The investigation revealed the following:

Regarding Allegation #1: Staff neglect resulting in resident developing pressure injuries.

This investigation revealed that Resident #1 was admitted to the facility on 08/31/21. A review of the resident’s “Physician’s Report” documented under “Physical Health Status: No history of skin breakdown.” A review of Resident #1’s medical records (dated 01/17/22) from Memorial Care Hospital Palliative Care Unit documented Resident #1 was diagnosed with a Stage III (1.5cm x 1.5cm) pressure injury to the right heel on 01/05/22 and (again) on 01/10/22; Stage III (2cm x 2cm) pressure injury to back of right heel on 01/03/22; Stage III (2cm x 3cm) pressure injury to the right foot, back of heel on 12/31/22. Resident #1 had a wound care plan on file from Memorial Care Palliative Services (dated 01/03/22) and was receiving wound care for palliative services (effective 10/07/21) from Memorial Care Palliative Care based on their Progress Notes (dated 10/12/21, 10/21/21, 12/29/21, 12/31/21, 01/03/22, 01/05/22, 01/10/22, 01/17/22). Interview conducted of Witness #1 corroborated that Resident #1 suffered from respiratory failure, septic shock, and deep-pressure injuries; and Resident #1 was not admitted to Memorial Care Hospital Palliative Care Unit until 01/17/22 due to multiple Stage III deep-pressure injuries.

(Evaluation Report continues LIC 9099-C)

Based on the evidence gathered and interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff neglect resulting in resident developing pressure injuries is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Civil penalties assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) entitled “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states: “a serious physical condition; including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss of impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement”.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Staff #1 (Maria Miclat).

The investigation revealed the following:

Regarding Allegation #2: this investigation revealed following a review of Resident #1’s “Physician’s Report” (dated 07/14/21) documented under “Capacity for Self-Care” the resident is “able to feed self”. A review of Resident #1’s “Appraisal/Needs and Services Plan” (dated 08/29/21) documented under “Needs – Method of Evaluating Progress: resident will be monitored daily of any decline.” Interviews conducted of staff (S1, S2, S3) corroborated that facility staff were properly caring (encouraging water intake) for Resident #1. Resident #1 had an 8 oz water cup that was provided during mealtimes including juice. An attempt was made to interview Resident #3 (R3) but was unavailable. Resident #5 (R5) and Resident #6 (R6) could not be interviewed due to their cognitive impairment. Resident #1 was not interviewed due to hospitalization on 01/17/22 and later passed away on 01/29/22 due to pneumonia.

(Evaluation Report continues LIC 9099-C)

Regarding Allegation #3: this investigation revealed based on interviews conducted of staff (S1, S2, S3) corroborated that facility staff were properly caring (food intake) for Resident #1. Facility staff had to spoon feed the resident and observe the resident consume their food due to the resident’s diagnosis. An attempt was made to interview Resident #3 (R3) but was unavailable. Resident #5 (R5) and Resident #6 (R6) could not be interviewed due to their cognitive impairment. Resident #1 was not interviewed due to hospitalization on 01/17/22 and later passed away on 01/29/22 due to pneumonia. A review of Resident #1’s “Physician’s Report” (dated 07/14/21) documented under “Capacity for Self-Care” the resident is “able to feed self”. A review of Resident #1’s “Appraisal/Needs and Services Plan” (dated 08/29/21) documented under “Needs – Method of Evaluating Progress: resident will be monitored daily of any decline.”

Based on the evidence gathered and 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 PERSONAL RIGHTS: Staff did not ensure resident is consuming food is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation revealed based on interviews conducted of staff (S1, S2, S3) corroborated that facility staff did not encourage Resident #1 to stay in bed; as the resident would be sitting in a recliner with their leg on top of a chair with their feet up so as not to place pressure on their wounds. A review of the resident’s Memorial Care Palliative Services Care Plan (dated 01/03/22) with Visit Sign-in Sheet (between 10/07/21 – 01/17/22) documented Witness #2 was observed “awake and sitting in a chair (recliner) or wheelchair”. Resident #1 was not interviewed due to their hospitalization on 01/17/22. An attempt was made to interview Resident #3 (R3) but was unavailable. Resident #5 (R5) and Resident #6 (R6) could not be interviewed due to their cognitive impairment. A review of Resident #1’s “Physician’s Report” (dated 07/14/21) documented under “Physical Health Status: Fair. No history of skin breakdown, ambulatory, and does not require bed care.” Under “Ambulatory Status: This person can independently transfer to and from bed. This person is considered ambulatory.”

(Evaluation Report continues LIC 9099-C)

Regarding Allegation #5: this investigation revealed based on interviews conducted of staff (S1, S2, S3) corroborated that facility staff administered Resident #1’s medications per physician’s order(s) and not administered with medications to sedate the resident. A review of Resident #1’s “Physician’s Report” (dated 07/14/21) documented under “Medication Management” that resident cannot administer own medications. A review of the Resident 1’s Medication Administration Record (dated January 2022) documented physician’s medication orders under “Treatment/Medication (type and dosage)” were administered by facility staff who had signed their initials following the administering of resident’s medications. Resident #1’s medications were audited with the MAR and no documentation of medication for sedation was observed to have been administered between the month of December 2022 thru January 16, 2022. Resident #1 was hospitalized on 01/17/22.

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 MEDICATIONS: Staff administering medications to resident without consent is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Staff #1 (Maria Miclat).