Complaint Investigation Report

Hospital records noted R1 presented with 4 pressure injuries. On 11/4/2021 the hospital completed a referral for home health care. Hospital records also documented that facility was instructed to reposition R1 every 2 hours. On 11/5/2021 a Initial Evaluation/Assessment was completed by Infinite Home Health. Upon completion of the evaluation/assessment R1 was diagnosed with a stage 2 pressure ulcer of right ankle, and a stage 4 pressure ulcer rt lateral malleolus. Home health records document that after every visit the facility home health staff “reinforced frequent change of position and diaper.” Staff verbalized an understanding to the home health nurse.

R1 was again hospitalized on 11/13/2021 at which time R1’s pressure injuries were assessed and documented to have worsened and the following pressure injuries were noted: unstageable left heel, stage 4 right lateral malleolus and a healing Stage 2 right elbow.

On 12/2/2021 from approximately 1:30 to 2:30 pm Investigator Zertuche conducted interviews with the assistant administrator Rima Araronyan, facility staff and residents. When interviewed Ms. Araronyan denied knowledge of the pressure injuries being over stage 2. Additionally, Ms. Araronyan admitted that staff did not reposition the resident because he was refusing and was able to turn himself, however facility and medical records document that R1 has no movement on his right side at baseline and was bed bound. Staff did not document the refusal, did not notify R1’s physician or home health agency.

On 2/3/2022 LPA Avetisyan called Canyon Oaks Nursing and Rehabilitation and spoke with the Case Manager who confirmed that R1 did not have any pressure injuries when discharged from their facility.

Information obtained during the course of the investigation confirmed that R1 developed pressure injuries while living at the facility. On 11/5/2021 the right lateral malleolus pressure injury was diagnosed as a stage 4 which is a prohibited health condition. Licensee/administrator and staff failed to follow hospital/home health instructions to reposition R1 which resulted in the pressure injuries worsening therefore the allegation is Substantiated.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).