Complaint Investigation Report

Hospital Physician corroborated this information by explaining that the pressure injuries could have developed over the course of a few days, but not in a single day. This suggests that the injuries likely developed during R1’s residency at Gardens at Laguna Springs.

The Executive Director of the facility, Guadalupe Ramirez (S1), reported that R1 wore briefs that were changed after every meal or accident, and staff reportedly checked briefs every two hours. However, there was no documentation or staff reporting of any pressure injuries. Staff member (S3) stated that R1 wore pull-ups as a preventive measure, that R1 was sometimes incontinent, and that pull-ups were changed approximately three times per day.

A review of R1’s medical records obtained from the hospital confirmed the presence of multiple pressure injuries which were described as "community acquired," with moisture components noted on the sacrum, bilateral buttocks, scrotum, penis, and coccyx.

Based on the information gathered, the allegation that resident R1 sustained multiple pressure injuries while under the care of Gardens at Laguna Springs Memory Care is SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit.

Exit interview was conducted with Guadalupe Ramirez and a copy of this report and appeal rights were provided.