Allegation #1: Staff neglect led to resident sustaining infection wounds.

It is alleged that staff neglect led to Client #1 (C1) sustaining infection wounds. During the investigation LPA Casillas reviewed all SIR’s submitted to Community Care Licensing (CCL) and was able to follow a detailed timeline of how the injury progressed. Based on documentation and interviews with Administrator and two (2) staff, it was discovered that there was no initial wound on C1. The injury was originally reported on 06/01/24 to have some swelling. Upon staff discovering this, immediate emergency room medical attention was sought. As the injury progressed, an additional hospital visit was made on 06/08/24 and on 06/26/24, however facility staff were told that C1’s wounds were not serious. Per Administrator, they did not agree with that diagnosis and the staff took C1 to a different hospital for a second opinion on 06/26/24 when the injury developed an open wound, C1 was provided with antibiotics. On 06/30/24 C1 was admitted to the hospital due to staff observing the wound progress without getting better. On 07/05/24 C1 was released from the hospital back to the facility. Based on observations, record reviews and interviews the facility staff sought the appropriate medical attention for C1’s injury therefore, it is determined that this allegation is Unsubstantiated at this time

Continued on LIC9099-C

It is alleged that staff did not meet C1’s medical needs. It was reported that staff did not meet C1’s medical needs by accepting C1 back into the facility when C1 should have gone to a skilled nursing facility. LPA interviewed Administrator who stated that C1 was released to the facility from the hospital, but that staff was not made aware that C1 needed to go to a skilled nursing facility. LPA reviewed documentation obtained by facility on 07/12/24 at 10:01 am stating that upon discharge of C1 on 07/05/24 from the hospital, C1 should have been released to a skilled nursing facility. During the reappraisal done by the Administrator on 07/05/24 at the hospital, the hospital staff failed to inform the Administrator that C1 was to be released to a skill nursing facility. On 07/05/24 three (3) staff members were trained by a licensed medical professional in order to provide wound dressing changes on C1’s wound, per Title 22 Regulation. During the days between C1’s discharge and being readmitted to the hospital the facility staff made numerous attempts to get the hospital to release documentation regarding the home health authorization. It was only until the facility staff received this documentation with a time stamp of 07/12/24 at 10:01am that it was discovered that C1 needed to be released by the hospital to a skilled nursing facility. Upon discovering this on 07/12/24, the facility staff returned C1 to the hospital where C1 was readmitted and later was released to a skilled nursing facility. Based on interviews and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation #3: Staff did not meet reporting requirements.

It is alleged that staff did not meet reporting requirements. It is reported that staff did not specify the type of wound that C1 obtained. During the investigation LPA Casillas reviewed all SIR’s submitted to Community Care Licensing (CCL) and was able to follow a detailed timeline of how the injury progressed to a wound. Based on documentation and interviews with Administrator and two (2) staff, it was discovered that there was no initial wound on C1, the initial SIR describes a bruise from the injury. Subsequent SIR’s describe the level of progression the staff noticed on C1’s foot and the actions that were taken. As the injury progressed, additional SIR’s were submitted to CCL describing the status of the injury, the actions taken and updates on hospital discharge information. Based on observations, record reviews and interviews, it is determined that this allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. A copy of this report provided to Administrator.