2. Unannounced Visit: Severe Neglect

Facility Type: 735 (Adult Residential)

Allegations
Severe neglect resulting in emergency medical treatment for treatment of maggots.
Proper hygiene care was not provided to resident resulting in severe skin tissue damage.

Investigation Findings
The Department’s Investigations Branch investigated the allegations listed above. R1 was taken to the Emergency Room at Methodist Hospital of Sacramento for edema and swelling in the bilateral lower legs. The physical exam stated “Alert, no acute distress, and warmth to bilateral lower extremities up to waistband, wounds to bilateral feet with maggots present.” Facility was aware of R1’s edema and poor hygiene from 2014 admission until he was hospitalized on 10/1/16. The facility informed R1s worker at Telecare; however, there was no follow up and no further action was taken to address his needs. This led to R1’s condition worsening to the point where he was hospitalized; therefore the allegations of neglect are substantiated.

Deficiency Type
Section Number
DeficienciesPlan of Correction
Type A
80078(a)
Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. The facility neglected to care for R1 which resulted in wounds to bilateral feet with maggots present.The Licensee shall submit a plan to CCL on how the facility will ensure/assist residents in meeting hygiene needs and notify responsible parties as needed should residents refuse personal hygiene.
Type A
Section Cited
80075(a)
Health Related Services. Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. The facility neglected to obtain medical care for R1 which resulted in wounds to bilateral feet with maggots present.The Licensee shall submit a plan on how the facility will ensure that resident's receive medical care and treatment as necessary. POC shall be submitted by, 07/31/17.
Type A
Section Cited
85075.4
Observation of the Client
The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. The facility neglected to observe R1 which resulted in wounds to bilateral feet with maggots present.
The Licensee shall submit a plan to CCL on how the facility will document observed changes of residents.

 

Source
Facility Report
https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=347004741&inx=22

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