Health inspection·June 20, 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 assess, and notify physician of a change in condition timely to ensure skin care was provided to prevent pressure injury for one of three residents (Resident 1). Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When a facility acquired pressure ulcer/injury developed and worsened resulting in Resident 1 being transferred to the Acute Hospital for further wound evaluation. 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: diabetes type II (body does not produce enough insulin, or resist insulin), end stage renal disease (kidneys cease functioning, need for dialysis), congestive heart failure (weakness of the heart). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. Initial skin assessment on admission, facility cannot provide skin assessment, but did provide Initial admission skin record dated January 22, 2023 @1905, document is blank, no wound assessment notes. 2. Wound Assessment from wound doctor dated February 22, 2023, indicates .Reevaluate for Right first digit wound from brace .pressure from medical device. 3. Wound Assessment from wound doctor dated March 01,2023 indicates . Reevaluate for Right first digit wound from brace. 4. Skin Integrity Report dated admission date September 22, 2022; initial wound date dated February 22. 2023 indicates . Right Index Finger callous/arterial . Necrotic March 31, 2023. 5. Nurse Progress Note dated April 18, 2023 @10:40 Doctor was notified of right index finger worsening, pictures sent. 6. Wound Assessment from wound doctor dated April 26, 2023, indicates . Reevaluate for Right fist digit wound from brace .Refer to surgical consult. Page 1 of 2 056372 056372 06/20/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7. Nurse Note dated May 08, 2023 @8:06, Resident has persisted pain rt index finger overnight, pending vascular appointment, Nurse Practitioner notified, sent out for further eval to hospital, wife made aware. During an interview on June 06, 2023, at 11:22 AM, with the Treatment Nurse, Treatment nurse stated, I was told by Physical Therapy about his finger, I went to assess and notified the doctor on February 22, 2023, and the wound doctor did his wound assessment. It started as callus to necrotic; the wound care treatment order didn't change. I observed the resident wrapping the affected finger, and I told him not wrap the self-adhering bandage so tight, he was very independent and had personal supplies at bedside, that was not from the facility, I'm not sure where they came from. I did skin assess the resident even before the finger ulcer. When asked, did you assess Resident 1's fingers while you did skin assessments? States, I did not look at the finger, the Physical Therapist told me about the pressure injury. During a concurrent interview and record review on June 06, 2023, at 11:22 AM, with the Assistant Director of Nursing (ADON), of Resident 1's Medical Records, ADON stated, We followed the protocol for this resident, we need better communication on the wounds. No resident should acquire a Pressure Injury [NAME]. During review of records ADON can agree to the following, the notes, states . Right first digit wound from brace .pressure from medical device. Cannot provided initial skin assessment, the one provided is blank. Also, Documents show wound is necrotic March 31, 2023, and doctor notified April 18, 2023. During an interview on June 06, 2023, at 12:46 PM, with the Director of Nursing (DON), DON stated Any resident should not develop a Pressure Injury in the facility but is also depends on their comorbidities. Avoidable and unavailable and the interventions put in place. During a review of the facility's policy and procedure titled, Change of Condition Reporting (no date), the policy and procedure indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician. During a review of the facility's policy and procedure titled, Skin and Wound Monitoring and Management revised January 2022, the policy and procedure indicated, The purpose of this policy is that the facility provides care and services to 1. Promote interventions that prevent pressure injury development; 2. Promote healing of pressure injuries that are present (including prevention of infection to the extent possible; 3. Prevent the development of additional, avoidable pressure injury. A. Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions . g. Ongoing skin and wound assessment . 056372 Page 2 of 2