Health inspection·August 22, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) Deep Tissue Injury (DTI) did not worsen and the resident did not develop further wounds. Residents Affected - Few This failure resulted in the DTI becoming worse and the development of three additional pressure injuries, an additional hospital stay, and increased pain for Resident 1. Findings: During a review of Resident 1's admission Record, dated 4/20/24, the admission Record indicated, Resident 1 had diagnoses including, a pressure induced deep tissue damage (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of right heel, spiral fracture of right tibia (break in bone from a twisting motion), Type II Diabetes (a chronic condition that causes high blood sugar levels in the blood which can delay and/or complicate wound healing), hemiplegia (Total paralysis of one side of the body) following a cerebral infarction (stoke, damage to tissue in the brain) muscle weakness and abnormal gait (walking). During a review of Resident 1 ' s Nursing admission Summary, dated 4/20/24, the Summary indicated, Resident 1 was discharged last week on 4/13/24. Resident 1 had a brace on her RLE (Right Lower Extremity) due to a fall at home after discharge. Resident 1 also had a Deep Tissue Injury (DTI) on her right heel, measured about 3 cm (centimeter) x 3 cm x 0.5 cm. During a concurrent interview and record review on 8/22/24 at 10:06 a.m. with a Licensed Nurse (LN 1), Resident 1 ' s Nursing admission Summary, dated 4/20/24 was reviewed. LN 1 stated Resident 1 came in with a fracture of right tibia and had a cast which caused irritation and had a pressure ulcer from the cast located on the heel. The cast was a half cast covering the posterior lower extremity and had a Velcro strap that went over the top of the right foot to secure it and Velcro around the lower right leg. The admission nurse removed the half cast to assess the heel and noticed the DTI. The wound assessment on 5/29/24 indicated wound goes from the heel to right ankle. This was a change. Resident 1 came in with one wound and ended up with an additional three wounds. Wound 1 is the right heel (present during admission), Wound 2 lateral right ankle, Wound 3 posterior right ankle, and Wound 4 medial right ankle. During a review of an email from Central Coast Orthopedics to Dr. (Name of Dr.) dated 5/2/24, the email indicated, Per Dr. (Name of Dr.), okay to modify immobilizer and add padding. If needed call the Orthotist that placed the immobilizer. During a review of Resident 1 ' s Orders, dated 5/11/24, the Orders indicated, RLE (Right Lower Extremity) brace – do not modify or remove until follow-up with orthopedic surgeon. Page 1 of 3 055563 055563 08/22/2024 Santa Maria Post Acute 820 West Cook Street Santa Maria, CA 93458

F 0686 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Wound Consult Progress Notes (Notes), dated 4/23/24 through 5/28/24, the Notes indicated the following: 1) On 4/23/24 Right heel Deep Tissue Injury (DTI) measurements, 3 cm (centimeters) x 4 cm x 0 (Length x Width x Depth). Wound color purple/maroon, 100% epithelialization, and skin intact. Residents Affected - Few 2) On 4/30/24 Right lateral heel is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Assessment of the wound was the same as on 4/23/24. Treatment (Tx) for Wound: Cleanse wound with mild soap and water, apply calcium alginate, cover with foam dressing, change dressing every day and as needed. Other: Heel protector. 3) On 5/7/24 Right lateral heel measurements, 5 cm x 4 cm x 0 with 100% epithelialization. A second wound was identified, right ankle DTI, measurements 2.5 cm x 4 cm x 0, persistent non-blanchable, maroon or purple discoloration and a status of Not Healed. No drainage, 100% epithelialization. This came from a pressure placed by an orthopedic device which has now been removed. Will continue to monitor. Wound orders changed. Orders the same for both wounds – Cleanse with NS/water, Apply skin prep M, W, F, cover with foam dressing – pad areas of concern. 4) On 5/14/24 No change in assessments or treatment orders. 5) On 5/21/24 Wounds #1 and #2, no change in assessments or treatment orders. A third wound was identified, medial ankle DTI, measurements 3 cm x 2 cm x 0, persistent non-blanchable, maroon or purple discoloration and a status of Not Healed. No drainage, 100% epithelialization. Continue same tx. as ordered on 5/7/24 for all three wounds. 6) On 5/28/24 A fourth wound was identified, posterior ankle DTI, measurements 2.5 cm x 2 cm x 0. Wounds #1, #2 and #3 remain without change. Continue same wound tx. For all four wounds. During a review of Nurse Progress Notes (NPN), dated, 5/22/24 through 5/29/24, the NPN indicated the following: 1) On 5/22/24, the Resident has been having extensive pain and is non-compliant with positioning . She has a brace to be left on continuously to the right leg, until her next appointment with the surgeon. 2) On 5/23/24, continued increased redness/dark purple to medial/lateral ankle due to pressure from immobilizer brace; skin remains intact; foam cushion padding between skin and immobilizer for pressure reduction. 3) On 5/27/24 at 10:24 a.m., Resident 1 was in significant pain and attempted to pull brace off. The wound care nurse and I went in the room and saw significant areas of eschar to posterior and medical ankle, and heel of the right foot. The wound care nurse removed the brace as it was significantly pushing in on her skin and disrupting the integrity of the skin. The wounds were measured, and pictures were sent to MD. The feet were placed in heel boots and propped with pillows for alignment and comfort. The splint edges caused deep tissue injuries into the skin and squeezed the ankles despite extra cushioning of the brace. Dr. (Name of Dr.) called and awaiting a call back. 4) On 5/28/24, Dr. (Name of Dr.) was in to see the pt. last night and agrees the pt. should not be wearing the brace she currently has due to the wounds she has. Waiting for a call from Dr. (Name of 055563 Page 2 of 3 055563 08/22/2024 Santa Maria Post Acute 820 West Cook Street Santa Maria, CA 93458

F 0686 Level of Harm - Minimal harm or potential for actual harm Dr.) office to see what our next option will be. Pt. foot is wrapped with gauze and placed in a heel protector with pillows propped to keep the leg aligned. 5) On 5/29/24 at 10:31 a.m., eschar to lateral/medial/posterior ankle due to increased pressure from immobilizer brace that has since been removed due to increased damage. Residents Affected - Few 6) On 5/29/24 at 10:49, The patient has significant abnormal lab values and UTI. She has lost weight and does not want food. She is in pain throughout the day due to her pressure wounds and fractures. Dr. (Name of Dr.) informed of the labs and concerns. She was sent to the hospital at 10:30 a.m. via AMR. On 5/30/24, the Discharge Summary (DS) was reviewed. The DS indicated the following: Resident has been having worsening of eschar on Achilles area and the eschar is progressively getting worse. Pt. has an orthotic placed around the lower extremity that need to be taken off given the extension of the deep ulceration. Pt. was transferred to the hospital. Pt. has significant deep eschar around Achilles area as well as may be on lateral aspects of the foot where the orthotic is lying. Lower extremity ulceration exacerbated by brace. During a concurrent interview and record review on 8/22/24 at 2:10 p.m., with the Director of Nursing (DON), Resident 1 ' s Care Plans (CP) were reviewed. CP date initiated 2/26/24, Revision on 7/1/24 – DTI right foot heel – DTI right lateral/medial/posterior ankle (5/7/24) (caused by pressure from immobilizer brace related to spiral fx.) immobilizer brace removed 5/27/24. The DON was unable to provide an answer why it was 20 days from the DTI to the time the brace was removed. During a concurrent interview and record review on 8/22/24 at 2:10 p.m. with the DON, the facility ' s policy and procedure titled, Pressure Injuries Overview, revision date March 2020 was reviewed. The P&P indicated, .Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear . Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident ' s clinical condition and risk factors; . Implementation of interventions that are consistent with resident needs, resident goals, and professional standards; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate . Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The DON confirmed the facility P&P was not followed. 055563 Page 3 of 3