On April 23, 2021, the Department concluded a complaint investigation and substantiated the following allegations: Facility failed to provide adequate care resulting in the injury of a resident; Facility failed to report a change in residents condition as required by Title 22; and Resident has stage three pressure injuries.

The licensee was cited for violation of California Code of Regulations (CCR) Title 22: §87465 (a)(1) Incidental Medical and Dental Care for failing to obtain appropriate medical care for (R1); §87211(a)(1) Reporting Requirements for failing to notify the Department that a resident (R1) sustained an injury while in care; and §87616(a)(1) Prohibited Health Conditions for retaining R1 with a stage 3 to 4 wound while R1 was not on hospice.

The investigation revealed that a R1 was admitted to the facility on July 2, 2020. R1’s physician report dated June 30, 2020, stated R1 has a diagnosis of hypertension and diabetes mellitus-type 2. R1 requires assistance with bathing, dressing, and toileting. R1 has a history of skin breakdown on bilateral heels and coccyx and is non ambulatory based on physical condition.

According to medical records, R1 was referred for services post operation of the left femur starting July 23, 2020. On July 23, 2020, it was noted that R1 did not have any pressure injuries and was considered a high risk for developing a pressure injury due to decreased mobility and diabetes. Facility staff were advised to provide frequent incontinence care. It was noted that R1 is fully dependent for mobility, transfers, toileting, bathing, and dressing. On July 31, 2020, during a home visit, R1 was noted to have mild redness on the buttocks.

Continued onto LIC809-C

On November 6, 2020, facility notes state that “sore getting worst” and that “cream was applied on the sore.” An incident report submitted by the facility states staff “observed a small, closed wound on R1’s buttocks when getting changed.” On November 7, 2020, an ambulance was called to take R1 to the hospital due to staff “observing an open wound on R1’s buttock.” Upon assessment at the hospital, R1 was found to have a pressure injury. Hospital records document that R1 was diagnosed with an “unstageable wound on the sacrum.” Upon discharge to a skilled nursing facility on November 8, 2020, R1 was diagnosed with a “pressure ulcer of coccyx stage 3 (full thickness skin loss).” An interview with hospital staff stated that all unstageable wounds are either stage 3 or stage 4.

Interviews with R1 stated that they did not have information about when the pressure injury began to develop on themself. R1 told the department that staff does not check on R1 and reposition or change R1’s diaper every two hours although they are supposed to.

At the time of the non-compliance conference on August 17, 2021, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code §1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the licensee failing to seek timely medical care resulting in R1 having a prohibited condition, Stage 3 pressure wounds, requiring hospitalization. Staff provided inconsistent information regarding the status/progression of resident’s wound and failed to contact responsible party or physician when resident refused to be transferred from bed, resulting in the prohibited condition of a stage three pressure injury which required hospitalization.

Today, 7/31/2024, the Department will be issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. In addition, the Department will be extending the Non-Compliance plan for the facility, a total of 2-years ending in 8/13/2026. Technical Support Program will be offered to Licensee.

Exit interview conducted. A copy of the report issued. Appeal rights provided, (facility representative) signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.