374600345-2-10-2023-08-AS-IESA-CPH8VD-20230228215058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600345
Report Date: 02/10/2023
Date Signed: 02/10/2023 05:16:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2020 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20200427124549

FACILITY NAME:	ATRIA ENCINITAS SOUTH		FACILITY NUMBER:	374600345
ADMINISTRATOR:	MARTINEZ, USBALDO		FACILITY TYPE:	740
ADDRESS:	504 S EL CAMINO REAL		TELEPHONE:	(760) 436-9990
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	0	CENSUS:	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	04:37 PM
MET WITH:			TIME COMPLETED:	04:38 PM

ALLEGATION(S):

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-Staff neglect lead to resident's multiple pressure injuries
-Staff neglect resulting in untreated skin condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegations. The facility is closed, reports mailed certified.

During the investigation, records were reviewed, and interviews conducted with staff, resident and outside sources. It was reported Resident #1 (R1) was admitted to the hospital on 04/25/2020 for multiple pressure injuries due to staff neglect. R1’s Physician’s Report dated 03/20/2018 indicated R1 was able to dress/groom, feed, toilet themselves, store and administer their own medications as long as their pill box was set up and required one person for stand by assistance with showers. R1’s Functional Needs Assessment dated 03/27/2018, indicated R1 did not require assistance with any activities of daily living (ADL). R1 was also re-assessed on dates 11/25/2019, 03/05/2020, and 03/14/2020, which indicated R1 required assistance with bathing and continence. R1’s Functional Needs Assessment dated 04/21/2020, identified R1 with a change in condition and now required assistance with grooming; dressing; eating; hydration; transfers; continence; and housekeeping. However, the facility did not obtain a new Physician’s Report for R1 to reflect the change in condition or what care was needed for R1. Continued on an LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200427124549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS SOUTH	FACILITY NUMBER: 374600345
	VISIT DATE: 02/10/2023

NARRATIVE

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On 04/25/2020, R1 was diagnosed at the hospital with pressure injury deep tissue contiguous region involving buttock and hip, cellulitis of multiple sites of buttocks, and xerosis of skin. Medical records revealed R1 had a large discolored area from mid back to mid thighs that appeared purple. Facility records indicated on 03/05/2020, facility staff observed an open wound on R1’s buttocks and had a care conference with R1’s authorized representative to discuss the care and documented an outside agency will provide the wound care. Also, the facility notified R1’s Primary Care Physician and documented facility staff will encourage R1 to reposition every two hours during sleeping hours and encourage resident to ambulate more often to relieve any excessive pressure to buttocks. Facility records reflected a note from an outside agency with an order dated 03/14/2020, for bilateral buttocks excoriation stage 2 superficial, Calmoseptine Cream applied. Medical records dated 03/18/2020, documented redness on the buttocks and a medical professional went to assess R1, R1 was sitting in their recliner and refused to get up for the assessment. On 03/23/2020, a nurse from the outside agency documented R1 was possibly going through alcohol withdrawal. Medical records dated 03/27/2020 reflected R1 was too tired to shower this morning, stuck in their room due to covid, and ordered alcohol and had it delivered. On 04/07/2020, excoriation and wound to buttocks and groin was documented. On 04/11/2020, redness/diaper rash to perineal area and skin abrasion to right buttocks was observed and documented by the outside agency. Medical records dated 04/15/2020, indicated R1 stays in their recliner chair at night and refused to get up to go to the bed to sleep.

On 04/17/2020, the outside agency documented they advised R1 to stay in bed to help with wound healing. Facility records indicated they were made aware by the outside agency on 04/20/2020 that R1’s skin was very dry and flaky and noted to have excoriation to peri area. The Facility’s Resident Notes dated 04/21/2020, confirmed R1 had a change in condition, requiring full assistance with all ADLs and left a message for the outside agency to discuss R1’s needs. Also, on 04/21/2020, R1’s skin was very dry, resident’s bottom and perineum excoriated, and abrasions noted due to scratching by resident. Resident used to stay in the reclined chair but now is in the bed most of the day.

Facility’s Resident’s notes dated 4/24/2020, instructed facility staff to reposition R1 every two (2) hours and change briefs every four (4) hours and outside agency will provide wound care for excoriated buttocks and additional home health aide four (4) times a week. Facility’s documentation dated 04/25/2020, revealed it was R1’s authorized representative that contacted the facility and requested R1 be taken to the hospital for evaluation/medical treatment. Continued on an LIC 9099C.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20200427124549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS SOUTH	FACILITY NUMBER: 374600345
	VISIT DATE: 02/10/2023

NARRATIVE

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R1 was transported to the hospital on 04/25/2020 and admitted for the multiple deep tissue injuries and did not return to the facility once discharged from the hospital on 04/29/2020. The facility documented a note for 04/23/2020 at 5:45am and 04/24/2020 at 8:00am, which stated R1 refused incontinence care. Interviews and facility documentation revealed R1 refused showers and brief changes.

R1’s interview confirmed being left in soiled briefs on multiple occasions. Medical Professional’s interview described the injury as severely damaged and severely excoriated, stating it was caused by constant moisture and acidity related to prolonged bladder and bowel incontinence. An outside agency representative confirmed during a routine visit on 04/24/2020 for wound care of the buttocks and perineum, R1 was found soaked in urine and had stool dried up in their rectum. On 04/24/2020, wound care was performed on the buttocks and perineum, changed and lotion for dry flaky skin. Also, medical records indicated R1 advised the outside agency representative that no one changed their briefs last night or this morning. As the deep tissue injuries progressed, the facility did not report the severity to R1’s Primary Care Physician, only to the outside agency.

It was also reported R1 was neglected resulting in an untreated skin condition. R1 was evaluated at the hospital on 04/25/2020 and diagnosed with Fungal Intertrigo. Medical records dated 03/24/2020, documented R1’s skin was very dry, noted some rashes on the coccyx, Lortisone cream ordered for rashes. Medical records dated 04/07/2020, indicated skin was very dry, noted some rashes on the coccyx, Lortisone cream ordered for rashes and Calazime ordered for the groin area to be applied after every incontinence episode. Medical records dated 04/11/2020, reflected redness/diaper rash to perineal area, skin abrasion to right buttocks. The nurse from the outside agency documented instructions for facility staff to do the following: apply Miconazole powder to redness area every shift or after diaper change; cleanse abrasion; apply bacitracin and cover with bordered gauze; and dressing change three times a week and PRN. Medical records dated 04/15/2020, indicated R1 was received sitting in their recliner chair, stays in the recliner chair at night and refuses to get up to go to the bed to sleep. Also, noted irritation and discoloration to the skin and buttocks. On 04/20/2020, R1 was observed by the outside agency with very dry itchy skin. The outside agency documented instructions to the facility to apply Lac Hydrin lotion daily to all extremities, back, chest and abdomen. Also, R1 refused to get out of bed. Outside agency documented on 04/21/2020, R1’s skin was very dry, bottom and perineum excoriated, and abrasions noted due to scratching by patient. Resident used to stay in their reclined chair but now is in the bed most of the day. A review of Healthline.com indicated the Fungal Intertrigo is a rash caused by inflammation and R1 also had a medical condition that caused inflammation. Continued on an LIC 9099C

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20200427124549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS SOUTH	FACILITY NUMBER: 374600345
	VISIT DATE: 02/10/2023

NARRATIVE

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Hospital records indicated R1 had a Sacral Ulcer and Fungal Intertrigo, suspected due to R1’s bed bound status combined with their medical condition unclear if there is significant infection of this area. The outside agency documented on 02/29/2020 skin was dry but that was all. The fungal rash started 03/24/2020. On 04/17/2020, R1 received treatment for groin, no other indicators of rash prior to 04/17/2020. By 04/25/2020, R1’s entire back and down their legs were covered in a rash. Hospital records indicated areas of possible fungal rash was seen at the ears, arms and head and genitalia and peri area. However, the outside agency providing care to R1 did not document any rashes in the ears, arms and head. Hospital records reflected Fungal Intertrigo was due to poor hygiene usually caused by diaper rash, moisture to skin. Hospice records 04/22/2020, wound care on buttocks and perineum area done as per care plan. Resident’s skin was very flaky and itchy, bleeds when scratched by resident. The resident was encouraged to change position every 2 hours. On 04/25/2020, the facility contacted the outside agency to report the ineffectiveness with a medication with itching, requesting a nurse visit. The outside agency’s nurse documented it was explained to R1’s authorized representative the symptom is manageable by the outside agency at the facility. The rash was being treated by the outside agency with different creams and powders but R1 also had medical conditions that possibly contributed to the rash.

During the course of the investigation interviews were conducted and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. A copy of this report along with the Licensee Rights (LIC 9058 01/16) were sent certified mail to the licensee due to the facility being closed.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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