Oakpark Healthcare Center
9166 Tujunga Canyon Tujunga CA 91042
Citation Number: 920011543
Citation Date: 09/16/2015
Violation Date: 1/27/2013
Class: AA
Penalty: $75,000

A female resident was transferred to the ER on 1/16/13, after developing a severely infected gangrene wound on her left heel, an infection of the bone, and a blood infection. She died on 1/27/13. The resident was admitted to the facility on 5/11/12 with kidney disease, dementia, and diabetes. On 11/12/12, it was documented that she had a Stage 2 left heel wound, but nursing notes since that date failed to document the condition or progression of the wound. The nursing staff also failed to monitor the wound for signs of infection, or obtain a wound consultation in a timely manner per physician's orders on 12/19/12. The resident repeatedly cried out "help me" to nursing staff, who responded by increasing her prescriptions for psychoactive medications, including Haldol. Her care plan did not include determining if the screaming for help was related to severe pain from her gangrene wound.