Health inspection·October 17, 2024

State Citation A was written. Regulation: CFR 483.25(d) Accidents. The facility must ensure that - CFR 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and CFR 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72521(a) Administrative Policies and Procedures. (a)Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 22 CCR 72523 (a) 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. 22 CCR 72311(a)(1)(A), (a)(2) Nursing Services-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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 8/2/24 at 9:25 a.m., an unannounced visit was conducted at the facility to investigate Complaint: CA00912177 which alleged Resident 1 sustained second- degree burns after being left outside in the sun unprotected. The facility failed to ensure resident's environment remained free of accident hazards when Resident 1 who had dementia (condition of progressive loss of memory, language and other thinking abilities which requires increased supervision of the individual) and had a known behavior of moving around in the facility in the wheelchair independently, exited unsupervised on 6/23/2024 to the rose garden on the facility grounds. Resident 1 was found in an area of exposed to the sun after being there for unknown amount of time on a day when temperatures reached up to 108 degrees Fahrenheit. As a result of this failure, Resident 1 sustained second-degree burns (a burn that affects the outer and middle layers of skin which results in blistering, swelling, redness and pain) to the top of his scalp, right ear, back of neck, left shoulder and both knees and an acute kidney injury (a sudden episode of kidney damage), which required hospitalization from 6/24/24 - 7/2/24. Resident 1 was an 87-year-old male, admitted to the facility on 6/21/24. He had diagnoses that included dementia and Stage 3 chronic kidney disease (a condition where the kidneys have moderate damage and are less able to filter waste and fluid from the blood), and severe cognitive impairment. During an interview on 8/2/24 at 10:22 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, staff would always have to supervise Resident 1 because he would wheel himself around the facility in his wheelchair and was always trying to go home. CNA 1 stated, Resident 1 was a fall risk and had alarms on his bed and wheelchair to alert the staff when he got up without assistance. CNA 1 stated, the staff should not have allowed Resident 1 to be outside alone without staff supervision due to the risk of being sunburned. During an interview on 8/2/24 at 10:48 a.m. with Director of Nursing (DON), DON stated, Resident 1 had sundowners (a person with dementia who becomes increasingly irritable as the day progresses) behaviors and yelled out for his wife. DON stated, Resident 1 was in a wheelchair and liked to go outside. DON stated, Resident 1 was admitted to the hospital from 6/24/24 until 7/2/24 to be treated for the burns that were sustained while residing at the facility which required further evaluation and treatment. During an interview on 8/2/24 at 10:57 a.m. with Assistant Director of Nursing (ADON), ADON stated, Resident 1 opened the door and wheeled himself out into the sun-exposed area of the rose garden patio on 6/23/24 and was outside without staff supervision for an unknown amount of time. ADON stated, an AM (morning shift that works from 7 am to 3 pm) CNA saw Resident 1 outside, alerted a PM (night shift that works 3 pm to 11 pm) CNA of Resident 1's location outside and the PM CNA brought Resident 1 inside. ADON stated, it was not known how long Resident 1 was outside for. ADON stated, blisters were found on Resident 1's scalp and neck and treatments to the affected areas were completed. ADON stated, Resident 1 was found to have inflammation and swelling to the face, neck and scalp on 6/24/24. ADON stated, Resident 1 was sent to the hospital for evaluation due to the swelling and was gone from the facility for about a week. During an interview on 8/2/24 at 11:03 a.m. with DON, DON stated Resident 1 was originally admitted on 6/21/24 to the facility and the first blisters were observed during the NOC (overnight shift that works 11 pm to 7 am) shift by staff on 6/23/24. DON stated, Resident 1 had a popped blister to the posterior neck which was open and contained slough (material covering wound bed that is made of dead tissue, pus and other debris) when he came back from the hospital. DON stated, Resident 1 also had an open and popped blister to the scalp, a popped left shoulder blister, a popped right ear blister, a popped right knee blister and an intact left knee blister when Resident 1 returned back from the hospital. During an observation on 8/2/24 at 11:46 a.m. outside in the rose garden, the rose garden was positioned in the center of facility. The rose garden contained concrete paths around the perimeter, a covered patio area and grass. The covered patio area was located on the side closest to the only door used to access this outdoor area. The farthest area of the rose garden had a concrete path and was unshaded. During an interview on 8/2/24 at 11:58 a.m. with CNA 2, CNA 2 stated, she worked the AM shift on 6/23/24 and saw Resident 1 sitting in the rose garden at the end of the shift. CNA 2 stated, CNA 2 went and told PM shift staff that Resident 1 was outside and needed to be brought back inside. CNA 2 stated, Resident 1 was a fall risk. CNA 2 stated, Resident 1 should have been supervised and not left unattended outside because it was the staff's responsibility to ensure safety and security for the residents. During a phone interview on 8/8/24 at 9:41 a.m. with CNA 4, CNA 4 stated, she was working the PM shift on 6/23/24 and at the start of the shift, another CNA was leaving, looked out to the rose garden and saw a resident sitting outside alone. CNA 4 stated, Resident 1 was in the rose garden on the sidewalk on the far side, which was unshaded. CNA 4 stated, Resident 1 was strong enough to open the door, get outside and wander in the rose garden. CNA 4 stated, the temperature outside was at least 110 degrees Fahrenheit. CNA 4 stated, she went outside, approached Resident 1 and said Resident 1 should come inside due to the excessive heat. CNA 4 stated, it was unknown how long Resident 1 had been outside and the skin on Resident 1's arm was warm to touch. CNA 4 stated, CNA 4 brought Resident 1 inside to cool down. CNA stated, Resident 1 was provided with cold water and a popsicle in order to make Resident 1's temperature lower. CNA 4 stated, Resident 1 was placed near his assigned nurse for the shift so the nurse could assess Resident 1. CNA 4 stated, facility staff did not pay attention where Resident 1 wandered to and should have supervised Resident 1 because it was so hot outside. CNA 4 stated, it was best to monitor the residents and residents should not be left unattended at any point. During a phone interview on 8/9/24 at 3:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN stated, Resident 1 had a diagnosis of dementia. LVN 1 stated, LVN 1 worked the 6/23/24 NOC shift which started at 11 pm. LVN 1 stated, a CNA alerted LVN 1 of a blister on the top of Resident 1's head during that shift on 6/24/24. LVN 1 stated, the RN (registered nurse) supervisor was notified to assess Resident 1, notified the NP (Nurse Practitioner) and the wound was treated. LVN 1 stated, the treatment nurse and wound doctor came in the morning of 6/24/24 and were notified to treat and evaluate Resident 1. LVN 1 stated, Resident 1 also had multiple small and intact blisters to the back of his neck. LVN 1 stated, LVN 1 was notified by the NOC CNA that Resident 1 was outside earlier in the day and was wheeled into the facility by a CNA. LVN 1 stated, it was very hot the day this incident occurred. LVN 1 stated, Resident 1 should not have been left unattended and needed monitoring. LVN 1 stated, Resident 1 should have been closely monitored to prevent Resident 1 from getting dehydrated by being outside, getting lost or sustaining a fall. During a phone interview on 8/9/24 at 3:48 p.m. with LVN 2, LVN 2 stated, Resident 1 was alert and oriented to his name only and answered questions with one word only. LVN 2 stated, she worked the PM shift on 6/23/24. LVN 2 stated, Resident 1 had been outside, and the PM CNA brought Resident 1 inside. LVN 2 stated, she observed Resident 1 after PM CNA gave him water, a popsicle and checked his vitals. LVN 2 stated, the CNAs requested LVN 2 to assess Resident 1 in the evening because swelling was noted to his face. LVN 2 stated, Resident 1 had swelling to the side of his face. LVN 2 stated, the NP was notified, and orders obtained to send Resident 1 to the hospital. LVN 2 stated, Resident 1 was sent to the hospital on the evening of 6/24/24 was diagnosed with second-degree burns. LVN 2 stated, Resident 1 should have been supervised outside due to the possibility of wandering, not knowing what they were doing and potentially falling. During a concurrent phone interview and record review on 8/13/24 at 4:00 p.m. with DON, Hospital 1's "SNF Packet" (SP- Patient documentation provided by Hospital 1 to SNF facility), dated 7/1/24 was reviewed. The SP indicated, "...Chief Complaint...Blister Pt [patient] brought in by ambulance for blisters to top of head and posterior (back side) neck secondary to being outside yesterday for unknown amount of time. Today blisters popped, facility would like skin sites evaluated...found to have second degree burn in the scalp and neck. Cr [Creatinine- a chemical waste product in the blood, urine and muscle where a high result can indicate a kidney problem] increased to 2.0 from 1.3. BUN [Blood Urea Nitrogen- a substance in the blood created when protein breaks down and a high level can indicate kidney problems] 52 from 37...Acute kidney injury superimposed [a secondary diagnosis occurring during or immediately following the original diagnosis] on CKD...Likely due to dehydration from staying under the sun yesterday Associated with second degree burn in the scalp and neck...2nd degree (blister) burn of scalp and neck from contact with sunlight; probably related to underlying dementia; Total body surface area: <10%..." DON stated, Resident 1 was sent to the hospital and it was reported to the hospital staff that Resident 1 was outside for an unknown amount of time. DON stated, the hospital diagnosed Resident 1 with second-degree burns and an acute kidney injury. DON stated, Resident 1 had a known diagnosis of dementia with behaviors of wandering in his wheelchair outside and because of this should have been supervised while outside in the rose garden. DON stated, due to the lack of supervision for Resident 1 while he was alone outside unprotected on a hot day, he sustained and was hospitalized for second-degree burns to the scalp, ear, neck, shoulder and knees as well as an acute kidney injury. DON stated, staff should have done frequent rounding and checking on Resident 1 while he was outside for safety purposes, to assess for pain and to make sure staff can monitor for anything Resident 1 could not have verbalized for himself. During a review of Resident 1's "Progress Notes" (PN), dated 6/24/24, the PN indicated, "...06/24/2024 04:57...NOC cna reported to writer that pm cna reported to her that am cna found the resident outside (in between am and pm shift) AM cna quickly wheel in resident inside the facility. NOC cna reported to writer resident has big open blister on top of the head, multiple intact blister on the back of the neck w/ [with] redness discoloration and warm to touch. Writer assess, notified noc RN supervisor...Treatment applied as per NP order Cleanse w/ ns [normal saline], pat dry, apple triple ABX [antibiotic], covered xerofoam [a fine mesh gauze dressing that has medication within it to promote wound healing] dressing. To be evaluated by treatment nurse and wound doctor this morning..." During a review of Resident 1's PN, dated 6/24/24, the PN indicated, "...06/24/2024 11:09...Seen resident this morning as endorsed from previous shift, resident had blister to his head. Noted dressing on his off and open blister red in color, no bleeding, with 2 small intact fluid filled on surrounding area. Also noted scattered intact blister on posterior neck...treatment orders clarified...Monitor intact blisters for untoward signs of skin breakdown..." During a review of Resident 1's PN, dated 6/24/24, the PN indicated, "...06/24/2024 11:16...Report from nursing staff received that resident propels self towards lobby most of the time when he is up. Has Dx [diagnosis] of Dementia, verbally responsive...Spoke with resident, verbalizes wants to go home, resident in his room at this time. NP...made aware via phone, ordered to apply wander guard [an alarm system used to monitor residents who are at risk of leaving a safe area] due his exit seeking behavior..." During a review of Resident 1's PN, dated 6/24/24, the PN indicated, "...06/24/2024 22:29 [10:29 p.m.] ... Nurse was notified of swelling to resident's face, head and neck swelling with scattered large blisters...NP...notified with orders to send out for further evaluation. Patient sent out to [name of Hospital- Hospital 1] ..." During a review of Resident 1's Hospital 1's "Emergency Department Timeline" (EDT), dated 6/24/24, the EDT indicated, "...ED [Emergency Department] Pt Care Timeline...Arrival...06/24/2024 21:28 [9:28 p.m.] ...Chief Complaints...Blister (Pt brought in by ambulance for blisters to top of head and posterior neck secondary to being outside yesterday for unknown amount of time. Today blisters popped, facility would like skin sites evaluated) ... IV fluid Indication...clinical dehydration...SW [Social Worker] Consult...SW called [ADON]...to ask if patient was locked out of the facility. Per [ADON], patient went out to the garden to sit...she is not sure how long patient sat outside. When patient came inside, they realized there were blisters on his head...Case Management Initial Screening...Contacted pt's spouse...Spouse reports she...was told pt was found outside and ended up getting blisters due to the heat...Contacted...admissions at [skilled nursing facility name] ... Per...staff did not bring pt outside as it was over 100 degrees yesterday..." During a review of Resident 1's "Admission Readmission Screen and Baseline Care Plan" (RS), dated 7/2/24, the RS indicated, "...07/02/2024 21:42 [9:42 p.m.]...Admitted From...Acute Hospital...Admitting Diagnosis...Acute Kidney injury...Level of cognitive impairment...Severe impairment (affecting all areas of judgment)...With exit-seeking behavior...Amoxicillin [medication used to treat infections] Oral Tablet 500 MG [milligram- unit of weight measurement]...1 tablet by mouth every 8 hours for Partial thickness [second-degree] burn of scalp... Resident is a returning patient of this facility, prior to transfer to acute care, resident noted to have multiple areas of popped blisters, as per skin assessment upon arrived, popped blister to posterior neck- L [length] 6.5 cm (centimeter- unit of length measurement), W [width] 7 cm, D [depth] UTD [depth unknown] - wound bed 90% necrotic [death of normally living tissue] tissue, mild drainage noted, no mal [foul] odor...popped blister to left shoulder, wound bed pink in color, popped blister to top of head..." The RS indicated, Resident