Other·March 9, 2023

Section. 72313 - Nursing Service -Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (5) All medications and treatments shall be administered only by licensed medical or licensed nursing personnel with the following exceptions On 12/8/22 at 10:26 a.m. an unannounced visit was conducted at the facility to investigate a complaint regarding an unlicensed nurse providing treatment to residents. The facility failed to ensure wound treatment and assessments were performed by a licensed nurse when eight patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10) were provided treatment by an unlicensed nurse. A review of an admission record indicated Patient 2 was admitted to the facility on 10/26/22 with diagnoses which included a skin abscess on the perineum (groin area) and diabetes (a chronic condition that affects the way the body processes blood sugar, which decreases the body's ability to heal wounds). A review of an order summary report, printed 12/15/22, indicated Patient 2 had the following physician's orders: -The perineum/coccyx (tailbone) surgical site was to be cleansed with a wound wash; and barrier and wet gauze dressings with an absorbent foam dressing border were to be applied twice daily starting on 10/26/22. -Starting on 11/3/22, the sacrum (lower back) wound was to be cleansed with wound solution, dressed with foam and secured with clear film to ensure suction of the Negative Pressure Wound Vacuum-assisted closure (NPWV) (a device/method of enhancing wound healing). Staff was instructed to check the NPWV three times a week to ensure suction was intact with no leaks. -The coccyx wound was to be cleansed with wound solution and a debridement medication (medication that helps to remove dead tissue from the wound) was to be applied to the wound bed, followed by calcium alginate (used for wound healing) and foam dressing every day shift starting on 11/8/22. A review of a care plan for Patient 2's potential for impaired skin integrity due to the presence of the perineum abscess, initiated on 10/27/22, indicated licensed nurses were to evaluate the skin weekly. A review of Patient 2's progress note dated 10/27/22 at 9:20 a.m. and documented by the Unlicensed Nurse 1 (UN 1) indicated, "...Patient presents with open surgical wound to coccyx...Treatment done. This nurse cleansed open surgical area... [leptospermum honey in a hydrocolloidal suspension used for wound healing] applied to wound bed followed with calcium alginate and a foam dressing..." A review of an admission record indicated Patient 3 was admitted to the facility on 10/29/22 with diagnoses which included a fracture of the upper end of the left humerus (upper arm). A review of an order summary report, printed 12/15/22, indicated Patient 3 had a physician's order for a skin inspection and nursing assessment weekly, each day shift on Fridays starting on 11/4/22. A review of a skin and wound evaluation for Patient 3, dated 11/15/22 at 8:19 p.m., indicated the assessment was conducted by the UN 1. A review of an admission record indicated Patient 4 was admitted to the facility on 10/30/22 with diagnoses which included a right femur (upper leg) fracture. A review of a care plan for Patient 4's potential for impaired skin integrity related to a right femur fracture, initiated 11/1/22, indicated licensed nurses were to evaluate the skin weekly. A review of Patient 4's progress note dated 11/1/22 at 5:44 p.m. and documented by the UN 1 indicated, "...Patient presents with surgical incision covered with surgical dressing to right hip. Dressing presents with 25% exudate [drainage] to dressing no indication of changing at this time..." A review of a skin and wound evaluation for Patient 4, dated 11/15/22 at 3:15 p.m., indicated the assessment was conducted by the UN 1. A review of an admission record indicated Patient 5 was admitted to the facility on 11/7/22 with diagnoses which included spondylosis of the lumbar region (degeneration of the vertebrae and disks of the lower back). A review of an order summary report, printed 12/15/22, indicated Patient 5 had a physician's order to monitor the adhesive bandages to both surgical incisions in the lower back every day shift starting on 11/9/22. A review of Patient 5's progress note dated 11/8/22 at 2:44 p.m. and documented by the UN 1 indicated, "...Patient presents with bilateral surgical incisions to lower back. Incisions present with [adhesive bandages] clean and intaact [sic]. A review of a skin and wound evaluation for Patient 5, dated 11/8/22 at 5:19 p.m., indicated the assessment was conducted by the UN 1. A review of a skin and wound evaluation for Patient 5, dated 11/15/22 at 3:10 p.m., indicated the assessment was conducted by the UN 1. A review of an admission record indicated Patient 6 was admitted to the facility on 11/8/22 with diagnoses which included cellulitis (a potentially serious bacterial skin infection). A review of a care plan regarding Patient 6's potential for pressure ulcer development, initiated 11/15/22, indicated nurses were to evaluate the skin weekly. A review of Patient 6's progress note dated 11/9/22 at 4:45 p.m. and documented by the UN 1 indicated, "Admissions skin & wound assessment...Patient presents with redness and irritation to inner thighs and bilateral groin..." A review of an admission record indicated Patient 7 was admitted to the facility on 11/8/22 with diagnoses which included chronic pain syndrome. A review of Patient 7's progress note dated 11/9/22 at 4:31 p.m., indicated the UN 1 conducted a wound assessment. A review of an admissions record indicated Patient 8 was admitted to the facility on 11/8/22 with diagnoses which included a bacterial infection. A review of a care plan regarding Patient 8's skin and wound was created by the UN 1 on 11/9/22 and indicated licensed nurses were to evaluate the skin weekly. A review of Patient 8's progress note, with an effective date of 11/23/22 at 4:14 p.m. and documented by the UN 1, indicated, "Skin & Wound Assessment completed 11/9/2022...Patient present with peri-anal open area. This nurse cleansed with...wound solution...Followed with [leptospermum honey in a hydrocolloidal suspension used for wound healing] and calcium alginate to wound bed secured with foam dressing. Patient presents with superficial MASD [Moisture Associated Skin Damage]. This nurse cleansed with...solution...followed with [sterile coating to cover wound and protect from incontinence] to wound area..." A review of an admission record indicated Patient 10 was admitted to the facility on 11/14/22 with diagnoses which included partial amputation of the right midfoot and diabetes. A review of Patient 10's progress note dated 11/15/22 at 2:19 p.m. and documented by the UN 1 indicated, "Admission skin & wound assessment...Patient presents with complete right foot transmetatarsal [forefoot] [sic] amputation. Right foot trans metatarsal amputation presents closed by stitches. Patient presents with endarterectomy [surgical removal of part of the inner lining of an artery] surgical incision to right groin closed with skin adhesive...." A review of two skin and wound evaluations for Patient 10, dated 11/15/22 at 7:16 p.m. and 7:47 p.m., indicated the assessments were conducted by UN 1. A review of an order summary report, printed 12/15/22, indicated Patient 10 had a physician's order to apply betadine-soaked non-adherent gauze, wrap with bandage roll, and apply elastic wrap loosely to the right foot every day shift starting on 11/16/22. A review of a care plan regarding Patient 10's skin and wound care was created by the UN 1 on 11/17/22 and indicated nurses were to complete treatment per order and certified nurse assistants were to monitor/document the location, size and treatment of the skin injury, abnormalities, failure to heal, and signs and symptoms of infection to the physician. In an interview on 12/15/22 at 11:30 a.m., the Director of Nurses (DON) stated in order for a person to be hired as a treatment nurse at the facility, the person had to be licensed to practice in the state. The DON also stated the UN 1 had failed the National Council Licensure Examination for practical/vocational nurses (NCLEX-PN) the first time she took the test; however, was reinstated as a treatment nurse once the UN 1 provided a passing result the second time she took the test. The DON confirmed prior to the UN 1's employment termination she performed treatments on residents. In an interview on 12/15/22 at 11:56 a.m., the Director of Staff Development (DSD) stated she called the state license board with the UN 1 to find out what was holding up the posting of her license. The DSD stated the state license board received the UN 1's passing NCLEX-PN results but was unable to post her license because of a pending background check. The DSD also confirmed the state license board stated a passing NCLEX-PN result did not qualify the UN 1 to practice as a nurse. A review of the NCLEX-PN passing result the UN 1 provided to the facility on 10/22/22 indicated, "...The nursing regulatory body to which you applied for licensure will mail your official results to you. Please note that a passing result alone does not authorize you to practice as a licensed nurse." A review of the California Code of Regulations: Scope of Vocational Nursing Practice, 16 CCR 2518.5, filed 9/19/96, indicated, "The licensed vocational nurse performs services requiring technical skill...which include the following...uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan...Provides direct patient...care by which the licensee...Performs basic nursing services...Administers medications...Applies communication skills for the purpose of patient...care and education..." In violation of the above cited standards, the facility failed to ensure wound treatment and assessments were performed by a licensed nurse when eight patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10) were provided treatment by an unlicensed nurse. This violation had a direct or immediate relationship to the health and safety of patients.