Health inspection·April 3, 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 observation, interview, and record review the facility failed to ensure to assess, notify to physician and Resident's responsible party (RP: person act on behalf of resident), and document pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on bilateral (both) buttocks for one of two sampled resident (Resident 1). Residents Affected - Few This failure had the potential for delayed wound healing, adverse effects on the health and wellbeing of Resident 1. Findings: Review of Resident 1 face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 11/14/2023. Resident 1's admission diagnoses including diabetes type 2 (high sugar levels in blood), and dementia (loss of cognitive functioning, thinking, and reasoning those interfere with daily functioning). Resident 1's FS also indicated family member assigned as RP for Resident 1. Review of Resident 1's braden scale for predicting pressure sore risk assessment upon the admission to facility dated 11/14/2023 indicated score of 14 (score of 13-14: moderate risk). Review of another braden scale for predicting pressure sore risk assessment for Resident 1 dated 2/6/2024 indicated score of 12 (score of 10-12: high risk). Review of Resident 1's physician orders dated 2/7/2024 indicated, bilateral buttocks clean with normal saline (solution used to clean wounds), apply calazime (ointment used to protect skin, and treat skin irritation) daily. Review of Resident 1's clinical documentation indicated there was no documented evidence of change of condition (COC: detecting and promptly reporting changes of resident's clinical condition), or situation, background, assessment, recommendations (SBAR: written communication tool helps to provide essential, concise information), measurements of affected area, and notification to physician or RP of pressure injury for bilateral buttocks for Resident 1 on 2/7/2024. During a concurrent record review and interview with licensed vocational nurse A (LVN A) on 3/4/2024 at 2:09 p.m., LVN A confirmed physician order on 2/7/2024 for bilateral buttocks area for Resident 1. LVN A acknowledged there was no documentation for pressure injury assessment, measurements of pressure injury on the bilateral buttocks. LVN A also confirmed there was no documentation for notification to Resident 1's physician or RP of the pressure injury area on 2/7/2024. LVN A stated there was a non-blanching (skin does not turn white when applied pressure, clinically important skin Page 1 of 2 056037 056037 04/03/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few abnormality) redness on both buttock area and received order to treat the area from physician on 2/7/2024. LVN A further stated she did not measure area of redness, document, inform RP and physician regarding pressure injury on bilateral buttoks for Resident 1 on 2/7/2024. During an interview with director of nursing (DON) on 3/4/2024 at 3:06 p.m., DON confirmed there was no documentation for assessment for pressure injury for Resident 1. DON stated nursing staff should have assessed, measured, informed RP and physician, and documented for Resident 1 on 2/7/2024. DON also stated there was a potential for pressure injury delayed healing process without appropriate clinical assessment. Review of facility's policy and procedure (P&P) titled, Change of Condition, dated 2016, the P&P indicated, Document assessment findings and communication as soon as practical. Notify physician and responsible party as assessment findings. Review of facility's P&P titled, Skin Integrity, dated 2016, the P&P indicated, If skin integrity issues are identified post-admission to the facility the following documented information is required: Wound Specifics: Location of wound, Size of the wound . 056037 Page 2 of 2