Complaint Investigation Report

Instructions contained a notice for R1 to return the the ER if there was any increased redness, pain or swelling, and to return in 10 days to have sutures removed. Based on interviews conducted, a previous staff person felt it was the safer for R1 if they were stay in bed while recovering. Facility did not have any documentation whether the wound was cleaned or checked from 10/28/2023 to 11/08/2023. On 11/08/2023, R1 returned to the Hospital for suture removal and was admitted for an infection of the wound. Based on hospital records, R1 was found to have several new pressure injuries since the previous visit on 10/28/2023.

Based on interviews conducted, the staff responsible for resident care during this time frame left employment on 11/29/2023. LPA spoke with Administrator about changes that were made in facility operation to ensure residents are observed for changes and how staff are being trained. Administrator informed LPA they are communicating more frequently with resident care teams and responsible parties to ensure resident needs are being met.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

A copy of this report was left at facility and Appeal rights were given.