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32 | Records (MARs) and interviewed the Current House Manager / Angelito Bajita.
The investigation revealed the following;
Allegations: Resident sustained pressure injuries while in care, Facility retained a resident with a prohibited health condition, Facility did not provide resident prompt medical treatment, and Facility did not maintain accurate resident’s records.
During the course of this investigation, DS obtained and reviewed R1's medical records and facility file and conducted interviews with investigatory leads. The outcome of the investigation revealed that R1 was admitted to Los Angeles Community Hospital (LACH) on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. R1 was also observed thin and frail. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) (prepared by RN Maria Aguilar), show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries. Staff were not aware of the six pressure injuries R1 had developed during his stay at Cogswell Garden Home. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for lack of documentation and failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. Based on the information gathered by DS, there is sufficient evidence to support the above allegations to be true.
(See LIC 9099C for additional information) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
87609(b)(2) | 1
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7 | Allowable Health Conditions and the Use of Home Health Agencies. Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident | 1
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7 | Administrator will review Title 22 Regulations Section 87609 on Allowable Health Conditions and the Use of Home Health Agencies and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. |
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14 | receiving home health care. This requirement is not being met as evidenced by: R1 was admitted to Los Angeles Community Hospital on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. This poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | ***An immediate civil penalty is being assessed in the amount of $500.00.*** |
Type A
08/16/2023
Section Cited
CCR
87615(a)(1) | 1
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7 | Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not being met as evidenced by: | 1
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7 | Administrator will review Title 22 Regulations, Section 87615 on Prohibited Health Conditions, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date. |
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14 | Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
87465(a)(2) | 1
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7 | Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs.
This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure | 1
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7 | Administrator will review Title 22 Regulations Section 87465 on Incidental Medical and Dental Care and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. |
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14 | wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care. | 8
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Type A
08/16/2023
Section Cited
CCR
87465(c)(2) | 1
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7 | Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not being met as evidenced by:
On 8/15/23, LPA reviewed medications/Medication Administration Record (MAR) | 1
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7 | Administrator will review Title 22 Regulations, Section 87465 on Incidental Medical and Dental Care, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date. |
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14 | for Resident 4 (R4) and discovered that the Thick-It Powder (PRN) for R4 was missing at the facility. According to the Current House Manager, staff are administering Resident 5's (R5's) Thick-It Powder to R4 because R4's Thick-It Powder "ran out". This poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | Administrator will also order a Thick-It Powder (PRN) for R4 and submit proof of correction to CCL by the POC due date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/31/2023
Section Cited
CCR
87211(a)(1)(B) | 1
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7 | Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. | 1
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7 | Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and conduct an in-service training with all staff and submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date. |
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14 | Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not being met as evidenced by: Investigator / Dennis Seng
conducted an interview with the Administrator and the Administrator admitted that facility staff failed to report the hospitalization and pressure injuries involving R1 to CCL. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
08/31/2023
Section Cited
CCR
87411(d)(1-6) | 1
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7 | Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance... | 1
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7 | Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements - General, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. |
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14 | This requirement is not being met as evidenced by: Staff and facility Registered Nurse (RN) / Nelia Aquino stated that there were no formal trainings conducted for Cogswell Garden Home staff to care and treat for the pressure injuries sustained on R1 and any other residents until after the incident involving R1. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries due to lack of training. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/31/2023
Section Cited
CCR
87611(b)(1)(A-D) | 1
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7 | General Requirements for Allowable Health Conditions. The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: Documentation from the physician of the following: (A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services; (C) Method of intervention; (D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance. | 1
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7 | Administrator will review Title 22 Regulations Section 87611 on General Requirements for Allowable Health Conditions, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. |
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14 | This requirement is not being met as evidenced by: During the course of this investigation, facility staff were unable to produce records showing that there was a care plan for the R1's pressure wound (right buttock area) and if staff were following the care plan. On 8/15/23, the Current House Manager looked in the file of R1 and was unable to produce a copy of a care plan for R1. This poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
08/31/2023
Section Cited
CCR
87506(b)(13) | 1
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7 | Resident Records. Each resident’s record shall contain at least the following information:
Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not being met as evidenced by: | 1
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7 | Administrator will review Title 22 Regulations Section 87506 on Resident Records, and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date. |
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14 | R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. This poses a potential health, safety or personal rights risk to persons in care. | 8
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