Complaint Investigation Report

On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. On 10/09/2024, the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m.

On the allegations "Staff admitted a resident with a prohibited health condition" and “Staff did not perform appropriate assessment for a resident”; it is the concern of the reporting party (RP) that Resident #1 (R1) was admitted to the facility on 02/19/24 and then asked to leave the facility the following day on 02/20/24 due to wounds that might violate licensing requirements. RP further reported that the wound in question was located on the residents’ leg, and they were Venous stasis and not a pressure wound, however the Administrator at the time believed they were a stage 3 pressure wound. Lastly, the RP reported that the facilities Administrator and additional staff had performed a pre-placement assessment on R1 prior to admitting them and should have caught the prohibited health condition if it was a stage 3 pressure wound. To investigate the allegation the LPA conducted a file review and interviews.

A review of R1’s head-to-toe assessment form for any physical change, dated 2/14/2024, and completed by facilities Administrator and Retirement Counselor indicated that R1 had sign of redness or sore around the ankle area, however it did not indicate if it was a pressure injury. Additional assessment forms signed by previous Administrator Gary Lee indicated that they did not have any concerns regarding R1’s care plan. A review of R1’s physician’s report, dated 02/13/2024, indicated R1’s primary diagnoses was listed as cellulitis of left upper limb, and secondary diagnosis was listed as chronic kidney disease, stage 3A. The report indicated R1 had mild cognitive impairment, was able to follow instructions as well as communicate needs, and had history of skin condition or breakdown. R1’s physician report did not indicate any pressure injuries. A review of R1’s, Shoreline Care Center, skilled nursing facility records, dated 02/19/2024, obtained from Glen Park at Ojai indicated some of R1’s diagnoses were listed as cellulitis of left upper limb, venous insufficiency (chronic), non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, among other diagnosis, however pressure wounds of any stage were not listed as a diagnosis.

Interviews with Administrator Gary Lee revealed that on 02/14/24 they and the Retirement Counselor had performed a pre-placement assessment on R1, prior to admitting them to the facility. Administrator Gary Lee revealed they looked for injuries, they did a head-to-toe, and looked to see if R1 had any open skin.

Report will continue on LIC9099-C (3rd page).