Health inspection·December 26, 2024

The following reflects the findings of the California Department of Public Health during a Recertification Survey Event ID: I15U11 42 C.F.R. 483.21(b) Comprehensive Care Plans 483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and 42 C.F.R. 483.5 Neglect Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation 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. California Code of Regulations Title 22, 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations Title 22, 72543 Patients' Health Records (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. California Code of Regulations Title 22, 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. The facility: 1. Failed to ensure that Resident 3 remained free from negligence when it a. Failed to address Resident 3's lower extremity edema and edema-associated wound according to standards of nursing care, including with compression stockings. b. Failed to assess the fit of Resident 3's shoe size required for his lower extremity brace, consistent with standards of nursing care. 2. Failed to develop and implement a comprehensive person-centered care plan when it a. failed to develop a care plan for monitoring and treating Resident 3's bilateral lower extremity edema, consistent with standards of nursing care. b. Failed to develop and implement a plan to check Resident 3's brace upon applying it to Resident 3's leg to be sure that the brace fit properly. 3. Failed to maintain current records kept in detail consistent with good medical and professional practice based on the service provided to each patient when it falsely documented in a "Weekly Nursing Note" no skin breakdown, and no skin impairments treated in the last seven days. 4. Failed to notify the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly upon discovering the patient's condition, as evidenced by the CNA's statement that they did not report to the nurse about the improper adhesive dressing on Resident 3's right inner ankle. 5. Failed to implement its P&Ps, including "Comprehensive Assessments and the Care Delivery Process," "Change in a Resident's Condition or Status," "Wound care," and others to ensure that Resident 3's goals and facility objectives were achieved. These deficiencies resulted in Resident 3 experiencing undertreated lower extremity edema, and resulted in Resident 3 wearing an improperly fitting brace on his edematous right lower extremity, causing the serious harms of physical injury, infection risk, immobility, and pain. On 11/5/24 at 7:30 a.m., an unannounced visit was conducted at the facility to conduct a standard recertification survey. Resident 3 is a 78-year-old male, admitted to the facility on 4/10/12. Resident 3 has diagnoses that include cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting the right dominant side, hemiplegia (loss of ability to move and sometimes feel anything on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident 3 is alert and oriented to person, place, time and situation. Resident 3 is cognitively intact for thinking ability and memory with a Brief Interview of Mental Status (BIMS) score of 15, (BIMS scores range from 0-15 with scores of 13-15 indicating cognition is intact). Resident 3 uses a wheelchair as the primary mode of locomotion and uses the right leg brace and walker when ambulating with Restorative Nurse Assistant (RNA). During a concurrent observation and interview on 11/5/24 at 11:11 a.m. with Resident 3, in Resident 3's room, Resident 3 was observed dressed and sitting in his wheelchair. Resident 3 was alert and answered questions clearly. Resident 3 stated he had been at the facility for a "long time". Resident 3 stated he was at the facility due to having a stroke. Resident 3 stated he was getting daily physical therapy (PT) and returned from PT earlier this morning (11/5/24). Resident 3 stated he wore a brace on his right lower leg which cut into his right ankle. Resident 3 was observed to have a wound on his right lower leg above his foot with no dressing. Resident 3 stated the nurse would put a band aid on his wounds. Resident 3 stated he had pain in his right lower leg above his ankle. Resident 3 stated he took acetaminophen for his pain, which helped his pain. During a record review of Resident 3's "Admission Record (AR)", dated 11/8/24, the AR indicated, Resident 3 was admitted to the facility on 4/10/12 with diagnoses of hemiplegia, hemiparesis and cerebrovascular disease affecting the right dominant side. During a review of Resident 3's " Minimum Data Set (MDS - a federally mandated resident assessment tool)", dated 9/25/24, the MDS section C indicated, Resident 3 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 3 was cognitively intact. During an interview on 11/7/24 at 9:12 a.m. with Resident 3, Resident 3 stated he wore compression stockings years ago, but they kept going missing and were not replaced. Resident 3 stated he took Acetaminophen this morning for his leg pain. Resident 3 stated the nurse put an adhesive dressing on his right inner ankle wound this morning (11/7/24). During a concurrent observation and interview on 11/7/24 at 9:27 a.m. with the Certified Nursing Assistant/Restorative Nurse Assistant (CNA/RNA), in the hallway near Resident 3's room, the CNA/RNA was observed applying a right lower extremity brace to Resident 3. The CNA/RNA stated when Resident 3's right leg gets swollen, Resident 3 would let her know. The CNA/RNA stated it had been "months" since Resident 3 wore compression stockings. The CNA/RNA observed the open wound to Resident 3's right shin with no dressing. The CNA/RNA verbalized observation of an adhesive dressing to Resident 3's right inner ankle. The CNA/RNA stated Resident 3's wounds should have been covered with gauze. During a concurrent observation and interview on 11/7/24 at 12 p.m. with Resident 3 and the Clinical Supervisor Nurse (CSN) in Resident 3's room, Resident 3's right inner ankle wound was observed to be bleeding through the adhesive dressing, onto Resident 3's sock. Resident 3 stated the right leg brace was pinching his skin. The CSN was observed checking Resident 3's right ankle wound. The CSN stated the charge nurse needed to assess the wound immediately to get the right treatment for Resident 3 to prevent infection. The CSN stated applying an adhesive dressing was not the right treatment. During a concurrent observation and interview on 11/7/24 at 1:50 p.m. with the Treatment Nurse (TN) in Resident 3's room, the TN was observed assessing Resident 3's wounds. The TN stated she contacted the Wound Nurse Care Practitioner (NP) and received orders for Resident 3's wound care. The TN stated she was not aware Resident 3 had wounds. During a concurrent interview and record review on 11/8/24 at 8:20 a.m. with the CNA/RNA, Resident 3's "Restorative Nursing Referral (RNR)", dated 1/5/24, was reviewed. The RNR indicated a list of goals and treatment plan, which did not include the use of a walking brace when ambulating. The CNA/RNA stated the RNR did not indicate the use of a walking brace when ambulating Resident 3. The CNA/RNA stated that Resident 3 was on the RNA program for ambulation with the use of a walking brace. The RNA stated she received training from the Physical Therapist (PT) regarding the brace application during ambulation. The CNA/RNA stated she observed an adhesive dressing on Resident 3's right inner ankle on 11/4/24 and 11/5/24. The CNA/RNA stated she did not report to the nurse about the adhesive dressing on Resident 3's right inner ankle. The CNA/RNA stated she thought the nurse knew about Resident 3's wounds as nurses were the only staff members with access to the locked treatment cart. The CNA/RNA stated she always applied Resident 3's brace when he ambulated. The CNA/RNA stated nurses did not apply the brace to Resident 3. The CNA/RNA stated nurses should have checked the brace when it was applied to Resident 3's leg to be sure the brace fit properly, and the brace was properly applied to Resident 3's leg to prevent injury. The CNA/RNA stated Resident 3 would be injured if the brace was not properly fitted to the resident and was not put on correctly. The CNA/RNA stated she observed a white dressing applied on the right shin area of Resident 3 when she ambulated the resident on 11/5/24. The CNA/RNA stated Resident 3 told her his shin wound was "oozing and weeping". The CNA/RNA stated Resident 3 always had swelling in his bilateral lower extremities. During a concurrent interview and record review on 11/8/24 at 9:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 3's "Order Summary Report", dated 11/8/24, was reviewed. The "Order Summary Report" indicated, no order for the use of Resident 3's brace. LVN 1 reviewed Resident 3's electronic medical record (EMR) and she was not able to locate Resident 3's care plan for monitoring skin while using a brace, and no care plan was in place for monitoring Resident 3's bilateral lower extremity edema. LVN 1 stated monitoring the skin was important to prevent skin issues. LVN 1 stated the order for Resident 3's use of compression stockings was discontinued on 3/16/24. LVN 1 stated she could not remember why the order for the use of compression stockings for Resident 3 was discontinued. LVN 1 stated she had no time to assess Resident 3's wound or to put a nursing note in Resident 3's electronic medical chart. LVN 1 stated there should have been a physician's order and care plan in place for Resident 3's use of a brace. LVN 1 stated monitoring the application of the brace, and the skin was important to prevent skin issues. LVN 1 stated Resident 3 reported he was bleeding this morning. LVN 1 stated she assessed Resident 3 and observed an open wound to Resident 3's right inner ankle. LVN 1 stated she covered Resident 3's wound with an adhesive dressing. LVN 1 stated Resident 3 informed her his brace was causing the wound to his right inner ankle. LVN 1 stated Resident 3 had been using the brace since she started working at the facility in 2019. LVN 1 stated Resident 3 used the brace when he ambulated with the CNA/RNA. LVN 1 stated the CNA/RNA applied the brace and the nurse would help the CNA/RNA apply the brace to verify it was applied properly and did not harm the resident. LVN 1 stated she did not remember getting training on the brace application. During an interview on 11/8/24 at 9:42 a.m. with the Physical Therapist (PT), the PT stated Resident 3 was a long-term resident who came to the facility with an AFO (ankle foot orthosis [brace]). The PT stated the AFO was appropriate for the resident. The PT stated that Resident 3's brace required a bigger shoe size. The PT stated if Resident 3's shoe was too tight, the brace would not fit properly. The PT stated he informed the Social Service Director (SSD) two weeks ago to call the family to change the shoes to a one-inch size bigger shoe to properly fit the brace. The PT stated the PT Department instructed the CNA/RNA how to properly put on and take off Resident 3's brace, and to check for skin redness. During an interview on 11/8/24 at 11:33 a.m. with the SSD, the SSD stated she spoke to Resident 3 this morning (11/8/24) about how his shoe fit his brace. The SSD stated Resident 3 informed her he believed the problem was the brace and not his shoe. Resident 3 stated he did not want the care conference team to call his daughter since she was very busy. The SSD stated the PT would call the Orthotic company to evaluate Resident 3's brace. During an interview on 11/8/24 at 2:38 p.m. with the Director of Nursing (DON), the DON stated Resident 3 should have had a care plan for edema to monitor the edema. The DON stated the skin could open due to swelling and skin breakdown could occur. The DON stated Resident 3 should have had a physician's order and care plan for the use of a brace when the brace was initially applied to Resident 3. The DON stated nurses should have been applying Resident 3's brace to ensure the brace was properly applied to prevent skin breakdown. The DON stated nurses did not receive training on the use of Resident 3's brace. The DON stated her assessment of Resident 3's right ankle indicated the traumatic wound was caused from using the brace. The DON stated Resident 3's wound to the right inner ankle was avoidable. The DON stated her expectation was that all nurses followed the policies and procedures when providing care and treatment for residents including skin and wound assessment, Medical Doctor (MD) notification of change of resident's condition and establishing a care plan. The DON stated it was important for nurses to initiate and develop a care plan if issues arise, to monitor the resident's condition and ensure proper care was being followed by staff. The DON stated applying an adhesive dressing to the wound was not appropriate treatment for Resident 3. During an interview on 11/8/24 at 3:22 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated it was important to develop an individualized care plan so staff would be aware of the plan of care for the resident. During an interview on 11/8/24 at 3:48 p.m. with the CSN, the CSN stated a care plan should have been initiated when Resident 3's br