Health inspection·January 4, 2024

F686, Treatment/CVCS to Prevent/Heal Pressure Ulcer Section 483.25(b) Skin Integrity Section 483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Title 22, Section 72311, Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. Title 22, Section 72523, Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/3/23 at 1:50 p.m., an unannounced visit was conducted at the facility to investigate complaints regarding quality of care. The California Department of Public Health (CDPH) determined the facility failed to evaluate resident specific risk factors and changes in health conditions that caused the development of pressure ulcers (an injury that breaks down the skin and underlying tissue caused by being in one position for too long) for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 1's nursing assessment was not completed on 8/3/23 upon the discovery of a stage three pressure ulcer (affecting the deepest layer of your skin) to Resident 1's ischial tuberosity (also known as the "sitting bone", as this is where the weight of the body is held when seated); and, 2. Resident 2's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 2's nursing assessment done on 8/8/23 was not completed upon the discovery of a stage two pressure ulcer (Partial thickness loss of the middle layer of skin presenting as a shallow open ulcer) to Resident 2's tailbone. These failures led to the development of a stage three pressure ulcer to Resident 1's right ischial tuberosity and the development of a stage two pressure ulcer to Resident 2's tailbone. 1. A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on 4/19/23 with diagnoses which included weakness on the right side of the body, hyperglycemia (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body ) chronic wounds (a wound that does not heal in a predictable amount of time), edema (swelling caused by too much fluid trapped in the body's tissues) to both lower legs and nicotine dependence. A review of Resident 1's Quarterly Minimum Data Set (MDS, an assessment tool), dated 7/9/23, revealed a score of "12" on the Brief Interview for Mental Status which indicated slight cognitive impairment. Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers and was not on a turning/repositioning program. Resident 1's mobility documented on the 7/9/23 MDS indicated Resident 1 did not walk, needed the assistance of two people for bed mobility and transfers, and used a wheelchair. The MDS also revealed Resident 1 was frequently incontinent of bowel and bladder (little or no control of bowel and bladder function) and was not on a toileting program (scheduled or prompted use of the bathroom for bowel or bladder retraining). A review of Resident 1's assessment titled, " ...Bowel and Bladder Screener ...", dated 7/3/23, revealed a score of "9" which indicated Resident 2 was a " ...good candidate for retraining [bladder retraining] ..." During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Licensed Nurse (LN) 1 confirmed Resident 1 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 1's assessment titled, "BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK [an assessment used to determine if a resident is at risk for developing pressure ulcers]", dated 4/19/23, revealed a score of "18" which indicated Resident 1 was at risk of developing pressure ulcers on admission to the facility. The next Braden completed was dated 7/3/23 and revealed a score of "13" which indicated a moderate risk for developing pressure ulcers (at risk 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below). During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's meal intake for the months of July, August, and September of 2023 were reviewed. LN 1 confirmed Resident 1 was on a low salt, double portioned diet and that in July facility staff did not document Resident 1's meal intake for breakfast 7 times, for lunch 8 times, and for dinner 3 times. Resident 1 refused three meals, ate 0-25 percent of his meals 10 times, and ate 26-50 percent of his meals 12 times. In August of 2023, facility staff did not document Resident 1's meal intake for breakfast 11 times, and for lunch 12 times. Resident 1 refused 11 meals, ate 0-25 percent of his meals 11 times, ate 26-50 percent of his meals 5 times, and N/A (non-applicable) was documented 2 times. In September of 2023 Resident 1 was in the facility for 12 days. Facility staff did not document Resident 1's meal intake for breakfast 5 times, and for lunch 7 times. Resident 1 ate 0-25 percent of his meals 6 times and ate 26-50 percent of his meals 2 times. LN 1 confirmed Resident 1 consumed 50 percent or less of his meals over half of the time and there was no offer of an alternative meal documented or any type of calorie replacement supplements ordered. LN 1 confirmed the findings and verified poor nutrition was a risk factor for the development of pressure ulcers. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's weights were reviewed. On 4/25/23 (six days after admission), Resident 1 weighed 235.4 pounds. And on 8/1/23 (three months after admission), Resident 1 weighed 202 pounds. LN 1 stated Resident 1's weight loss was attributed to a medication used to reduce the fluid accumulation in his lower legs. LN 1 confirmed Resident 1 was admitted to the facility with 2-3+ pitting edema (a score given to measure how long it takes for the skin to rebound after being pressed) to both lower legs according to his admission assessment dated 4/19/23. A review of Resident 1's daily nursing monitors to measure the edema revealed from 8/1/23 to 8/14/23 Resident 1 continued to have 2-3+ pitting edema. From 4/25/23 to 8/1/23, Resident 1 lost 33.4 pounds (a 14 percent loss). During an interview on 11/10/23, at 12:38 p.m., LN 1 stated pressure ulcer risks for Resident 1 included being a daily smoker, refusal of care, incontinence, right sided weakness, right sided hand, and knee contractures (a fixed tightening of muscle, tendons, and ligaments which prevents normal movement of the associated body part) and a decline in mobility. LN 1 stated on admission in early 2023 Resident 1 was able to transfer himself from bed to his wheelchair, and around June of 2023 Resident 1 was no longer able to transfer himself and required staff to use a lift device to transfer Resident 1. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans and clinical record were reviewed with LN 1. The first care plan reviewed, dated 4/27/23, indicated, " ...Focus ...alteration in skin integrity due to: edema, PVD [peripheral vascular disease, a disease affecting the veins], stasis ulcers [a wound that takes longer to heal due to vein and blood flow issues] ...Interventions ...Assess/record changes in skin status ...avoid pressure ...complete skin report weekly ..." LN 1 confirmed the nurses required weekly summary of Resident 1, the summary should include a skin report. LN 1 verified in June 2023 two summaries were completed (out of 4), and one summary in August 2023 (out of 4) was completed. An additional care plan reviewed, dated 5/1/23, indicated, " ...[Resident 1] has potential for impairment to skin integrity r/t [related to] ...venous stasis ulcers ...to lower extremities, with episodes of incontinence ...he is at risk for further skin breakdown ...Interventions ...Monitor for skin breakdown/pressure ulcer formation daily ..." LN 1 confirmed the Resident 1's "at risk for skin breakdown care plans" did not include other identified risk factors such as being a daily smoker, poor mobility, refusal of care, weakness on the right side, and contractures. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's nurses notes were reviewed with LN 1. LN 1 confirmed there was not a progress note, a change in condition note, or any other type of entry from a nurse that Resident 1's pressure ulcer to his right ischial tuberosity was assessed for cause, location, stage, size (length, width, depth), odor, or necrotic/eschar tissue (dead skin tissue). LN 1 acknowledged there should have been documentation on the pressure ulcer to monitor if the pressure ulcer was improving or worsening. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans were reviewed with LN 1. LN 1 confirmed on 8/3/23 a care plan was initiated which read, " ...Focus ...[Resident 1] has cellulitis (a skin infection) to wound right ischium UTD [unable to determine, unable to see the wound entirely due to dead skin tissue] PU [pressure ulcer] ...Goal ...The resident will have no complications resulting from the cellulitis through the review date ...Interventions ...Educate the resident that prevention of cellulitis starts with good hygiene ...importance of compliance with showers and turning and repositioning ...give antibiotics ...monitor/document and report to MD [medical doctor] the following symptoms of Cellulitis ...WOUND/DRESSING per MD order ..." LN 1 confirmed the care plan was geared towards the potential infection of the pressure ulcer as opposed to person centered interventions to treat/heal the pressure ulcer. LN 1 confirmed there was never a specific care plan initiated for the pressure ulcer discovered on 8/3/23 to Resident 1's right ischial tuberosity outlining interventions to prevent worsening of the pressure ulcer. A review of Resident 1's Physician Assistant's (PA) note, dated 8/9/23, indicated the PA examined Resident 1 on 8/9/23 (six days after the discovery of the pressure ulcer) which read, " ...complaints: none ...Skin ...exam ...yes ..." Further review of the note revealed under the area for the PA to write a "Plan" the area was blank. A review of Resident 1's wound physician's note, dated 8/10/23, indicated, " ...Patient has a large pressure injury on right ischium. He now spends most of his time in his wheelchair. I discussed repositioning with him. I also am recommending a LAL mattress [an air mattress that redistributes pressure] and a Roho cushion [a chair cushion designed to relieve pressure] for his wheelchair ...Initial wound encounter measurements are 7cm [centimeters, a unit of measure] length x 6.5cm width with no measurable depth, with an area of 45.5 sq [square] cm ...wound bed has 100% eschar ...surgical debridement ...removed ...necrotic/eschar ...used ...scalpel ...post debridement measurements: 7cm length x 6.5cm width x 3cm depth ..." A review of Resident 1's wound physician's note, dated 8/17/23, indicated, " ...Right Ischium is a Stage 3 Pressure Injury ...no change in the wound progression ..." During an interview on 10/26/23, at 5:24 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 would get up into his wheelchair on the day shift and not go back to bed until approximately 9 p.m. " ...[Resident 1] would just want to stay in his chair ...we told nurses every time he did not want to go back to bed. Sometimes he won't let us change him either ..." During an interview on 11/1/23, at 11:29 a.m., the Director of Nursing (DON) stated Resident 1 should have had a Roho cushion prior to the pressure ulcer forming because he shifted to one side due to his right sided weakness and was up in his wheelchair most of the time which put him at risk for skin injury or further skin injury. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 1 spent more time up in his wheelchair than in bed. LN 1 stated there was no documentation to verify that Resident 1 was being repositioned in his wheelchair or in bed. LN 1 confirmed Resident 1's Roho cushion and LAL mattress were not added to a care plan. LN 1 added care plans were the documented plan of care the resident should receive. LN 1 verified, prior to 8/10/23, Resident 1 did not have any other pressure relieving devices to help prevent pressure ulcers except for the same mattress every resident had in the building. A review of Resident 1's change in condition nurse's note, dated 9/12/23, indicated, " ...Resident [1] presented with ...foul odor from wound to R [right] ischium, lethargic [drowsy], pale and clammy ...MD advised to send resident to acute for further evaluation for ...sepsis [body's extreme reaction to an infection. Without prompt treatment, it can lead to organ failure, tissue damage and death] ..." 2. A review of Resident 2's face sheet indicated Resident 2 was admitted to the facility in mid-2023 with diagnoses which included diabetes (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs which can cause fatigue, constipation, and dry skin), overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control), and had a history of urinary tract infections (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system.) A review of Resident 2's Quarterly MDS, dated 8/13/23, revealed a score of "4" on the BIMS which indicated significant cognitive impairment. Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers, had a stage two pressure ulcer (developed three months after admission), and was not on a turning/repositioning program. Resident 2's mobility documented on the 8/13/23 MDS indicated Resident 2 needed the assistance of one person for bed mobility and transfers and used a wheelchair. The MDS also revealed Resident 2 was frequently incontinent of bowel and bladder and was not on a toileting program. A review of Resident 2's assessment titled, " ...Bowel and Bladder Screener ...", dated 8/10/23, revealed a score of "9" which indicated Resident 2 was a " ...good candidate for retraining ..." During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 2 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 2's assessment titled, "BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK", dated 5/17/23, revealed it was blank (not completed on admission to the facility). The next Braden was completed on 8/10/23 and revealed a score of "16" which indicated Resident 2 was at risk for developing pressure ulcers. During a concurrent interview and record review on 10/26/23, at 4:49 p.m., LN 1 confirmed Resident 2's 5/17/23 Braden assessment was incomplete