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32 | According to interviews conducted of 8 staff, 3 residents, resident’s R1 family member and documentation reviewed by IB investigator, the Department learned that on 2/4/2021 facility staff reported that “wound looked like a pimple” and by 2/10/2021 resident R1 had an open wound. On 2/10/2021 at approximately 05:02 hours, facility staff submitted physician’s fax report that stated “’Resident R1’ has an open wound on her lower right buttock’s cheek. The wound is the size of two quarters placed next to each other. The area around the wound is faded light purple and has peeling skin. The wound is red around the edges and the inside is white. There is a black spot on the actual wound. ‘Resident R1’ is not complaining of pain, but the area around the wound is hard.”; physician didn’t reply to fax report. (copy of documentation & pic on file) On 2/12/2021, facility submitted a physician’s fax report with information pertaining to resident R1 informing physician that open wound is getting worse. (copy on file) On 2/16/2021, physician replied by fax with referral to Home Health. By 3/2/2021 facility had a referral for Home Health which had not visited to perform wound care. As per facility staff and documentation, resident’s R1 by 3/2/2021 resident R1 wound “is big and smelling bad… the resident needs urgent care.” (copies on file)
Facility didn’t send resident R1 out to the hospital until 3/3/2021 at approximately 15:00 hours due to a fall. (copy of incident report on file) Resident R1 returned to facility at approximately 20:30 hours and was admitted to Suncrest Home Health and Hospice on 3/4/2021. Since facility staff noticed that wound opened up and was identified as black per staff there was approximately 22 days. Facility staff reported to facility and documented the development of a wound since 1/28/2021. As per Kaiser permanent ER medical records, doctor that examined resident R1 determined that “on right buttock was a large, very foul-smelling ulceration with surrounding erythema. The ulcer was covered in a black eschar (which is a thick, dry, and black necrotic tissue) and boggy to the touch.” When resident was further examined, medical records stated that “there was a cant drainage on the pad under resident R1 when she was rolled. (copy of documentation on file)
Continue LIC 9099-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/18/2021
Section Cited
CCR
87465(g) | 1
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7 | 87465(g)Incidental Medical and Dental Care Services.This requirement isn't met as evidenced by: **Based on docs review & interviews facility didn't comply w/reg above on 1of1 resident which poses an | 1
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7 | Facility agrees to submit a plan and procedure regarding residents needing medical attention on different situations and steps of how medical attention will be provided. Facility to submit plan and procedure to |
 | 8
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14 | immediately Health & Safety risk to resident in care.Staff reported to facility on 2/4/21"wound like a pimple" no medical attention was provided;3/3/21 "Doctor'
discussed progression infection to sepsis and death from sepsis."
(copies on file) | 8
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14 | CCL by POC 6/18/2021. In addition, facility to submit proof of staff training on precedure and how to provide medical attention after Department approval - by 7/2/21 - sign in sheet + staff names, trainer, date of training. |
Type A
06/18/2021
Section Cited
CCR
87615(a) | 1
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7 | 87615(a)Prohibited Health Conditions-This requirement is not met as evidenced by:Based on docs reviewed & interviews facility didn't comply w/reg above on 1of1 resident w/a prhibited condition which poses an immediately | 1
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7 | Licensee to ensure that residents with prohibited health conditions shall not be admitted or retained. Licensee to provide a written plan indicating how facility will ensure complaince with this Title 22 Regulation by POC date of |
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14 | Health & safety risk o residents in care.Facility kept resident R1 in care with "large, very foul-smelling ulceration with surrounding erythema. The ulcer was covered in a black eschar and boggy to the touch." (on file) | 8
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14 | 6/18/2021. In addition, facility will provide caregivers, med techs, and supervisors w/ Prohibited Health Conditions training.Sign in sheet + staff names, trainer, date of training, & topics covered to be submitted by 7/2/2021.. |