Health inspection·December 8, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number CA00767879. Representing the Department, HFEN #38534 State Citation A was written: CLASS A CITATION - PATIENT CARE F 684 CFR 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. On 10/12/2022, an unannounced visit was conducted at the facility to investigate a complaint of patient care. The facility failed to ensure Resident 1, who had a diagnosis of Type 2 Diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), received comprehensive skin monitoring and assessment, when Resident 1's left foot wound with infection was not monitored, assessed, and evaluated. This resulted in Resident 1's left foot developing gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) and Resident 1's left foot being amputated (the action of surgically cutting off a limb). Resident 1 was a 72-year-old man, admitted to the facility on 11/5/21. Resident 1 had diagnoses including Type 2 Diabetes. Resident 1 was full code (if a person's heart stopped beating and/or they stopped breathing, all reviving procedures will be provided to keep them alive). A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool to guide resident care) Section G, dated 11/12/21, indicated Resident 1 needed supervision for walking. A review of Resident 1's "Point of Care History... ADLs (Activities of Daily living), How did the resident walk in his /her room?" indicated, Resident 1 was walking with assistant and supervision until 12/25/21. The ADL record further indicated Resident 1 stopped walking from 12/25/21 through 12/29/21, when Resident 1 was transferred to the GACH 1 on 12/29/21. A review of Resident 1's "Nursing weekly summary" indicated Resident 1 was assessed by the nurses on 11/9/21, 11/30/21 and 12/14/21 and it indicated Resident 1 had no skin issue or wound. During a concurrent interview and record review on 9/13/22 at 1:20 p.m., with Regional Director of Clinical Operation (RDCO), Resident 1's nurses weekly skin assessments were reviewed. RDCO confirmed weekly nurse skin assessments were completed for dates 11/9/21, 11/30/21 and 12/14/21. RDCO stated nurses should do weekly skin assessment for residents to identify early issues or wounds and report any abnormality. During an interview on 9/13/22 at 11:11 a.m., with Resident 1's family member (FM) 1, FM 1 stated the family was not able to see Resident 1 due to COVID-19 (a respiratory infection) outbreak at the facility. FM 1 stated, FM 2 visited Resident 1 on 12/28/21 and informed FM 1 and facility nurses that Resident 1's left foot had a cut and bad odor. FM 1 stated she went to the facility and requested the facility to send Resident 1 to the hospital. FM 1 stated Resident 1's left foot was amputated at the hospital on 12/29/21. FM 1 further stated she was very frustrated and angry at the facility's care because Resident 1 would still have his foot if the facility monitored and evaluated Resident 1's foot. During a concurrent interview and record review on 9/14/22 at 10:30 a.m. with the Director of Nursing (DON), Resident 1's Braden Scale (for predicting pressure sore risk) assessment, dated 11/6/21 was reviewed and the score was 18 which means at risk for pressure sore. DON stated Braden Scale needed to be checked upon admission and weekly for four weeks. DON further stated it was important to check the residents' skin weekly to assess, monitor, and address residents' skin situation and skin issues immediately. DON confirmed the nurses did not provide skin assessment for Resident 1 on a weekly basis. DON stated Resident 1's Braden Scale assessment was assessed once only. During an interview on 9/14/22 at 11:58 a.m. with DON, DON stated the licensed nurse who was in charge at the time of discharge was not available for interview, and she was out of country. During an interview on 9/14/22 at 12:30 p.m., with Treatment Nurse (TN), TN stated no nurses reported any wound or skin issue for Resident 1. TN stated he was responsible for completing residents Braden Scale assessments for all residents upon admission and once a week for up to four weeks, and as needed. TN stated nurses usually complete weekly resident skin assessments. TN confirmed he completed a Braden Scale assessment for Resident 1 one time on 11/6/21. A review of Resident 1's "Resident Progress Notes", dated 12/29/21, indicated, "Resident noted declining in ADL's generalized body weakness, used to walk, not walking anymore, poor po (Per Oral) intake. Fluids encouraged. Family requesting to send out to [Acute Care Hospital 1] for evaluation..." A review of Resident 1's care plan for skin care, dated 11/6/21, indicated, "... Goal: Decrease skin dryness and fragility... Approach: Monitor skin during care for bruises, swelling, skin tears, redness, irritation and breakdown, inform MD (Medical Doctor) for interventions, weekly skin check. A review of Resident 1's Braden Scale, dated 11/6/21, indicated Resident 1's Braden Scale was 18 which indicated Resident 1 was at risk for pressure ulcer. A review of Resident 1's general acute care hospital (GACH) document titled, "Podiatric [branch of medicine treating disorders of the foot, ankle, and lower legs] surgery consult note", dated 12/29/21, indicated "... left forefoot [front part of the foot] global gangrene, wet with sloughing epithelium (a break or loose area of corneal epithelium ( the outermost layer of the cornea, whose functions include transparency, and protection from the external environment) larger than 2.0 mm [millimeter, unit of measurement] x 2.0 mm.), left 1st met head full thickness ulcer (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc.) 3x3 cm (centimeter)... Patient has severe pain with probing but this tracks past the level of the ankle joint and had 10cc (cubic centimeters ) of easily expressible pus (a thick yellowish or greenish opaque liquid produced in infected tissue ) and air..." A review of Resident 1's GACH document titled, "Triage Note", dated 12/29/21, indicated "... PT (Patient) coming from []Nursing Facility with a chief complaint of failure to thrive- according to staff PT has become non-verbal over the last several days, refusing to ambulate, eat and drink. Per EMS (Emergency Medical Services) a left wound noted-foul smelling, decaying tissue..." " A review of Resident 1's GACH document titled, "Operative note", dated 12/29/21, indicated Resident 1's left foot was amputated by general surgeon. A review of the facility's policy and procedure titled, "Skin Care Management", updated 5/2020, indicated, "... 3. The initial admission and weekly for 3 weeks screens for patient risk are completed using the Braden Scale... 5. All patients will be checked from head to toe, weekly by a licensed nurse to identify any new pressure ulcer or any other type of skin breakdown..." In violation of the above cited standards, the facility failed to ensure Resident 1 received comprehensive skin monitoring and assessment, when Resident 1's left foot wound with infection was not monitored, assessed, and evaluated.