Complaint Investigation Report

Hall reported that C1 ran out of prescribed ointment cream back in June of 2023 but did not follow back up with the doctor’s office. Instead, Hall continued to purchase over the counter cream for C1’s wounds and four of four caregivers confirmed providing care for C1’s wounds despite them not being a skilled trained professional. Hall reported she felt the over the counter creams worked better than the prescribed creams.

Staff 1 (S1) reported sending Hall pictures of blood in C1’s stool but was told to give C1 Imodium and Pepto-bismal without reaching out to C1’s doctor. Staff further reported observing liquid for C1’s colonoscopy in the fridge but never being told by Hall to administer it to C1. Hall did not follow through with C1’s scheduled colonoscopy appointment. Hall was asked by Orange County Regional Center (OCRC) to provide documentation of C1’s doctor appointments but failed to provide requested documentation.

Hall stated a few months prior C1 was going a few days without passing stool followed by having chronic bouts of loose stool. On 08/02/2023 Hall took C1 to see her Primary Care Physician where they noticed C1 had pressure injuries that needed to get looked at.

C1 was taken to OC Global Medical Center. Upon being admitted, C1 was found to have multiple stage three and stage two pressure injuries including wounds on the upper right back, bilateral left and right foot and sacral area and stage two wounds on right and left gluteal area gallstones. The OC Global Medical Center wound care nurse further found scar tissue around the wounds from old healed pressure injuries resulting from infrequent repositioning. In addition to the wounds, C1 was diagnosed with pneumonia and blocked stool causing a leakage. C1 was placed on a feeding tube as a result of the pneumonia in an effort to give C1’s throat a rest to recover. C1’s wound care nurse from OC Global Medical Center, Primary Care Physician and Dermatologist all confirmed C1’s pressure injuries were unrelated to C1’s pre-existing skin condition.

Interviews with four of four staff and Hall confirmed C1 often would sit in the living room watching TV. Interviews with OCRC reported asking Hall to sign C1 up for a day program but that Hall never did. Hall reported she could not sign C1 up for a day program as all day programs were closed in 2020 due to the Covid pandemic; however, after approximately a year upon reopening C1 was still not signed up for a day program as requested by OCRC. Hall reported delaying C1’s enrollment due to needing to get C1 a California Identification Card and wanting to enroll C1 and the other facility clients all in the same day program.