Complaint Investigation Report

Allegation: Staff failed to provide adequate supervision resulting in resident sustaining pressure injuries :

It was reported to Community Care Licensing that on 02/28/2022 the facility notified Resident (R1)’s responsible party of pressure injuries on R1’s feet. On 02/24/2022 Home Health indicated R1 developed: one stage III pressure injury, one un-stageable deep tissue injury and one intact blister. Interviews conducted revealed, R1’s wounds were quite deep and were likely not to have developed within one or two days, staff should have observed the initial start of the wounds if they had provided adequate supervision. In addition, interviews with relevant parties indicated such injuries would not have resulted on R1, if staff were to have given R1 proper body positioning.

As a result of resident (R1)'s injury, the violation warrants a civil penalty assessment based on Health & Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.

Allegation: Staff did not follow resident's care plan:

Review of facility records revealed a lack of required documentation to ensure R1’s care plan to meet their needs. Administrator did not do a proper pre-assessment of R1 prior to admitting R1 to L & S Gentle Care II. R1 is a 2-3 person assist and the facility did not have the proper fire clearance approval to admit or retain R1 due to their ambulatory status.

Allegation: Staff did not inform resident's authorized representative of resident injuries:

It was reported staff did not inform resident (R1)'s authorized representative of an incident. The unreported incident resulted in R1 sustaining a contusion on their lip and resulted in R1 needing oral surgery. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. Staff interviews stated they were unaware if R1 sustained any falls or direct hit to R1's face that resulted in a contusion and oral surgery.

It was reported staff did not seek timely medical attention after R1 sustained an injury resulting in a contusion on their lip and oral surgery. Staff statements indicate they did not witness if R1 fell or that they were hit on the mouth. Interviews with relevant parties indicated R1's lip contusion resulted from a fall or direct hit to R1's mouth. R1's medical records indicate R1 was non-ambulatory at the time, was not able to walk independently and requires a 2-3 person assist. Staff statements indicated they notified R1's representative when R1 was found chewing on one of their teeth. Staff statements indicated they believed R1's tooth "just fell out" on its own. Staff then notified R1's representative, however staff did not seek medical assistance for R1's contusion. Report continued on LIC9099-C