Complaint Investigation Report

ALLEGATION: Resident has multiple pressure injuries.

It was a lleged resident has multiple pressure injuries. The investigation revealed the alleged victim, Resident #1 (R1) moved into the facility on 1/18/2012 with no injuries and no history of skin conditions or breakdown. R1 was not receiving home health services and hospice care. Medical records show on 9/27/2013, R1 began to visit a dermatologist for a left ear health condition and underwent an outpatient skin surgery on 12/14/2019. Investigator Kujawa interviewed Staff #1 (S1), who revealed that R1 refused to eat and became weak after surgery. S1 denied R1 had pressure injuries during interview. S1 stated on 12/19/2019 she called 911 and paramedics took R1 to Providence Little Company of Mary. Medical records indicate R1 was admitted to the hospital for generalized body weakness, loss of appetite, and multiple pressure injuries. On 12/20/2019, R1 was transferred to Providence Little Company of Mary Skilled Nursing Facility (SNF) and was treated for multiple pressure injuries including R lateral hip – Stage 3 – measuring: 3.1x3.1cm; Right IT – Stage 2/Unstageable – measuring: 1.9x1.5cm; L dorsal 2 nd toe – Unstageable – measuring 4x1cm . On 12/25/2019, medical records show R1 was placed on hospice care.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed Stage 3 and Unstageable pressure injuries while in care , therefore the above allegation “Resident has multiple pressure injuries” is found to be SUBSTANTIATED .

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (ref. LIC 9099D) and civil penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to House Manager, Catherine Espino.