Complaint Investigation Report

On September 14, 2020, home health staff documented R1 had an unstageable pressure injury on their sacrum. R1 also had a stage 1 pressure injury to their left leg. Records indicated staff were educated on the importance of repositioning R1. R1 began receiving hospice services on October 3, 2020. A review of home health records noted that skilled medical professionals deemed the sacral pressure injury as a possible Kennedy Terminal Ulcer based on the rapid progression and location of the pressure injury. Per the National Institutes of Health, a Kennedy Terminal Ulcer is an unavoidable skin breakdown that occurs in some patients as part of the dying process. It often appears on the sacrum or coccyx. Interviews revealed conflicting statements regarding incontinence care and repositioning of R1. Interviews with outside medical professionals who visited the facility and observed R1 did not have concerns regarding neglect or unmet needs for R1. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R1’s medication. R1 passed away at the facility on October 13, 2020. According to the County of San Diego Certificate of Death, R1’s cause of death was listed as Alzheimer’s Disease.

A review of records revealed that R2 was bedridden and required assistance with all activities of daily living, including bathing, dressing, grooming, feeding, transferring, and incontinence care. R2 was diagnosed with a major neurocognitive disorder and was unable to communicate their needs. R2 began receiving hospice services from a hospice agency the day after being admitted to the facility. Interviews with staff indicated staff checked on R2 approximately every two hours to assist with repositioning and assisted R2 with incontinence care. Interviews with outside sources and records review revealed that R2 suffered multiple falls and continuous decline before entering the facility. Interviews with outside sources and outside medical professionals who visited the facility observed that R2 did not have concerns regarding neglect or unmet needs for R2. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R2’s medication. R2 passed away at the facility on October 10, 2020. R2’s cause of death was listed as Vascular Dementia and Cerebral Atherosclerosis. Outside source and residents interviewed regarding the language barrier, there are no concerns, and staff could communicate with residents in their preferred language.

Based on the investigation findings, the allegations made against the staff regarding: Questionable Deaths, Staff Mismanagement of Residents' Medications, Staff Failure to Meet Residents' Needs, Untrained staff, and Staff Unable to Communicate with Residents Due to a Language Barrier—are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with the director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and her signature on this report confirms receipt of the Licensee Rights.