Health inspection·May 2, 2024

F687 Foot Care 483.25 Section 483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. California Code of Regulations, Title 22, Section 72301(d) Required Services Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. California Code of Regulations, 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. California Code of Regulations, Title 22, Section 72523(a). Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/1/24 at 8:55 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding concerns of quality of care related to foot care. The department determined, between 12/4/23 and 2/13/24, the facility failed to: 1. Monitor and assess Patient 1's wound, located on the second toe of the right foot, per nursing standards; and, 2. Provide transportation services to Patient 1's podiatry (the medical care and treatment of the human foot) appointments. These failures led to Patient 1 not receiving thorough foot care which led to a partial right foot amputation (surgical removal of part of the body). A review of Patient 1's face sheet, dated 3/1/24, indicated Patient 1 was admitted to the facility on 11/11/20 with diagnoses which included: peripheral vascular disease (PVD, a narrowing of a blood vessel which decreases circulation of blood to a body part), diabetes (DM 2, a chronic condition that affects the way the body processes blood sugar, which slows the body's ability to heal wounds), heart failure (CHF, when the heart does not pump blood efficiently throughout the body), peripheral neuropathy (nerve damage that can cause weakness, numbness, and pain that usually affects the hands and feet), history of diabetic foot ulcer (wound on foot that develops in people with diabetes), osteomyelitis (swelling caused by infection of the bone) and partial left foot amputation. A review of an electronic mail (e-mail), dated 10/9/23 at 11:51 a.m., indicated Patient 1 had an appointment with his Podiatrist (a medical professional who specializes in the treatment of disorders of the foot, ankle, and related structures of the leg) on 10/11/23 at 11 a.m. Patient 1 missed this appointment and there was no documented reason in his facility medical record. A review of an e-mail, dated 11/3/23 at 1:22 p.m., indicated Patient 1 had an appointment with his Podiatrist on 11/7/23 at 11:10 a.m. Patient 1 missed this appointment and there was no documented reason in his facility medical record. A review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 11/23/23, indicated Patient 1 had no memory impairments. A review of Patient 1's care plan, created on 12/3/20 and edited on 11/27/23, indicated, "Problem...Self care deficit r/t [related to] h/o [history of] osteomyelitis of [left] foot with partial foot amputation, PVD, DM 2 with peripheral neuropathy, CHF...Goal...Resident will be able to function at the highest possible level as evidenced by X [times] 3months [sic]...Approach...[nurses will] Shower/Bathe two times each week as scheduled..." A review of Patient 1's care plan, edited 11/27/20 and on 11/27/23, indicated, "Problem...At risk for impaired skin integrity r/t...decreased sensation to BLE [both lower extremities] hitting...against bed/bedside table and is unaware of the incident...[h/o] left partial foot amputation...Approach...Licensed nurse to assess resident skin head to toe weekly...Monitor feet/heels for s/s [signs and symptoms] of skin breakdown, poor circulation such as redness, dry skin and/or open area. Notify MD [medical doctor] if found...Observe skin for s/s of skin breakdown...Podiatry as ordered...Wound consultant as needed..." A review of Patient 1's order summary report indicated, "...[Starting on 12/4/23, nurses were to] Dry scab to right 2nd toe...leave area open to air. Monitor area daily. Every day shift..." This order summary report also indicated an order for, "Podiatry for skin/nail problem conditions...order date 12/23/23." A review of a nurse progress note dated 12/24/23 at 12:45 p.m. indicated, "[Patient 1] was taking off his [Left] leg/foot brace [with] right foot and upon doing so tore right second toe ulcer scab and started bleeding, cleaned...wrapped [with gauze], Treatment nurse made aware of incident." A review of Patient 1's "Orders- Administration Note" written by the Treatment Nurse 2 (TN 2), dated 1/11/24 at 1:46 p.m., indicated, "Dry scab to right 2nd toe... leave open to air. Monitor area daily. Every day shift. Scab re-opened; covered with bandaid, MD notified..." A review of Patient 1's "SNF [Skilled Nursing Facility] Custodial Visit", dated 1/30/24, by Patient 1's Primary Care Physician (PCP), indicated no documented evidence Patient 1's right foot had been assessed. A review of Patient 1's "SNF Visit and Generalized Body Pains" note written by the Nurse Practitioner 1 (NP 1), dated 2/9/24 for a visit conducted on 2/8/24, indicated, "[Patient 1] tells me he feels 'achy' and didn't want to eat much this morning...last saw [Podiatrist] 9/28/23, was to follow up in one month? Was a now [sic] show for podiatry appts in October, Nov, December...Extremities- has dry scab on right foot second toe, old healed scabs from scratching on legs...2/9/24 labs now show WBC [white blood cell count] 19.2 [expected range 5-10]...DM 2 [with] ULCER OF RIGHT FOOT Unchanged, not sure why patient was no show will message [nurse] to call SNF with appointment..." A review of a nurse progress note dated 2/10/24 at 2:07 p.m. indicated, "[Patient 1] on [oral antibiotic for] foot infection...foot has scabbed. [Patient 1] encouraged not to pick at scabs...will continue to monitor." A review of a weekly wound observation tool, dated 2/12/24 at 4:50 p.m., indicated, "...Wound type...Diabetic ulcer...Describe other...Probably moisture-related...Present upon admission...No...What date wound was identified...2/12/24...Length...1.3 cm [centimeters, a unit of measurement]...Width...1.5 [cm]...Depth...0.2 [cm]...Exudate [fluid that leaks out of blood vessels into nearby tissues which may ooze from cuts or from areas of infection]...Moderate...Exudate Type...Serosanguineous [thin, watery, pale, red/pink drainage] [and] purulent [containing pus] thick, opaque [cannot see through], tan/yellow drainage...Wound Stage...Stage 3: full thickness skin loss ...Describe Wound Edge/Margin...Erythema : [Redness of the skin]...Unable to fully visualize wound bed due to location. Wound edges are erythematous [abnormal redness of the skin]" A review of a skin/wound note, dated 2/12/24 at 4:55 p.m., indicated, "[Patient 1] is not sure how injury occurred. He has a [history] of diabetic neuropathy [nerve damage caused by diabetes that can cause weakness, numbness and pain that usually affects the hands and feet] and has frequent injuries to bilateral lower extremities that he cannot recall. Spoke with [staff] at [Podiatrist's] office...who states [Patient 1] has missed several recent appts over the last few months but has scheduled appt with wound care this Fri., 2/16. Office informed of new wound and states a message will be sent to [Podiatrist] in the meantime...[NP 1] informed...[NP 1] will photograph wound in [morning]..." A review of telephone encounter note from Podiatrist 1 (PD 1), dated 2/13/24, indicated, "...it does appear that [Patient 1] has missed several appts [appointments]-both with preventative RN [Registered Nursing] staff AND me over past year...[NP 1] to assess for the infection... if there is infection, patient should be seen in [Emergency Room]..." A review of a "SNF Transfer and Toe Problem" note, dated 2/13/24 at 4:10 p.m., indicated, "... [Patient 1] toes had multiple scabs but today his right foot second toe is edematous, macerated [softening and breaking down of skin resulting from prolonged exposure to moisture] with what looks like necrotic tissue [dead tissue] between, the toes...Transfer to ED [Emergency Department] for further evaluation, high risk patient..." A review of a nurse progress note dated 2/13/24 at 5:01 p.m. indicated, "Received orders to send [patient 1] to hospital to r/o [rule out] sepsis [a severe response to infection which can lead to organ damage] r/t [related to] second toe wound." A review of Patient 1's skilled nursing facility discharge summary, dated 2/13/24, indicated, "...[Patient 1] is a long term care patient...after...left midfoot amputation...today his right foot second toe is edematous, macerated with what looks like necrotic tissue between the toes...transfer to ED for further evaluation, high risk patient..." A review of Patient 1's hospital ED treatment note, dated 2/13/24, indicated, "[Patient 1]...present with concerns for an ulcer between his right toe...there is some necrotic tissue along the lateral aspect [the side] of the second toe with ulceration [break in skin]..." A review of Patient 1's hospital podiatry consult note, dated 2/14/24, indicated, "[Patient 1]...Patient present with ongoing swelling, infection to the right lower extremity second digit [toe or finger]. Positive probe to bone, indicative of osteomyelitis...Podiatry team will plan for right foot second digital amputation on 2/14/24..." A review of Patient 1's hospital discharge summary, dated 2/29/24, indicated, "...hospital course and significant findings...admitted with diabetic ulcer right foot, s/p [status post] TMA [transmetatarsal amputation, surgery to remove part of foot] [2/24/24]..." In an interview on 3/1/24 at 9:10 a.m., the Executive Director (ADM) stated the facility's Social Services Coordinator (SSC) was expected to arrange transportation services to outside appointments, such as podiatry appointments, for long term patients. In an interview on 3/1/24 at 12:27 p.m., Patient 1 stated the facility was supposed to set-up transportation to his podiatry appointments and he was aware he had missed at least one podiatry appointment. Patient 1 stated staff did not explain why he had missed his podiatry appointments. Patient 1 confirmed he developed a wound on his right foot in December of 2023. Patient 1 stated he was upset and felt the care of his foot had not been prioritized. In an interview on 3/1/24 at 1:25 p.m., Licensed Nurse 1 (LN 1) stated she cares for patients who have wounds by reviewing the documented history of the wound(s) and carefully reading the treatment administration record. In an interview on 3/1/24 at 1:35 p.m., Certified Nursing Assistant 2 (CNA 2) stated if staff did not monitor skin issues, then open wounds could become infected and can affect the bone which can change the way a patient can function. The CNA 2 added the infection could be painful and cause the patient to not want to eat. In an interview on 3/1/24 at 1:50 p.m., Treatment Nurse 1 (TN 1) confirmed she worked at the facility as a dedicated treatment nurse. As a treatment nurse, TN 1 stated she attended weekly wound meetings with the Assistant Director of Nursing (ADON) to discuss concerning wounds. The TN 1 stated she was expected to conduct and document weekly assessments of patient wounds. In an interview and concurrent record review on 3/1/24 at 2:37 p.m., the ADON stated a wound that was persistent for two months would have been discussed in the weekly wound meeting which consisted of the ADON, the unit manager, treatment nurses, and a dietician. The ADON also stated she expected persistent wounds to be documented at least weekly to determine if it was improving or worsening. The ADON stated she believed Patient 1's dry scab on the right second toe had healed but was unable to provide documentation the wound had resolved. The ADON stated she could not recall discussing Patient 1's wound in any of the weekly wound meetings or interdisciplinary team meetings and verified Patient 1's medical chart showed no documented evidence of such discussions between December 2023 and February 2024. The ADON acknowledged, based on documentation available, the wound on Patient 1's right second toe had been present from December 2023 to February 2024. The ADON stated transportation for outside appointments were arranged by the social services department. The ADON further stated if there is no documentation in the patient's chart, then it was not done. In an interview on 3/1/24 at 3:30 p.m., the Social Services Director (SSD) stated the social services department arranged transportation to outside appointments when the nurse notified them of the patient's appointment. The Social Service Coordinator (SSC) then communicates to the nursing unit of the confirmed transportation. The SSD stated the unit nurses were responsible for getting the patient up and ready for transportation. In an interview on 3/1/24 at 3:40 p.m., the SSC confirmed she arranged for transportation for Patient 1's podiatry appointments. The SSC stated she was first made aware of Patient 1's missed podiatry appointments in early February of 2024 by the NP 1. The SSC stated the last podiatry appointment transportation she arranged for Patient 1 was in November 2023. In an interview on 3/20/24 at 9:18 a.m., the SSC stated there was a failure in communication which led to Patient 1's missed podiatry appointments. In an interview on 3/20/24 at 9:55 a.m., License Nurse 2 (LN 2) stated a patient with diagnoses of PVD and DM 2 would have a risk of developing wounds and added vascular and diabetic ulcers are difficult to treat and heal. The LN 2 stated he expected each wound to have a care plan which included monitoring and documentation of the monitoring. The LN 2 further stated measurements of the wound needed to be documented to determine its progress. An interview on 3/20/24 at 10:20 a.m., Treatment Nurse 2 (TN 2) accessed Patient 1's medical records on her computer. The TN 2 stated she had been monitoring Patient 1 for a "non-healing" scab since December 2023. The TN 2 stated she monitored the wound by looking at it and wo