Complaint Investigation Report

It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained an unstageable wound on their tailbone at the facility. Per R1’s UCI Medical Records, on July 15, 2024, R1 was admitted to the hospital and diagnosed with a 2.5 centimeter by 2.5 centimeter unstageable bed sore on the tailbone which is black in appearance. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and is incontinent. R1’s undated Appraisal/Needs and Services Plan indicates R1 is incontinent, uses diapers, and requires staff to change their diapers. Four staff described that R1 needs assistance with all activities of daily living and spends a majority of their time in bed. Based on this information, R1 was at risk for developing pressure injuries. Three staff stated that residents are repositioned and checked for skin conditions every two hours, as well as during clothing changes, diaper changes, and showers, but no body check logs are maintained and instead any issues are reported verbally to the medication technician. Staff #1 (S1), who changed R1 at least once during the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, denied seeing any wounds on R1, but also denied that they were properly repositioning R1 because R1’s body is very rigid. Staff #2 (S2) stated they noticed a quarter-sized red wound on R1’s tailbone around July 8, 2024, they reported it to Staff #4 (S4), the facility’s medication technician, and they put cream on the wound but were unable to tell if the wound was improving. S4 claimed they first learned of R1’s wound on July 15, 2024, confirmed they are not qualified to provide wound care, and stated that when they learned of R1’s wound on July 15, 2024, they reported to Witness #1 (W1), a third-party nurse who was present at the time. W1 stated they have previously provided treatment for R1’s occasional rashes, on July 15, 2024, they were advised by S4 of R1’s wound, they were unable to assess the wound due to R1 having a separate injury which required transfer to the hospital, but they were able to place a bandage on the wound prior to R1 going to the hospital. R1’s Nurse Progress Notes, which date from May 18, 2024, through R1’s hospitalization on July 15, 2024, do not document that any wounds were noticed or treated. Based on the information obtained, facility staff were not properly repositioning R1 and did not obtain assessment or treatment for R1’s wound for a week after its discovery around July 8, 2024.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.