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32 | [CONTINUED FROM LIC 809]
According to hospice agency electronic progress notes, their nurse visited on 10/23/2021 and found R1 flat on their back in bed (not rotated, as was instructed by R1’s physician). The pillows provided to facility staff to prop up and reposition R1 were instead on the floor of their bedroom. Facility records, hospice records, and interviews of facility managers and outside sources further showed: Licensee held a 10/27/2021 care conference with R1’s hospice agency staff and R1’s responsible person to announce that routinely turning/repositioning R1 in bed and floating their heels was not something that facility staff did for R1 since they moved in, and not something facility staff would do for R1 going forward. Later the same day, R1’s hospice agency and responsible person had R1 sent to a hospital emergency room (ER) for treatment of multiple pressure injuries.
According to hospice notes, on 10/27/2021, R1’s coccyx pressure injury had expanded to 2 cm long by 2 cm wide, with “purulent” (i.e., containing pus) drainage. The pressure injury on R1’s right upper back was now 2.5 cm long by 2 cm wide, with “purulent” drainage. R1 also now had an “unstageable” ulcer on their left hip that was 1 cm long by 2 cm wide with no drainage, plus a “Stage 1” (i.e., redness, closed skin) pressure injury on their left heel which was 3 cm by 3 cm, and “blisters” on their right heel which were 3 cm by 3 cm. According to ER hospital records, R1 came to the ER on 10/27/2021 because they had a “wound on coccyx and staff at the facility are unable to care for it.” Hospital staff assessed R1’s “sacral / coccygeal” pressure injury as 2.5 cm long by 3 cm wide, “unstageable,” and infected (but not septic), for which R1 received intravenous antibiotics. They also assessed R1’s left and right heels as both “Stage 1.”
Based on interviews and records, a preponderance of evidence exists to show that Licensee did not ensure that R1’s skin condition (which was an allowable health condition at their time of their move-in) was cared for in accordance with their physician’s orders and that their medical needs were met. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D) page. The Department determined that the violation resulted in injury to a resident in care. An immediate civil penalty of $500 was already assessed on a separate Complaint Visit report for this incident involving R1.
Since the facility had closed and ceased operations as of the date of deficiency issuance, no Plan of Correction was formed with the Licensee. A copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee via USPS certified mail. |