Complaint Investigation Report

Based on medical records dated 7/29/23 at 3:48:46pm responsible party contacted home health, which is indicated in the report that facility was aware of pressure injury. However, the facility did not seek timely medical from 7/29/23 until 8/7/23 when R1 met with their primary care physician through a virtual appointment and was diagnosed with a stage 2 pressure ulcer on their right heel. On 08/09/2023, R1 was assessed by hospice care staff and was diagnosed with a stage 2 pressure ulcer on their right heel. The Department obtained R1’s care plan dated 5/3/23 indicating that R1 needs assistance with daily activities including toileting, showering, and dressing. LPA conducted interviews with staff who informed LPA that they verbally notified responsible parties including home health agency about the blister that popped up from R1’s foot supposedly due to their socks that were assumed that were too tight. Facility failed to seek medical treatment when they noticed that the blister popped up to stage 2 pressure injury. Based on the information obtained by the Department during this investigation and confidential interviews conducted with witnesses, staff did not contact R1’s physician to seek timely medical attention after concerns about R1’s pressure injury. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The Department will be reviewing to determine if additional civil penalties are wanted.

Regarding allegation about staff did not properly report an incident involving a resident. Per reporting party, staff did not notify R1’s responsible parties including the Department about R1’s pressure injury. Based on records review, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Administrator could not provide proof that incidents were reported to CCL. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. The Health and Safety Code is cited on the attached LIC 9099D. Appeal Rights Given.