Health inspection·December 17, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) # CA00920798. Survey Event ID: DEK611 State Citation B was written. §72319 (k) (2) (A) (B) Nursing Service - Restraints and Postural Supports. (k) "Postural support" means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints. (1) The use of postural support and the method of application shall be specified in the patient's care plan and approved in writing by the physician, psychologist, or other person lawfully authorized to provide care. (2) Postural supports shall be applied: (A) Under the supervision of a licensed nurse. (B) In accordance with principles of good body alignment and with concern for circulation and allowance for change of position. On 9/27/24 at 10:43 am, an unannounced visit was conducted at the facility to investigate an Entity Reported Incident regarding a quality of care/treatment allegation. Resident 1 was elderly with a diagnosis of left-hand contracture (a permanent tightening of the muscles, skin, or other tissues that limits a body part's normal movement). Resident 1 was admitted to the facility in 2023. Resident 1 was dependent on staff for care and mobility and was at high risk of developing skin injuries. Resident 1 had severely impaired thinking ability and memory. Resident 1's fifth finger (pinky) was inserted tightly into a finger contracture cushion and was left unattended and unsupervised for over seven hours. After bleeding of the pinky finger was noted at 10 p.m. on 9/9/24, the finger contracture cushion was removed, and the left pinky finger had a painful open, bleeding wound with purplish discoloration and exposed bone of the pinky finger. Resident 1 went to acute care hospital for evaluation of the pinky finger wound and received antibiotic treatment for the wound and wound care treatment. The facility failed to provide appropriate contracture management to Resident 1 when a hand roll applied for a left-hand contracture was not applied or regularly assessed for circulation by a licensed nurse. This failure resulted in the development of a painful open wound on Resident 1's left pinky finger to the level of bone exposure. During a record review of Resident 1's physician's order dated 7/4/24, the record indicated to apply a hand roll to Resident 1's left hand for six (6) hours a day every day. During an interview on 9/27/24 at 12:00 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was the assigned morning shift (7 a.m. to 3 p.m.) assistant for Resident 1 on 9/9/24. CNA 1 stated Resident 1 used a hand roll with four (4) loops for finger placement for the hand contractures on the left hand: the second, third, fourth, and fifth fingers were each inserted into a loop. During an observation and interview on 9/27/24 at 1:14 p.m., with Restorative Nursing Aide (RNA) 1, RNA 1 stated he placed a hand roll to Resident 1's left hand whenever he was on duty, but he did not work on 9/9/24 when Resident 1 sustained injury to his pinky finger. RNA 1 brought a sample hand roll "Finger Contracture Cushion" of the same kind Resident 1 used for his left hand: there were three loops in the center of the roll with one flat strap sewn down on each side of the loops. RNA 1 stated and demonstrated with his hand, how the three middle fingers (fingers two, three and four) were placed inside the three loops, while holding the roll in his hand. RNA 1 stated the flat straps were not to be used for finger insertion: the hand roll did not have a loop for the pinky finger or thumb. During an observation and interview on 9/27/24 at 1:58 p.m. with CNA 1, the finger contracture cushion/hand roll sample was observed. CNA 1, at this time, stated she only placed the hand roll in the left hand of the Resident 1 to hold it and did not insert any of Resident 1's fingers into the loops of the cushion. CNA 1 stated "somebody" might have mistakenly placed the left pinky finger into the flat strap on the end of the roll. During an interview and observation on 9/27/24 at 3:37 p.m., with CNA 2, CNA 2 stated she took care of Resident 1 in the evening shift (3 p.m. to 11 p.m.) on 9/9/24. CNA 2 stated on 9/9/24, around almost 10 p.m., she went to the Resident 1's room and noticed "something was wrong" with Resident 1. CNA 2 stated she was about to give bed bath to Resident 1, but he resisted care at that time. CNA 2 stated she saw Resident 1's left hand pinky finger was inserted in one of the tight rings of hand roll causing purplish discoloration, and she went straight to RN 1. CNA 2 stated she suggested RN 1 to cut the tight ring of the hand roll, because it was very tight. CNA 2 demonstrated the placement of the left pinky finger using the sample hand roll, and how the left pinky finger was inserted in the tight ring hole. CNA 2 stated her shift was from 3:00 p.m. to 11:15 p.m. but she had not noticed Resident 1 had the hand roll on his left hand until 10 p.m. During an interview on 9/27/24 at 3:22 p.m. with Registered Nurse (RN) 1, RN 1 stated during evening shift on 9/9/24, CNA 2 called her attention for Resident 1. RN 1 stated she saw Resident 1's left pinky finger placed on the flat strap of the hand roll and stated she was not sure if it was supposed to be there. RN 1 stated the left pinky finger was purplish in color and was bleeding. RN 1 stated Resident 1 was "moaning" at that time. RN 1 stated she rushed to get a scissor but was not sure how to cut it since Resident 1's left pinky finger was tightly stuck in the flat strap of the hand roll cushion. RN 1 demonstrated the placement of the left pinky finger using the sample hand roll, and the left pinky finger was placed all the way inside the flat strap. During an interview on 9/27/24 at 3:45 p.m., with RN 2, RN 2 stated he was Resident 1's assigned charge nurse in evening shift (3 p.m. to 11:30 p.m.) on 9/9/24. RN 2 stated on 9/9/24 around 5:00 p.m., he saw Resident 1 lying in bed when he administered evening medications to him but did not remember seeing the Resident 1's hands. RN 2 stated he did not know Resident 1 required a hand roll and had not seen him using one before. RN 2 stated he did not know who put on the hand roll in Resident 1's left hand. RN 2 also stated somebody must have placed it on, since Resident 1 did not have the ability to do so. RN 2 stated he saw Resident 1's left hand after RN 1 had already cut the hand roll cushion. RN 2 stated Resident 1 had a cut open wound about 1.0 cm. deep and it was bleeding. RN 2 stated hand rolls should be removed intermittently, or hand rolls could impede the blood circulation in fingers. During a record review of Resident 1's progress notes dated 9/9/24, documented by RN 1, the record indicated, "Around 10:15p.m., [CNA 2] showed to [RN 1] [Resident 1's] left pinky. [RN 1] assessed finger and finger was purple and noted to be wrapped with the ring part of a hand splint. [RN 1] cut the ring around the finger and the finger was almost falling off. Bone was visible. [RN 1] reported to on-call [Medical Doctor] and [Medical Doctor] gave an order to send out [Resident 1]. [RN 1] called 911 and ambulance came around 10:30 p.m. Ambulance left with [Resident 1] around 10:50 p.m. [RN 1] notified [Responsible Party] ..." During a record review of Resident 1's Acute Care Hospital record dated 9/10/24, the record indicated, the Skilled Nursing Facility found a left pinky open wound, after one day of application of a cushion to his left hand to prevent him from scratching himself. The hospital record indicated the Skilled Nursing Facility had speculated the cushion had been wrapped around Resident 1's finger too tightly, which caused the hand roll to dig into Resident 1's finger. The hospital record indicated Resident 1's left pinky finger wound was open and had bone exposed. The hospital record indicated Resident 1 received antibiotic treatment at the hospital for a likely infection of the open wound on Resident 1's left 5th digit. During a review of the National Pressure Injury Advisory Panel (NPIAP) article, "Pressure Injury Prevention Points," dated 2016, the article indicated, "Assess pressure points...beneath medical devices." In violation of the above cited standards, the facility failed to provide appropriate contracture management to Resident 1 when a hand roll applied for a left-hand contracture was not applied or regularly assessed for circulation by a licensed nurse. This failure resulted in the development of a painful open wound on Resident 1's left pinky finger to the level of bone exposure. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.