Complaint Investigation Report

However, it is noted that R1 was receiving hospice services effective August 11, 2022, and at that time, Hospice Nurse indicated R1 has wounds to bilateral heel, left foot, left arm and right hip. It is also noted that facility staff acknowledged at the time that R1 had been declining for the past several months.

R1 was admitted to the facility on May 27, 2022. R1 was assessed as non-ambulatory and used a wheelchair for mobility. Physician assessment indicates R1 was fall risk and was lifetime wheelchair assist due to generalized weakness. R1 was also incontinent and needed staff assistance with toileting needs, including changing of incontinent briefs. In addition, R1 needed care and assistance with activities of daily living such as bathing, dressing, and eating. R1 did not have a history of skin breakdown, according to an assessment dated April 19, 2022. Staff #1 (S1) indicated that they were not aware that R1 developed any pressure injuries while in care. In addition, records review did not reveal R1 change in condition following any hospitalizations nor an update to R1 written record of care.

On August 17, 2022, R1 was admitted to the hospital for dehydration and malnutrition. Upon admission, medical records show that R1 was diagnosed as having multiple pressure injuries including right lateral hip and right ankle. R1 was reported to have right lateral hip eschar/pressure injury and right ankle pressure ulcer. Moreover, multiple additional wounds are noted on R1.

Based on investigation, it is concluded that there is sufficient evidence to substantiate allegation of staff neglect of R1. As documented, R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff did not provide the services needed by R1 to meet R1 needs. As a result, R1 sustained right lateral hip eschar/pressure injury, right ankle pressure ulcer and multiple additional wounds while in care. Furthermore, due to severity of R1’s pressure injuries, R1 was recommended at the hospital to consider surgery evaluation for right lateral hip wound debridement. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An immediate Civil Penalty in the amount of $500.00 is assessed. The licensee was informed that a civil penalty may be assessed based on Health and Safety Code 1569.49(f).

A copy of this report (LIC9099), LIC9099D, LIC421IM and Appeal Rights was mailed to facility’s designated mailing address