Complaint Investigation Report

On 09/22/2020, from 11:35 a.m. to 1:35 p.m., LPA Jeffries conducted the initial complaint visit telephonically with Executive Director/Administrator, Michael Mayfield. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted telephonically and through FaceTime. LPA Jeffries conducted a physical plant tour from 11:35 am to 1:35 pm and requested copies of pertinent documents relevant to the investigation and took photographs of Resident 1’s (R1) room.

During Investigator Rippe’s investigation, interviews were conducted, medical reports were obtained and reviewed. Investigator Rippe conducted interviews with R1’s responsible party on 10/06/2020 at 7:25 a.m. and 12:20 p.m.; and with R1 at 12:02 p.m.; with staff on 10/15/2020 at 1:00 p.m.; with Regional Director of Operations on 10/20/2020 at 3:16 p.m. and on 10/22/2020 at 10:07 a.m.; with staff on 10/22/2020 from 11:26 a.m. to 12:47 p.m.; with the Executive Director/Administrator on 10/29/2020 at 8:56 a.m.; with staff on 11/04/2020 at 12:57 p.m.; and with staff on 11/13/2020 from 8:37 a.m. to 3:21 p.m.

On the allegation: Resident sustained multiple pressure injuries while in care - The Wilshire Home Health (HH) reports for September 2020 stated that R1 had a stage two pressure injury on right buttocks, a stage one pressure injury on sacrum, and a stage one pressure injury on coccyx area. According to the last report from HH on 09/29/2020 the pressure injuries has been staged as a 3 by a Medical Doctor. Based on this information, the Department has sufficient evidence to support the above allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Resident’s diapering needs were not being met- HH records revealed on 08/25/2020 R1 was assisted in brief change during transfer to toilet resident was soiled with stool and HH staff held a conference with the facility staff Medication Technicians (MT) and Resident Assistants (RA) about R1 not being aware of loss of control and asked staff to visually inspect briefs for adequate hygiene and infection process.