 indicated upon admission, R1 had a rash. Interview with S2 – S3 indicated that R1 is repositioned every two – two ½ hours. S1 indicated R1 was bedbound around the last week of October. R1 could sit in a wheelchair but was always in bed. R1 could move left to right but was very tired from dialysis (three times per week). S1 indicated S1 looked for home health services for R1 but there was an issue with insurance. R1 was discharged from the facility on 11/16/25. R3 indicated R3 is able to reposition self. LPA observed R2 and R4 to be ambulatory.

Regarding the allegation, “Staff did not prevent resident from developing a pressure injury,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.