Health inspection·September 22, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision and maintain safety to prevent an avoidable accident for one of three sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen. Findings: During a review of Resident 1's admission Record dated 9/8/23, the admission Records showed Resident 1 was admitted in May 2022. During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage. During an interview on 9/8/23 at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs on 8/25/23 because she had menstrual cramps. Resident 1 stated CNA 1 'broke them and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30 45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses station to ask the nurses what was on her abdomen and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor. During an interview on 9/8/23 at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs at approximately 7 p.m. on 8/25/23. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 Page 1 of 5 055715 055715 09/22/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0689 Level of Harm - Actual harm Residents Affected - Few stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs. During a concurrent observation and interview on 9/8/23 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button). During a telephone interview on 9/8/23 at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse on 8/25/23, the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only. During an interview on 9/8/23 at 4:42 p.m. with DON, DON stated Resident 1 did not have a physician order for hot packs. DON also stated hot packs fell under the facility's Hot Compress Policy and a physician order was required. DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging. During a phone interview on 9/21/23 at 2:50 p.m. with Resident 1's doctor (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's diabetes (a disease that impairs the way the body uses blood sugar) caused her decreased sensation and may have contributed to Resident 1's burns. During a review of the facility's Incident Investigation Summary, undated, the Investigation Summary indicated on 8/25/23, Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so. The Investigation Summary further indicated, Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access. During a review of the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm, dated 2/2018, the P&P indicated, 1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. During a review of [NAME] Instant Disposable Hot Compress packaging, undated, the package indicated, Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes. 055715 Page 2 of 5 055715 09/22/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards for care for one of three residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen. Findings: During a review of Resident 1's admission Record dated [DATE], the admission Records showed Resident 1 was admitted in [DATE]. During a review of Resident 1's Minimum Data Set (MDS - an assessment used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Resident 1 was wheelchair bound and Section G of the MDS showed her functional status included needing extensive assistance transferring and independent when moving about the unit once in her wheelchair. Section M of the MDS showed Resident 1 had intact skin but was at risk for developing pressure ulcers/injuries and had moisture-associated skin damage. During an interview on [DATE] at 12:30 p.m. with Resident 1, Resident 1 stated she asked Certified Nurse Assistant (CNA) 1 for hot packs because she had menstrual cramps. Resident 1 stated CNA 1 'broke them and handed two hot packs to her. Resident 1 further stated she took the hot packs to her room and placed them on her abdomen for 30 45 minutes. Resident 1 removed the hot packs when she repeatedly felt moisture and stinging. Resident 1 stated she went to the nurses station to ask the nurses what was on her abdomen and they told her she had a burn. Resident 1 stated her pain was 8/10. Resident 1 further stated Licensed Vocational Nurse (LVN) 1 applied medicine and covered the wound after calling the doctor. During a concurrent interview and record review on [DATE] at 1:02 p.m. with Director of Nursing (DON), CNA 1's California Department of Public Health Nurse Assistant Certification, dated [DATE], was reviewed. The certificate indicated CNA 1's Nurse Assistant certification expired [DATE]. DON stated CNA 1 was registry staff and provided an orientation binder specific to registry on her start date. DON also stated registry staff were required to sign an acknowledgement they reviewed the orientation binder. DON provided an email from CNA 1's employer, dated [DATE], and stated CNA 1 started at the facility on [DATE]. DON further stated she expected certified nurse assistants, including registry, to do shift-to-shift handoff (the transfer of resident information and status from one staff to another between shifts) and go to the charge nurse for any questions. Staff inservices (training/information provided at work) completed in 2023 were also reviewed. CNA 1 attended two of five inservices provided for certified nurse assistants, one on [DATE] for razor disposal, and one on [DATE] for heat packs provided after Resident 1's injury. DON stated no prior inservices for hot packs had been provided. 055715 Page 3 of 5 055715 09/22/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 2:43 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated hot and cold packs required permission from the charge nurse. She stated she had applied hot and cold packs on residents before and used a towel to protect the resident's skin from getting too hot or too cold. During an interview on [DATE] at 2:59 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated hot packs required a physician's order and were only applied by the charge nurse. LVN 3 also stated hot packs were wrapped in a cloth or towel, and the nurse assessed whether the resident held the hot pack. During an interview on [DATE] at 3:10 p.m. with CNA 1, CNA 1 stated Resident 1 asked for two hot packs. CNA 1 stated she asked Licensed Vocational Nurse (LVN) 2 and was instructed to check the closet in Station 2. CNA 1 stated she activated the hot packs, placed them on a medication cart shelf at Station 2, and told Resident 1 to wait while she got towels. CNA 1 stated she was gone approximately 15 minutes and when she returned, Resident 1 was found in her room with nurses caring for a burn on Resident 1's abdomen. CNA 1 stated she didn't know if Resident 1 had an order for hot packs but assumed it was okay since LVN 2 told her to get the hot packs. During a concurrent observation and interview on [DATE] at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's abdominal wound was observed during a dressing change. LVN 1 stated the wound measured 5 cm x 12 cm. The lower abdominal wound was midline and extended to the right. The wound had pink margins and a white wound bed with two grayish-tan areas, one in the middle of the wound and one to the left. In addition, there were two small, approximately 0.5 cm x 0.5 cm dried, dark brown blisters located just inferior and to the left of Resident 1's umbilicus (belly button). During a telephone interview on [DATE] at 4:33 p.m. with Licensed Vocational Nurse (LVN) 2 and Director of Nursing (DON) present, LVN 2 stated she was the charge nurse the evening of Resident 1's injury. LVN 2 stated CNA 1 did not ask her to use hot packs for Resident 1. LVN 2 further stated Resident 1 did not have an order for hot packs, and she previously told Resident 1 to drink warm water to help relieve her cramping. LVN 2 stated hot packs required a physician order and application by licensed nurses only. During an interview on [DATE] at 4:42 p.m. with DON, DON stated Resident 1 did not have a physician order for hot packs. DON also stated hot packs fell under the facility's Hot Compress Policy and a physician order was required. DON further stated facility staff are expected to follow the manufacturer's instructions on the hot pack packaging. During an interview on [DATE] at 5:03 p.m. with DON, DON stated they could not provide CNA 1's signed orientation binder acknowledgement. During a phone interview on [DATE] at 2:50 p.m. with Resident 1's primary physician (MD 1), MD 1 stated he never ordered hot packs for Resident 1, nor was he called for an order. MD 1 also stated he would have ordered ibuprofen (medication that reduces inflammation) rather than hot packs as treatment for menstrual cramps if he had been called. MD 1 stated Resident 1's diabetes caused her decreased sensation and may have contributed to Resident 1's burns. During a review of the facility's Incident Investigation Summary, undated, the Investigation Summary indicated on [DATE], Resident 1 had an open abdominal wound that measured 5 cm x 12 cm x 0.1 cm 055715 Page 4 of 5 055715 09/22/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caused by two hot packs applied directly to her abdomen. The Investigation Summary also indicated CNA 1 said she was unaware she can't apply items like a heat pack on residents and only a nurse can do so. The Investigation Summary further indicated, Supply of heat packs removed from a nursing supplies closet to allow only licensed personnel to access. During a review of the facility's policy and procedure (P&P) titled, Compress or Soak, Applying Warm, dated 2/2018, the P&P indicated, 1. Verify there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. During a review of [NAME] Instant Disposable Hot Compress packaging, undated, the package indicated, Peak temperature may reach 160?. Do not apply directly to skin, wrap in towel or cloth for protection. Do not use for more than 30 minutes. 055715 Page 5 of 5