Health inspection·September 1, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy and procedure for a thorough admission assessment when a surgical wound did not receive a treatment order on admission causing a delay in treatments for one of five sampled residents (Resident 1). Residents Affected - Few This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When the surgical wound assessments and treatments to promote wound healing were started 4 days after admission. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: fracture of T11-T12 vertebra (thoracic spine fracture), diabetes type II (body does not produce enough insulin, or resist insulin), obstructive sleep apnea (airflow blockage during sleep), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Skin Evaluation dated July 23, 2023 at 11:07: Mid back surgical incision length 30 width 1.0, Rash/redness under right breast, 1+ pitting edema, Xerosis(rough, dry skin) Right and Left feet, hyperpigmentation to Right and Left lower legs, Intravenous Left Arm, Pacemaker(battery-powered device to prevent heart from beating slow) in place, skin tear to Left lower arm covered with Mepilex(foam dressing) C/D/I dressing, ecchymosis(bruising) to Left upper arm, ecchymosis to Right lower abdomen, Spine surgery with 69 staples present, covered with mepilex AG C/D/I, dry scab on posterior aspect of neck fold. 2. No record of wound care physician notification of Skin Evaluation on July 23, 2023, for wound care treatments. 3. Treatment Administration Record (TAR) dated July 01, 2023-July 31, 2023: 2a. Order date 07/26/23: Ammonium Lactate external cream 12% apply to Right and Left foot every day .Treatment started on July 27, 2023. 2b. Order date July 26, 2023: Mid-back surgical site, cleanse with Normal saline pat dry, cover with dry dressing every day for 21 days .Treatment started on July 27, 2023. Page 1 of 2 055708 055708 09/01/2023 Arrowhead Springs Healthcare 1335 N. Waterman Ave. San Bernardino, CA 92404

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2c. Order date July 26, 2023: Posterior aspect of neck fold moisture associated wound with scab; cleanse w/Normal Saline, pat dry, paint w/Betadine, may leave open to air every day, shift for 21 days .Treatment started on July 27, 2023. 2d. Order date July 27, 2023: Skin tear to left forearm (POA), Cleanse with Normal saline, pat dry, cover with foam dressing and change every other day and PRN x 21 days. Treatment started on July 29, 2023. During an interview on August 22, 2023, at 11:30 AM, with the Treatment Nurse, Treatment nurse stated, On admission Resident 1 came in with the wounds, the skin assessment was done the following day, but the treatment orders were placed on the July 26, 2023. I don't know why the orders should have been placed when admission assessment was done, and it wasn't. During a concurrent interview and record review on August 22, 2023, at 12:11 PM, with the Director of Nursing (DON), of Resident 1's Medical Records, DON stated, Resident 1 came in on August 22, 2023, at 9:58 PM, there was an initial skin evaluation the following day from admission. I do see the treatments starting on July 27, 2023. I don't know why the wound care treatments were not done until days later from admission. I can agree that it should had been on initial skin assessment, we should have had and order for wound treatments sooner. During a concurrent interview and record review on August 22, 2023, at 12:14 PM, with the Operation Manager (OM), of Resident 1's Medical Records, when asked, Should the resident have had wound care treatments sooner rather than starting 4-5 days later from admission? Yes, resident should have had a wound treatment care sooner. During a review of the facility's policy and procedure titled, Wound Care & Treatment Guidelines (reviewed January 2023), the policy and procedure indicated, It is the policy of this facility to provide excellent wound care to promote healing. During a review of the facility's policy and procedure titled, Skin Management System (reviewed January 2023), the policy and procedure indicated, It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures take to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the residents clinical condition makes the development unavoidable .1. Residents will have a head-to-toe skin assessment by a licensed nurse at the time of admission. Any skin lesions will be documented on the Nursing admission Assessment. A treatment order will be obtained from the Attending for areas requiring treatment. i.e. pressure injury, surgical wounds, open skin tears, abrasions, lacerations etc. 7. Surgical wound sites will be checked for signs and symptoms of infection until staples are removed or areas have healed . 055708 Page 2 of 2