- Date
- 7/27/2025
- Report number
- CALMS - 00086967
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to adequately plan discharge
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 08/04/25, the facility’s failure to comply with the Monitoring requirements was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
Compliance Specialist (CS) reviewed Resident’s 1’s (R1) service plan dated 05/11/25, progress notes/observation notes dated 06/01/25 through 07/27/25, physician orders 06/01/25 through 07/27/25, after-visit summaries dated 06/01/25 through 07/27/25, discharge summaries 06/01/25 through 07/27/25 , communications with PCPs and outside providers 06/01/25 through 07/27/25, and incident reports dated 06/01/25 through 07/27/25, which indicated the following:
07/12/25-07/13/25 – R1 admitted to hospital for surgical procedure 07/12/25 Esophogastroduodenoscopy w/biopsy. Released back to the facility on 07/13/25 with aftercare instructions. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to. R1 was placed on alert charting after return from the hospital, diagnosed GI Bleed. Discharge summary lists a history of chronic illnesses as reasons for hospital stay, none of which include wounds or wound care.
07/21/25-07/23/25- CG reported rash on R1 buttocks and scrotum area. R1 requested RN from an outside provider to assess rash. Witness 1 (W1) sent in orders for ointment on 07/22/25 to be self-administered by R1. During a phone call on 08/04/25 with Witness 1 s/he assessed the resident on 07/15/25 and 07/23/25, s/he also stated that R1 refused to let him/her look at his/her buttocks area. Facility faxed PCP that R1 had some red-rashy areas that were open and bleeding on the buttocks and coccyx area. R1 was placed on alert charting. No RN notes documented in progress notes regarding R1's rash on scrotal or buttocks area. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to.
07/25/25-07/26/25 – Resident was seen at a medical center for scrotal ulcer and buttocks, prescribed cream and donut for healing of the area. 07/26/25 resident tested positive for COVID. The resident was placed on alert charting. No RN notes documented in progress notes regarding R1's rash in scrotal or buttocks area. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to.
07/27/25- Resident sent out to hospital. The above indicated the facility failed to comply with monitoring requirements for R1 on the above dates by not providing a monitoring plan to staff on every shift.
In an interview, Staff 1 stated the following: The facility had a COVID outbreak during this time, and the facility was moving over to a new system; this could have been why a monitoring plan or TSPs were not done. R1 was on alert charting, and staff were following the physician's orders and charting any change of condition for R1.
In an interview with Staff 2 and Staff 4, they both stated that due to the RN being on vacation and COVID outbreak, staff called an outside provider for an assessment on R1 instead of the LPN at the time. R1 was unable to be interviewed or observed due to being out of the facility.
The facility’s failure to comply with the monitoring requirements was substantiated.