Health inspection·November 16, 2023

F600 Free from Abuse and Neglect 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 1/18/23 at 9:35 a.m., an unannounced visit was conducted at the facility to investigate complaint CA00820959 regarding a patient (Resident 1) who presented to an emergency department with "significant infections," to bilateral (both) hands, feet, and buttocks. Resident 1 was readmitted to the facility in December 2022 with a moderate risk for the development of pressure wounds (damage to the skin and underlying tissue caused by reduced blood flow to the area due to constant pressure on the area; also known as pressure ulcers), was dependent on staff for care, and had a known history of nail/finger biting. The facility neglected to provide appropriate interventions and monitoring surrounding the nail/finger biting, and the wound on the buttocks, which resulted in "partial amputations," and "open wounds," to bilateral fingers, as well as a worsening pressure sore to the buttocks. This led to severe infections and hospitalization of Resident 1. The facility failed to ensure necessary services were provided to avoid physical harm for one resident (Resident 1), for a census of 84, when: 1. Resident 1 had no care plan and monitoring for an identified behavior of biting his own fingers and treatments for the self-inflicted bite wounds were not consistently provided as ordered by the physician; 2. Resident 1 did not receive treatments or interventions to prevent skin breakdown and to decrease the likelihood of developing pressure wounds; and 3. Resident 1 was not monitored while on antibiotic (anti-infectives, used to treat infections) and the primary physician was not notified of the worsening bite wounds on bilateral hands/fingers. These failures resulted in Resident 1's admission to the acute care hospital for infected wounds on bilateral hands and pressure wounds on his buttocks. Findings: A review of the Admission Record indicated Resident 1 was initially admitted in August 2022 and subsequently in the middle of December 2022 with diagnoses including acute and chronic respiratory failure (develops when the lungs cannot get enough oxygen into the blood) and acute and chronic congestive heart failure (occurs when the heart muscle does not pump blood efficiently as it should). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/21/22, indicated the following: -Resident 1 had both short and long-term memory problems; -Resident 1 was totally dependent on staff for Activities of Daily Living (ADL- self-care activities); -Resident 1 was frequently incontinent of bowel; and -Resident 1 was at risk of developing pressure wounds. Resident had no pressure wound on admission, and no other open areas on the skin on admission. A review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk dated 12/15/22, with a score of 14 indicates Resident 1 had moderate risk of developing a pressure ulcer. A review of Resident 1's progress note dated 12/15/22, at 17:30 (5:30 p.m.), written by Licensed Nurse 1 (LN 1) indicated, "Admitted [Resident 1] ...needs total care with adls [sic]...skin assessment done no wounds..." A review of Resident 1's progress note dated 12/15/22, at 21:00 (9 p.m.) indicated, "[Resident 1] ... Combative to staff during assessment...otherwise skin intact...Spoked with wife...Wife aware of [Resident 1's] non-compliance behavior, also verbalized [Resident 1] with history of biting finger nails off, no episode noted at the moment..." A review of Resident 1's progress note dated 12/17/22, at 7:24 p.m. indicated, "...wife at bedside until 2100 [9 p.m.]. Checked and monitored resident with attempts to bite hand/fingers, No attempts on this shift noted." A review of Resident 1's Change in Condition Evaluation dated 12/18/22 (3rd day of admission), at 7:10 p.m., indicated, bite wound on back of right hand, index finger and thumb knuckle. Resident 1's primary physician was notified and there was a recommendation for wound care. A review of Resident 1's Treatment Administration Record (TAR) for December 2022 did not include wound care orders for the right index finger and thumb knuckle wound on 12/18/22. A review of Resident 1's progress note dated 12/18/22, at 7:35 p.m., indicated, "[Resident 1] on COC [change of condition] for bite wound at his right index finger, Called on-call [Nurse Practitioner - NP]. Per NP to do wound care." A review of Resident 1's physician's orders indicated that there was no treatment order obtained on 12/18/22, for the bite wound on the right hand specifically on the right index finger and thumb knuckle. A review of Resident 1's physician order dated 12/21/22 (three days later) indicated, "Saline Solution [solution with the same salt content as body tissues] ...Apply to 2nd digit [index finger] of left hand topically [on the skin] every day shift for Wound Management [sic]...pat dry, apply dry dressing." A review of Resident 1's record indicated there was no documented evidence of the date and time the wound on the 2nd digit of the left hand was identified. A review of another physician order dated 12/21/22, for Resident 1 indicated, "Monitor 2nd digit finger for sign of [sic] symptoms of infection every shift and noted notify md. [medical doctor] every day and night shift..." A review of Resident 1's Treatment Administration Record (TAR) for December 2022 for monitoring of second digit for signs & symptoms of infection indicated blank spaces and no signatures on 12/22/22, 12/23/22, 12/25/22, and 12/31/22 on night shifts and blank spaces and no signatures on 12/27/22, 12/29/22, and 12/30/22 for day shifts for the above treatment. A review of Resident 1's "COMS - Skin Only Evaluation" dated 12/22/22, indicated, "... [Resident 1] received in bed...Allowed treatment nurse to assess injuries to bilateral 2nd finger. Noted traumatic wound on admission...Resident has poor impulse control attempt to get to finger to bite..." A review of Resident 1's physician order dated 12/22/22, indicated, "Betadine Solution [an iodine-based germ-killing solution] ...apply to bilateral 2nd digit topically every day shift for Wound Management [sic]...cover with dry dressing." A review of Resident 1's TAR for December 2022 for the Betadine solution to bilateral 2nd digit indicated a blank space for 12/27/22 and 12/28/22. A review of Resident 1's physician order dated 12/23/22, indicated, "OK FOR HAND MITTEN ON BOTH HAND X 14 DAYS FOR WOUND TO HEAL AND KEEP [Resident 1] FROM BITING SELF (FINGERS/HANDS)." A review of Resident 1's progress note dated 12/25/22, at 7:54 a.m. indicated, "[Resident 1] awake at 0300 [3 a.m.] ...At 0445 [4:45 a.m.], [Respiratory Therapist] reported to this nurse that resident bit his right index finger. Old wound opened and was bleeding...Called and spoke to on-call [Nurse Practitioner] ... [Resident 1] has order for mitten on both hand x 14 days for wound healing...Left a note for mittens to be ordered and consent to be signed by wife..." A review of Resident 1's consents indicated there was no documented evidence an informed consent for hand mitten was obtained from Resident 1's wife from 12/23/22 to 1/3/23. A review of Resident 1's Medication Administration Record (MAR) from December 1-31,2022, indicated, "X" for the order of hand mitten on both hands and a D/C [discontinue date] of 1/4/23. A review of Resident 1's TAR from December 2022 did not include an order for hand mitten. A review of Resident 1's care plan initiated on 12/25/22 indicated, wound management on 2nd digit with interventions to monitor ulcer for signs of progression or declination, to notify provider if no signs of improvement on current wound regimen and to provide wound care per treatment order. A review of Resident 1's "Shower Skin Inspection" dated 12/26/22, indicated, "reddened area" on the buttocks. The document was signed by a CNA [Certified Nursing Assistant] and a licensed nurse. A review of Resident 1's medical record indicated there was no documented evidence of the primary physician being notified of Resident 1's reddened area on the buttocks and there was no treatment order obtained on 12/26/22. A review of Resident 1's progress note dated 12/27/22, at 18:03 [6:03 p.m.] indicated, "... [Resident 1] had an episode of biting on fingers causing them to bleed. Wrapped fingers with kerlix [gauze wrap] and applied arm braces [used to prevent bending of the elbow so that fingers cannot reach the mouth] ..." A review of Resident 1's physician order dated 12/28/22, indicated, "Collagen Hydrolysate Powder [collagen, or protein broken down into smaller units to assist in wound healing] ...Apply to RT [right] Doral [sic, dorsal; upper/back side] foot topically every day shift for Truamatic [sic] wound left hand dorsal 2nd finger..."ÿÿThe order was written for the right dorsal foot instead of the right hand [index finger]. A review of Resident 1's TAR for December 2022 for the Collagen powder treatment had blank spaces or no signatures on 12/29/22 and 12/30/22. The treatment was initiated on 12/31/22, three days after being ordered. A review of Resident 1's "COMS - Skin Only Evaluation" dated 12/28/22 indicated, "...Wound rounds done...by wound MD... left hand distal [end section farthest from the hand] 2nd finger self inflicted trauma- 80% slough [dead tissue separating from living tissue] ...Right hand dorsal 2nd finger, increased in size...mod [moderate] purulent [containing pus] drainage..." A review of Resident 1's medical record indicated there was no documented evidence of Resident 1's primary physician being notified of the clinical changes on bilateral 2nd finger wounds. A review of Resident 1's physician order dated 12/28/22, indicated, "Place bilateral weighted arm sleeves [used to help prevent inserting fingers into the mouth] daily, monitor every shift, if dislodged replace, every day and night shift for Management of bilateral 2nd finger injury." A review of Resident 1's TAR for December 2022 had blank spaces or no signatures on 12/29/22 and 12/30/22, on day shift for the bilateral weighted arm sleeves treatment. Resident 1's TAR for January 2023 had no signatures on 1/6/23, 1/8/23, and 1/9/23 for day shifts and no signature on 1/7/23 for night shift for the bilateral weighted arm sleeves. A review of Resident 1's Surgical Consult by the Wound Medical Doctor (WMD) dated 12/28/22, indicated the reason for the visit was to evaluate the wounds because Resident 1 continued to have the self-injurious habit of chewing on his fingers. The right dorsal 2nd finger had purulent drainage, necrotic tissue (dead tissue), 40 % slough, pre-debridement (before removing the dead tissue) measurement of 6 cm (centimeters, unit of measurement) x 4 cm x UTD (undetermined) with undermining (significant erosion occurs underneath resulting in more extensive damage beneath the skin surface) of 1.7 cm at 5 O'clock. The left-hand distal 2nd finger had no signs of infection, 80% slough, with pre-debridement (before removal of dead or injured tissue) measurement of 5 cm x 3.5 cm x UTD (unable to determine). The assessment and plan indicated protective devices were needed to prevent worsening injury or possible amputation. A review of Resident 1's medical record indicated there was no documented evidence of the primary physician being notified of Resident 1's wound on the right-hand dorsal 2nd finger having purulent drainage and necrotic tissue as documented by the WMD on 12/28/22. A review of Resident 1's Surgical Consult from the WMD dated 1/5/23, indicated the right hand dorsal second finger had signs of infection: purulent drainage, erythema (redness), malodorous (foul smelling) tissue, 100 % slough. The left-hand distal 2nd finger had no signs of infection with 90% slough. A review of Resident 1's Change in Condition Evaluation dated 1/5/23, indicated purulent drainage on right 2nd digit and the primary physician was notified on 1/5/23, at 7:34 p.m. There was no recommendation written. A review of Resident 1's physician order on 1/5/23, at 19:48 [7:48 p.m.] obtained by phone indicated, "Doxycycline Monohydrate Suspension Reconstituted [antibiotic] 25mg [milligram, unit of measurement]/5ml [milliliters, unit of measurement]. Give 20 ml ... two times a day for Right 2nd digit purulent drainage." A review of Resident 1's MAR for January 2023 indicated the antibiotic order was started on 1/6/23, at 8 a.m., over 12 hours from the time the antibiotic was ordered. A review of Resident 1's medical record indicated there was no documented evidence of Resident 1's primary physician being notified of the delay in the administration of the antibiotic ordered. A review of Resident 1's physician order dated 1/11/23, indicated, "Triad Hydrophilic Dress Paste [Wound Dressings] Apply to bilateral buttock topically everyday shift for Wound Management [sic]..." The treatment order was obtained 15 days after the reddened bottom was reported on 12/26/22. There was no assessment of the bilateral buttocks in the clinical records. A review of Resident 1's medical record indicated there was no documented evidence of monitoring of Resident 1's response to the antibiotic treatment from 1/6/23 to 1/10/23. A review of Resident 1's Change in Condition Evaluation dated 1/11/23, at 11:27 a.m. indicated, "...Wound md [sic, physician] present on site Noted [sic] swelling to right hand related to wound infection to right 2nd digit, currently taking [sic] atb [antibiotic]...not effective...NP notified of wound, advise to send out [to hospital]." In a concurrent interview and review of Resident 1's medical record on 1/18/23 starting at 1:12 p.m., the Director of Nursing (DON) stated Resident 1's bite marks were present since admission on 12/15/22 and Resident 1 had no pressure wounds. The DON further stated Resident 1 was monitored for biting and they tried the "puffy things" for the arms. The DON confirmed Resident 1 had episodes of biting from the previous admission. The DON stated Resident 1 was sent out to the acute care hospital on 9/17/22 for possible aspiration (the accidental breathing in of food or fluid into the lungs) due to chewing on his fingers and on 9/19/22, Resident 1 was readmitted to the facility from his acute hospital stay and Resident 1 was observed to bite on his hands/fingers, lip and this created a wound to his right index finger. During the concurrent interview and review of Resident 1's medical record on 1/18/23 starting at 1:12 p.m., the DON was not able to provide documented evidence of Resident 1 being monitored for the biting of hands/fingers since 12/15/22. In a telephone interview on 1/24/23, at 3:04 p.m., the DON stated a new antibiotic order should be given within four hours. The DON further stated if the antibiotic was not available in the Emergency kit [E-kit - emergency medication supply], the facility should notify the physician for the antibiotic to be given the following day. A concurrent telephone interview and review of Resident 1's medical record was conducted on 1/25/23 starting at 3 p.m. with the LN 2. The LN 2 stated she was the treatment nurse from October 2022 to 1/16/23. The LN 2 stated she was made aware from other licensed nurses of Resident 1's behavior of biting his fingers from his previous admission. The LN 2 confirmed Resident 1 had no behavior monitoring for biting of fingers. The LN 2 stated she observed Resident 1 with the arm weights and the LN 2 had no observation of Resident 1's use of hand mittens. The LN 2 confirmed she wrote Resident 1's "COMS - Skin Evaluation Only" dated 12/22/22. The LN 2 was unable to explain why she had the documentation on 12/22/22 when she was