Health inspection·November 15, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: (Complaint/Entity Reported Incident (ERI) #: CA00859624 Survey Re-licensing/Re-certification) Event ID: KOUF11 Representing the Department, HFEN # 47382 State Citation (B) was written. F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 9/8/2023 at 11:15AM, an unannounced visit was conducted at the facility to investigate an entity reported incident regarding... Resident 1 was provided two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier by a Certified Nursing Assistant (CNA 1) which was outside the scope of practice for a CNA. Resident 1 then placed the hot packs directly onto her abdomen and was not supervised or reassessed during the application. This resulted in a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen. The facility failed to ensure the resident's environment remains as free of accident hazards as is possible; and that residents receive adequate supervision and assistance devices to prevent accidents. 1.Failed to follow facility policy and procedures for applying a compress warm soak. 2. Failed to follow manufacturer directions and warnings for application of instant disposable hot compresses. 3. Failed to ensure a Certified Nursing Assistant provided care within their scope of practice. Resident 1 was admitted to the facility on 5/2022. According to Resident 1's face sheet, Resident 1's diagnoses included Diabetes Mellitus Type 1 (a condition where the pancreas makes little or no insulin. Insulin is a hormone the body uses to allow sugar to enter cells to produce energy) & respiratory distress (difficulty breathing). Resident 1 had intact mental status/cognition, however, physically, Resident 1 needed extensive assistance transferring from one surface to another, but was independent when moving about the unit once in a wheelchair. During a review of Resident 1's Admission Record dated 9/8/23, the Admission Records showed Resident 1 was admitted in May 2022. During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) dated 6/22/23, Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage. During an interview on 9/8/23 at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs on 8/25/23 because she had menstrual cramps. Resident 1 stated CNA 1 'broke them" and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30-45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses' station to ask the nurses what was on her abdomen, and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor. During an interview on 9/8/23 at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs at approximately 7 p.m. on 8/25/23. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs. During a concurrent observation and interview on 9/8/23 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button). During a telephone interview on 9/8/23 at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse on 8/25/23, the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only. During an interview on 9/8/23 at 4:42 p.m. with the Director of Nursing (DON), the DON stated Resident 1 did not have a physician order for hot packs. The DON also stated hot packs fell under the facility's "Hot Compress Policy" and a physician order was required. The DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging. During a phone interview on 9/21/23 at 2:50 p.m. with Resident 1's doctor (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's Diabetes caused her decreased sensation and may have contributed to Resident 1's burns. During a review of the facility's undated "Incident Investigation Summary", indicated on 8/25/23, that Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 "said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so." The Investigation Summary further indicated, "Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access." During a review of the facility's policy and procedure (P&P) titled, "Compress or Soak, Applying Warm," dated 2/2018, indicated, "1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed." During a review of the manufacturers undated packaging instructions, titled, "McKesson Instant Disposable Hot Compress", indicated, "Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes." Conclusion: In violation of the above cited standards, the facility failed to follow its policy and procedures for hot compress's when Resident 1 was provided two instant hot packs without a physician order or protective barrier by CNA 1. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This resulted in a second-degree burn on Resident 1's lower abdomen. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.