374604019-9-30-2020-08-AS-IESA-BTY569-20200930194022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604019
Report Date: 09/30/2020
Date Signed: 09/30/2020 05:56:45 PM

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
08/09/2019 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20190809110049

FACILITY NAME:	POINT LOMA ELDER CARE		FACILITY NUMBER:	374604019
ADMINISTRATOR:	GAURAV RATHI		FACILITY TYPE:	740
ADDRESS:	3941 LIGGET DRIVE		TELEPHONE:	(619) 255-6448
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92106
CAPACITY:	6	CENSUS: 4	DATE:	09/30/2020
		UNANNOUNCED	TIME BEGAN:	04:06 PM
MET WITH:	Gary Rathi		TIME COMPLETED:	04:23 PM

ALLEGATION(S):

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Severe neglect resulted in a resident sustaining a stage 4 pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura contacted Gary Rathi, Administrator, via video conference, due to COVID-19, to deliver investigative findings. LPA identified herself and discussed the purpose of the call with the Administrator.

Community Care Licensing has investigated the above listed complaint allegation. The Department’s investigation consisted of a review of facility records, review of resident medical records, outside source records, and interviews of the facility’s licensee, residents, facility staff, and outside sources.

Evidence shows that Resident 1 (R1) [licensee was provided an LIC 811 Confidential Names List that identifies the resident] resided in the facility from 11/13/2018 through 8/6/2019. Records reflect that R1 was visited at the facility by R1’s physician on 5/1/2019, and it was noted that no pressure injuries were present. R1 was visited again on 6/6/2019, and it was noted that R1 was beginning to develop pressure injuries along the heels and toes. On 6/27/2019, R1’s physician requested initiation of home health services to provide

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

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-20190809110049

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: POINT LOMA ELDER CARE	FACILITY NUMBER: 374604019
	VISIT DATE: 09/30/2020

NARRATIVE

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physical therapy and wound care for a foot wound. On 6/29/2019, home health services were initiated, and R1 was visited and assessed by a home health nurse. Evidence indicates that at the time of assessment, the nurse observed and noted that R1 had a small stage one pressure injury on their lower left leg, a small stage one pressure injury on their lower right leg, and a small wound on their toe. Records note that R1 was to be repositioned every two hours to decrease the risk of skin breakdown, R1 was made aware and acknowledged understanding of the need for repositioning. According to records collected during the investigation, no other pressure injuries were noted at that time.

Following initiation of services, home health wound care visits were conducted three times a week, and by 7/18/2019, a home health nurse observed that, in addition to other wounds, a stage one pressure injury had developed on R1’s sacrum. Records reflect that, at the time of the visit, the nurse documented the observation and instructed facility staff on how to clean the sacrum wound, change the soiled dressing, and educated the staff on repositioning R1 onto their side every two hours, while in bed, to prevent the pressure injury from worsening. A home health nurse visited R1 on 7/26/2019 and noted that the pressure injury on the sacrum had progressed to stage two. The visiting nurse documented that, during the visit, facility staff were trained on proper repositioning of R1 to take place every two hours. On 7/31/2019, it was noted by a visiting home health nurse that the sacral pressure injury had advanced to stage four. Evidence shows that the facility staff were, again, educated on body alignment and proper repositioning of R1.

The investigation revealed that, in addition to home health, a wound care specialist was visiting the facility to treat and clean the sacral wound 2 – 3 times weekly. Records note that the wound care specialist’s orders included instructions that R1 was to be turned every two hours as well. However, records reflect that on a number of occasions when home health, wound care, and medical personnel visited the facility, R1 was found lying on their back and with soiled dressing on the wound, despite facility staff having been provided instruction, which was documented by home health and wound care personnel a number of times, to keep the wound clean and dry and to rotate the resident every two hours. Additionally, during the investigation, interviews confirmed that while residing in the facility R1 was being left for more than two hours without being checked on by facility personnel, which also indicates that facility staff were not following through with instructions to rotate the resident every two hours.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20190809110049

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: POINT LOMA ELDER CARE	FACILITY NUMBER: 374604019
	VISIT DATE: 09/30/2020

NARRATIVE

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On 8/6/2019, R1 was transported to and admitted into the hospital. Records reflect that, at the time of admittance into the hospital, R1 had two stage four pressure injuries in the sacral area, the second of which was observed and noted by the wound care specialist during a visit on 8/3/2019. During the hospital stay, R1 underwent two surgical procedures to address the pressure injuries. On 8/20/2019, upon discharge from the hospital, R1 did not return to the facility and was admitted into a skilled nursing facility.

Based on interviews and review of documentation, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. At this time, pursuant to Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted, via virtual visit, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Gary Rathi, Administrator, via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20190809110049

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: POINT LOMA ELDER CARE	FACILITY NUMBER: 374604019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/01/2020 Section Cited CCR 87609(b)(2)	1 2 3 4 5 6 7	Allowable Health Conditions and the Use of Home Health Agencies: Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident	1 2 3 4 5 6 7	The Administrator offered to ensure that all staff receive training, provided by an outside vendor, on meeting resident needs. The Administrator agreed to provide the date of scheduled training to Community Care Licensing on 10/1/2020 and provide proof of
	8 9 10 11 12 13 14	receiving home health care. This req't was not met as evidenced by: Based on interviews and records review, the licensee did not provide the supporting care needed to meet the needs of R1 who was receiving home health care. This posed an immediate health risk to resident in care.	8 9 10 11 12 13 14	training to Community Care Licensing upon completion, which will be scheduled to occur within three weeks.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

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