Health inspection·October 30, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to ensure the wound care plan was updated and revised timely for one of 3 sampled residents (Resident 1) when Resident 1's moisture related skin condition deteriorated to a pressure ulcer stage 4 (pressure injuries extended to muscle, tendon, or bone) to include interventions ordered by the physician. This failure had the potential to result in an inaccurate evaluation of the progress of wound healing for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2022 and readmitted in January 2023 with diagnoses that included respiratory failure (not enough oxygen in the body), muscle wasting, diabetes (too much sugar in the blood), and reduced mobility. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's IDT [Interdisciplinary Team] Skin Integrity Review, dated 9/10/24, the review indicated, WEEKLY WOUND EVALUATION: 9/10/24 SITE: Sacrococcyx [tailbone] .Reclassified from shear injury [tissue layers shift in opposite direction] to Pressure injury by wound MD [medical doctor] during wound rounds. The review further indicated the Sacrococcyx pressure ulcer was Stage 4. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, WOUND ORDER: Pressure-Stage 4: WOUND VAC [uses suction to promote wound healing] .Ensure negative pressure is set at 125 mmHg [millimeters of mercury, a unit of pressure measurement] .one time a day every Tue [Tuesday], Thu [Thursday, Sat [Saturday]. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, Monitor Wound Vac dressing patency and functionality. every shift. During a review of Resident 1's physician order, dated 10/5/24, the order indicated, WOUND ORDER: Sacrococcyx-Stage 4 Pressure: Cleanse area with normal saline [mixture of water and salt] and pat dry. Apply calcium alginate [absorptive, non-occlusive wound dressing] with honey and pack with AMD [antimicrobial, kills or stops growth of bacteria] gauze. Cover with foam dressing. one time a day. During a review of Resident 1's care plan, initiated on 5/20/24, the care plan indicated, The resident has a Skin shear/potential for skin tear of the sacrococcyx .Reclassified to Stage 4 Pressure Page 1 of 2 055887 055887 10/30/2024 River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/10/24. The care plan further indicated it was revised 10/11/24, but no revisions were made at the time when the wound was reclassified on 9/10/24, and when new interventions were ordered by the physician on 9/24/24 and 10/5/24. During an interview on 10/30/24 at 2:20 p.m. with the Director of Nursing (DON), the DON stated, the progression of MASD [Moisture Associated Skin Damage, skin erosion caused by prolonged exposure to moisture] to Stage 4 pressure ulcer was a change in condition. The DON confirmed the wound was reclassified from MASD to Pressure Ulcer Stage 4 on 9/10/24, and verified there were no revisions made and no interventions were added to the care plan not until 10/11/24. The DON stated, I don't think there was need for changes in the intervention .I think we had all the interventions we needed. During a review of the facility ' s P&P titled Wound Care, revised 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Preparation .2. Review the resident's care plan to assess for any special needs of the resident . During a review of the facility ' s P&P titled Change in a Resident's Condition or Status, revised 4/2017, the P&P indicated, 2. A significant change of condition is a major decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); .c. Requires interdisciplinary review and/or revision to the care plan . During a review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s condition change .14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident ' s condition; b. When the desired outcome is not met . 055887 Page 2 of 2