Complaint Investigation Report

During a separate incident, R1 was found unresponsive on 9/2/2021 at the facility and was then taken to the hospital for medical care where R1 was observed to have bruising on the left inguinal (outer left hip) area and ecchymosis at the umbilical area. In addition, medical records for R1 identified and photographed a bilateral pressure injury on R1’s buttock after being admitted to the emergency department after being found unresponsive on 9/2/2021. Staff (S1) did state they were aware of a pressure injury on R1’s buttocks but did not document nor report it because S1 saw “white cream” on it which S1 believed the Med Techs were using to treat it. Interviews with Med Techs, Nurses and supervisors all stated they were unaware of the pressure injuries on R1’s body. Facility records show no documentation of R1 having a pre-existing pressure injury upon admittance at the facility.

Based on the departments record review, interviews with staff and outside parties the allegations that Staff did not seek timely medical care for resident in care and Neglect/Lack of Supervision resulting in resident sustaining multiple injuries are substantiated. The preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED.

An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. Additional Civil Penalty pending review per H&S Code Section 1548(d).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.