Other·October 28, 2022

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 (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of physician regarding sudden or marked adverse change in a patient's condition. On 8/03/2022 at 1:42 p.m., an unannounced visit was conducted at the facility to investigate a complaint of patient quality of care. The department determined the facility failed to do the following: 1) Follow their policy for comprehensive care planning to develop and implement a comprehensive person-centered care plan for Patient 1 based on admission diagnosis and assessment when Patient 1 was admitted with peripheral vascular disease (PVD - a slow and progressive circulation disorder) and was not monitored or treated appropriately for signs of impaired circulation and, 2) Follow their policy for Change in a Resident's Condition or Status to notify or consult the Director of Nurses (DON) or a primary care provider of a change of condition for Patient 1 when Patient 1 was noted to have a purple discoloration to the left foot and no one was notified of the change of condition for 24 hours. These failures led to a delay in the provision of physician services, a delay in treatment, and the subsequent amputation of Patient 1's left lower leg. According to an acute care hospital Inter-Facility Transfer Report, dated 7/4/22, Patient 1 was a 74-year-old female with multiple hospital problems including, chronic PVD, atherosclerosis (hardening or thickening from plaque buildup in arteries and veins) of native arteries of the left leg with ulceration (open sores or wounds) of other parts of the lower leg, and a diabetic (a disease that affects how the body uses blood sugar) left foot ulcer. Review of Patient 1's clinical health record revealed the following documents: A Resident Face Sheet, indicated Patient 1 was admitted to the facility on 7/4/22 with multiple diagnoses including, diabetes with foot ulcer (an open wound or sore), a non-pressure chronic ulcer of the left and right foot, surgical aftercare following surgery on the circulatory system, PVD, and atherosclerosis of the right and left leg with ulcers. An initial visit History and Physical physician note, dated 7/5/22 at 3:34 p.m., indicated Patient 1 had a past medical history significant for diabetes, peripheral vascular disease, a lower extremity angiography (a scan that shows blood flow through arteries and veins) with recent external iliac stent (a small wire mesh tube that is used to hold open an artery in the groin area that has been narrowed by atherosclerosis) placement, chronic diabetic foot ulcers, and was transferred to the facility for rehabilitation. A Minimum Data Set (MDS - an assessment tool), dated 7/7/22, indicated the patient had an active diagnosis of PVD and had a recent major surgical procedure during the prior inpatient hospital stay that required active care during the admission to the skilled nursing facility. A "Resident Progress Notes: [Patient 1]," dated 7/15/22 at 11:17 a.m., indicated Patient 1's condition was evaluated and "found to be stable." The note further indicated, "Nursing staff to monitor patient's physical, cognitive, and functional status and notify NP/MD [Nurse Practitioner/Doctor of Medicine] of any changes or concerns." An interview was conducted with Nurse Practitioner (NP) 1 on 8/24/22 at 12:15 p.m. NP 1 stated she recalled seeing Patient 1 on 7/15/22 and the patient had been admitted to the facility for, "multiple vascular issues and diabetic foot wounds." NP 1 indicated continuous assessment of the patient's vascular system would be important, that vascular conditions can "change pretty rapidly," and would expect staff to monitor a patient if a color change to the foot was noticed. A concurrent interview and record review was conducted with Licensed Nurse (LN) 1 on 8/3/22 at 3:45 p.m. Patient 1's Medication Administration Record was reviewed. LN 1 indicated parentheses around staff initials, such as those present for Order: "***Treatment Nurse*** Multiple diabetic ulcers to left foot - Paint with betadine, leave open to air," on date 7/18/22, indicated the treatment was not done. LN 1 confirmed all of the wound care ordered for Patient 1 on 7/18/22 was not completed as indicated by the parentheses present in the record. An interview was conducted with Treatment Nurse (TN) 1 on 8/5/22 at 2:25 p.m. TN 1 acknowledged Patient 1 was admitted after surgery to place stents in the legs. TN 1 stated there were no orders or care plan interventions to address the need to check Patient 1's circulation, however the patient was getting daily wound care and "CSM [circulation, sensation, motion - a nursing assessment used to determine blood flow to the extremities]," would be assessed when providing daily wound care for patients with vascular issues (such as Patient 1). TN 1 confirmed Patient 1's wound care had not been completed on 7/18/22, as indicated by the patient's clinical record. Patient 1's clinical record contained a "Resident Progress Notes: [Patient 1]," dated 7/19/22 at 9:08 a.m., indicated Patient 1 was "noted with mild purple discoloration to left foot. Patient wearing brace to left foot, writer checked fit of brace to make sure it was not cutting off any circulation. Pulse felt and foot blanching [a test done to check circulation], pt [patient] does not c/o [complain of] pain to foot. Pt refused to straighten leg out, she kept her legs crossed and pulled into body...Will continue to monitor." In the same interview on 8/5/22, TN 1 stated she went to provide wound care to Patient 1 on the morning of 7/19/22 (approximately 48 hours after the last provided wound care and therefore CSM assessment) and noticed the patient's left foot had changed in color. TN 1 further indicated she attempted to change the position of the patient's legs and the color seemed to improve, but Patient 1 did not allow her to complete her assessment. TN 1 stated the patient's nurse was notified of the color change and instructed to keep the legs elevated. TN 1 acknowledged the patient's frequent noncompliance with elevating the legs, and indicated the plan was to come back the next day and re-evaluate the patient's left foot. In and additional interview on 8/26/22 at 3:50 p.m., TN 1 stated the morning of 7/19/22, the patient was in the fetal position and the left foot was noted to be darker in color. TN 1 indicated the color change to the left foot went away temporarily when the patient's legs were extended, and then the discoloration came back because the patient was noncompliant with positioning - she repeatedly flexed her legs. TN 1 further stated, prior to 7/19/22, Patient 1 had no previous discoloration to the feet noted with position changes, and because the color change returned when the patient flexed her legs, the issue was not resolved that day. In the interview with NP 1 on 8/24/22 at 12:15 p.m., NP 1 stated she was not notified or aware of Patient 1's change in color to the left foot on 7/19/22. An interview was conducted with LN 3 on 8/19/22 at 2:49 p.m. LN 3 confirmed she took care of Patient 1 on the evening shift of 7/19/22 and stated she did check the patient's leg circulation because she read the patient's history and physical, but nothing "stood out." LN 3 stated she had only had the patient for one or two days, so could not be sure if the patient's foot looked different from before. LN 3 indicated she did not document the circulation assessment, and no one had communicated to her the patient had a color change in the foot earlier that day and/or might require increased monitoring. An interview was conducted with LN 4 on 8/24/22 at 9:34 a.m. LN 4 indicated she took care of Patient 1 "three to four times," during the patient's facility stay. LN 4 stated the patient was at the facility for diabetic wound care to the feet and could not recall if the patient had surgery prior to facility admission. Further, LN 4 indicated she had not received any reports or information from other nurses regarding a color change to Patient 1's foot on the morning of 7/19/22, or if the patient required additional monitoring. During an interview the Director of Nurses (DON) on 8/25/2022 at 12:28 p.m., the DON confirmed Patient 1 was admitted to the facility following a procedure to the vascular system. The DON indicated if an initial change was assessed, the expectation would be for nurses to increase monitoring for additional changes and notify the provider and other nurses taking over patient care. Patient 1's clinical record contained a "Resident Progress Notes: [Patient 1]," dated 7/20/22 at 9:17 a.m. The note indicated "Upon inspection Pts [Patient's] left foot found to be dark purple in color and Pt [Patient] reported it feeling cold. Wound nurse notified." Additionally, Patient 1's clinical record contained a "Resident Progress Notes: [Patient 1]," dated 7/20/22 at 10:00 a.m. The note indicated "Upon wound care this AM patient is noted with sever [sic] color change to left foot. Foot is noted with no palp pulse, cold to touch and non-blanching...NP [Nurse Practitioner] notified of change in condition of left foot and per NP okay to send to acute [hospital] for further evaluation." In the same interview on 8/5/22 at 2:25 p.m., TN 1 indicated upon arrival to the facility the next day, on 7/20/22, Patient 1's nurse immediately informed her "how bad" the patient's foot appeared. TN 1 indicated the left foot appeared dark and cold. An interview with the Facility Administrator, the DON, and TN 1 was conducted on 8/26/22 at 3:50 p.m. The Administrator and DON indicated the Patient 1's record was reviewed and did not contain a care plan specific to the patient's impaired circulation or the need for continued assessments of circulation. Review of the nursing textbook titled Basic Nursing: Concepts, Skills, & Reasoning (2014 FA Davis) indicated the following: A physical examination is performed by the nurse to "obtain baseline data about physical status and functional abilities of a patient to serve as a comparison as the patient's health status changes...To identify nursing diagnoses, collaborative problems, and wellness diagnoses, to form the basis for the plan of care...To monitor the status of previously identified problem...assess the vascular system by: measuring the blood pressure...palpating the peripheral pulses...Weak, absent or asymmetrical pulses may indicate partial or complete occlusion o f the artery. Other signs of arterial occlusion include pain, pallor, cool temperature, paresthesia [numbness], or paralysis." According to Yale medicine, "If peripheral vascular disease goes untreated, there is a chance that it may progress into critical limb ischemia, a severe stage of PVD that can result in the loss of an affected limb. But if caught in its early stages, peripheral vascular disease is a treatable and reversible disease." https://www.yalemedicine.org/conditions/peripheral-vascular-disease#:~:text=If%20peripheral%20vascular%20disease%20goes,a%20treatable%20and%20reversible%20disease. (Accessed 10/19/22) Review of Patient 1's general acute care hospital records revealed an "Hospitalist H&P [history & physical]," dated 7/20/22. The note indicated Patient 1 was brought to the hospital for concerns of "having difficulty moving her toes and foot being discolored." The note further indicated the patient was evaluated by a vascular surgeon "emergently in the emergency department...for evaluation of left lower extremity ischemia [an inadequate blood supply to an organ or part of the body]." The note further indicated, "Recommend plans for amputation after area demarcates [a term used to describe the line where skin color changes]." Review of Patient 1's general acute care hospital records revealed a "Vascular Surgery Consult," dated 7/20/22. The note revealed a physical exam of the "Left Leg: Diffuse [spread out] purple and gray mottling [patchy or blotchy skin indicating decreased blood flow] through foot, ankle, lower leg. No sensation below proximal [closer to the center of the body] thigh, no flexion or extension of knee, ankle, toes." The note indicated, "Revascularization is futile at this point, would provide no benefit..., and "Patient should be prepared instead for amputation after demarcation." The note further indicated, "Her limb appears grossly ischemic which appears to have been present for days, not hour [sic]." The facility policy titled, "Care Plans - Comprehensive," Revised October 2010, indicated "The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS." The policy further indicated, "Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; i. Reflect currently recognized standards of practice for problem areas and conditions." The facility policy titled "Change in a Resident's Condition or Status," revised April 2011, indicated, "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:...d. A significant change in the resident's physical/emotional/mental condition;...i. Instructions to notify the physician of changes in the resident's condition." The policy further indicated, "2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting')." A Facility Assessment Tool, dated 3/5/22, indicated "Part 1: Our Resident Profile...Diseases/conditions, physical and cognitive disabilities...Category...Heart/Circulatory system...Common Diagnoses...Peripheral Vascular Disease, Risk for Bleeding or Blood Clots, Deep Venous Thrombosis (DVT), Pulmonary Thrombo-Embolism (PTE)..." The Facility Assessment Tool further indicated, "Part 2: Service and Care We Offer Based on our Resident's Needs...General Care...Management of medical conditions...Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions..." The department determined the facility failed to do the following: 1) Follow their policy for comprehensive care planning to develop and implement a comprehensive person-centered care plan for Patient 1 based on admission diagnosis and assessment when Patient 1 was admitted with peripheral vascular disease (PVD - a slow and progressive circulation disorder) and was not monitored or treated appropriately for signs of impaired circulation and, 2) Follow their policy for Change in a Resident's Condition or Status to notify or consult the Director of Nurses (DON) or a primary care provider of a change of condition for Patient 1 when Patient 1 was noted to have a purple discoloration to the left foot and no one was notified of the change of condition for 24 hours. These failures led to a delay in the provision of physician services, a delay in treatment, and potentially contributed to the subsequent amputation of Patient 1's left lower leg. This violation presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of Patient 1's leg amputation.