INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: it is alleged that facility employees failed to provide an appropriate level of care and supervision which resulted in Resident #1 sustaining a Stage III pressure injury while in care. This investigation revealed that medical records from Torrance Memorial Medical Center documented that Resident #1 was admitted to the hospital on 06/09/23 and diagnosed with a Stage II pressure ulcer of unspecified site upon admission, not a Stage III as indicated by Witness #1. Resident #1 was discharged from the hospital on 06/20/23 and medical records referred to the pressure injury on the resident’s “sacrum/coccyx” (with no wound assessment – after the first assessment) as pressure ulcer of unspecified site, Stage III. Resident #1 returned to the facility on 06/20/23 with continued physician’s orders for home health wound care (effective 06/27/23). Interviews conducted of Resident #1 and Witness #3 (family member) corroborated that the resident had developed bed sores at a post-acute care skilled-nursing facility (SNF) prior to moving into the assisted-living facility on 04/22/23. Facility staff were meeting the resident’s needs and providing an appropriate level of care and supervision – coupled with Resident #1 receiving continued home health wound care. Interviews conducted of facility staff (A1, S1 – S3) corroborated that the home health agency was providing wound care a couple times a week to Resident #1 and facility staff would help keep it dry when the wound nurses were unavailable. Staff #3 (Health Services Director) corroborated that they would conduct weekly wound evaluation reports and review the home health visit records of Resident #1.

Regarding Allegation #2: this investigation revealed that Resident #1 had a catheter and wears diapers. Resident #1 denied any lack of care on the part of facility staff and remarked that “sometimes the urine just leaks.” Resident #1 suspected that some of the urine leaked during transport to Torrance Memorial Medical Center ER on 06/09/23. Interviews conducted of facility staff (A1, S1 – S3) corroborated that facility staff provide an appropriate level of care and supervision to the residents; and, they have never smelled urine on Resident #1. Interviews conducted of Resident #2 – Resident #3 corroborated that they feel safe living at the facility and have never observed any of the residents being neglected by facility staff and their needs are being met. Interview conducted of Witness #4 (home health agency administrator) corroborated that they would visit Resident #1 a couple times a week and facility staff were meeting the resident’s needs and providing an appropriate level of care and did not suspect any neglect coming from facility staff.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not ensure resident's hygiene needs are being met is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Activity Director (Lindy Hays).