Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation, Resident developed pressure injuries due to lack of care and supervision , the investigation is as follows: On August 18, 2025, R1 was found to have a stage 3 pressure injury on the coccyx, measuring 3cm x 4 cm x 0.3 cm; a linear ulceration on the left posterior thigh (probably friction and moisture related), measuring 0.5cm x 7cm x 0.2cm, and an unstageable pressure injury on his right heel, measuring 3cm x 4cm x unknown depth. The facility first noted an open wound on R1’s right heel and a pressure injury on his coccyx on August 11, 2025. During interviews, facility caregivers admitted that they were not repositioning R1 in his wheelchair and that the wounds were likely the result of continuous sitting on the wheelchair with his heel pressed against the footrest or floor. On August 13, 2025, R1’s coccyx pressure injury was documented at stage 2, measuring 5.2cm x 1.3cm, but measurements for the heel wound were not documented. The facility only arranged for R1’s hospitalization for assessment after his daughter/Power Of Attorney (POA) requested it, but by this time, the wounds had progressed to greater than stage 2. On August 18, 2025, R1 was admitted to Kaiser Anaheim Hospital due to multiple newly discovered pressure injuries that were not reported to his POA.

Based on staff admissions, following the discovery of these wounds, R1 continued being placed in his wheelchair, at his request, but was not being repositioned in it. The allegation that R1 sustained stage 3 and unstageable pressure injuries because of facility neglect is therefore Substantiated.

Regarding the allegation, facility did not seek medical attention in a timely manner, the facility was aware at least one full week before R1’s hospitalization, that resident had developed pressure injuries. Based on records obtained, Staff 1 (S1) was the first caregiver to document a “blister” on R1’s right heel, which was observed while providing R1 a bed bath on August 11, 2025. Per progress notes, Staff 2 (S2) documented on the progress notes that S1 reported having observed an “open wound” on R1’s right heel while providing a bed bath.