Health inspection·February 14, 2024

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 the repositioning (turning) schedule for one of two sampled residents (Resident 1). Residents Affected - Few This failure had the potential for Resident 1 to be at risk for worsening skin condition and/or pressure injury (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses of acute respiratory failure (a condition in which the lungs were not able to release enough oxygen into the blood), dependence on ventilator (a machine to support or replace the breathing of a person who was ill or injured), type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood) with foot ulcer (an open sore or wound), and pressure induced deep tissue damage (area of intact skin that looks purple or dark red due to damage to tissues under the skin) of right and left elbow, sacral region (area below the spine and above the tailbone), and right hip. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/10/2023, the MDS indicated, Resident 1 had severely impaired (weakened) cognition (the act of knowing and understanding). The MDS indicated, Resident 1 was dependent (helper did all of the effort and the resident did none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity) on staff for Resident 1 to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated, Resident 1 was at risk of developing pressure ulcers or injuries. During a review of Resident 1's Care Plan (CP), initiated and revised on 2/9/2024, the CP indicated, Resident 1 was at risk for developing pressure ulcer and other types of skin breakdown. The CP indicated, for the staff to turn and position Resident 1 as needed when in bed or wheelchair. During a review of Resident 1's Order Summary Report (OSR) dated 2/14/2024, the OSR indicated, a physician's order dated 1/30/2024, for treatment on the sacrum (area below the spine and above the tailbone) every day for 30 days for ulceration of skin for skin maintenance. During a review of Resident 1's OSR dated 2/14/2024, the OSR indicated, a physician's order dated 1/31/2024, for treatment on the right dorsal (relating to the back) foot every day for 30 days for Page 1 of 2 056291 056291 02/14/2024 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0686 ulceration (a break in skin or open sore) of skin. Level of Harm - Minimal harm or potential for actual harm During an observation on 2/14/2024 at 10:43 am, in Resident 1's room, Resident 1 was observed in bed with eyes closed and lying supine (lying on one's back, facing upward). Resident 1 was noted with pillows under the knees and Resident 1's heels were touching and resting directly on the mattress. Above Resident 1's bed was a repositioning schedule that indicated, at 10:00 am, Resident 1 was to be repositioned facing the door. The repositioning schedule indicated, at 12:00 pm, Resident 1 was to be repositioned facing the window. The repositioning schedule indicated, to float heels (a wound care term and intervention in which both heels are suspended in the air) of Resident 1. Residents Affected - Few During a concurrent observation and interview on 2/14/2024 at 10:59 am with Registered Nurse (RN) 1, RN 1 stated Resident 1 was lying supine and was not facing the door. RN 1 stated Resident 1's heels were not floated. RN 1 stated Resident 1's heels needed to be floated. RN 1 stated it was important to follow Resident 1's repositioning schedule to help with circulation and to maintain skin integrity (the health of the skin) so Resident 1 would not get a pressure ulcer. During an interview on 2/14/2024 at 1:41 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was not able to lift Resident 1's own heels off the bed. CNA 1 stated CNA 1 usually followed the repositioning schedule. CNA 1 stated the only time Resident 1 could be positioned on Resident 1's back was during patient care. During an interview on 2/14/2024 at 2:41 pm with the Director of Nursing (DON), the DON stated Resident 1 needed to be positioned on Resident 1's left side or right side due to Resident 1's history of having a wound on the sacral area. The DON also stated Resident 1's heels needed to be offloaded (elevating the foot off the bed to help prevent and heal pressure ulcer) because if Resident 1's heels were not offloaded, it could lead to worsening of the pressure ulcer. During a review of the facility's policy and procedure (P&P) titled, Pressure Sore Management, undated, the P&P indicated, all available measures shall be taken to reduce skin breakdown and pressure sores. The resident was to be re-positioned as scheduled. 056291 Page 2 of 2