Complaint Investigation Report

Although, home health continued to treat the wounds for R1, medical records dated 09/28/2021 and 09/29/2021, report R1 was again admitted to the hospital and diagnosed with numerous stage III and unstageable wounds. Treatment was provided by the hospital, and R1 was discharged back to the facility.

Allegation #2: It was alleged that resident’s pressure injury developed maggots while in care. According to the medical report reviewed by LPA, dated 07/09/2023, R1 was admitted to the hospital and diagnosed with pressure injuries of the foot. Home Health was ordered, and treatment started 07/16/2021 for the right heel, and right lateral foot, 3x a week. Medical records dated 09/09/2021 through 09/10/2021, report hospital discovered maggots in R1’s heel. R1 was treated and discharged back to the facility. Records show while in the care at the facility, R1’s skin condition and wounds were getting worse and not healing. Facility continued to allow R1 to reside at the facility, when R1 developed a prohibited health condition. From 10/09/2021 through 10/15/2021, R1 was admitted to the hospital and eventually transferred to a SNF for further treatment of wound care for ulcers of right foot, as well as other health related issues. Therefore, based on medical review and records, LPA determined both allegations are SUBSTANTIATED. This poses as a immediate health and safety risk for residents in care.

The following deficiencies were cited per CA Code of Regulations Title 22 – see attached 9099D; and immediate $500 civil penalty will be issued.

An exit interview was conducted, a copy of this report and appeal rights was provided.