Other·April 6, 2022

483.25(b) Skin Integrity 483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. On 1/24/22 at 0908 hours, an unannounced visit was conducted by the California Department of Public Health at the facility to investigate a complaint regarding pressure injury. The facility failed to ensure the necessary care and services were provided to prevent the development or worsening of the pressure ulcers for one of two sampled residents (Resident 1). Resident 1 was readmitted to the facility with a non-blanchable pressure ulcer to the sacrococcyx (tailbone area) on 10/26/21, which had progressed to a Stage 3 pressure ulcer on 1/12/22. * The facility failed to provide wound care treatments as ordered by the physician. * The facility failed to ensure Resident 1's skin assessments were consistently conducted to prevent the worsening of the pressure ulcer. * The facility failed to conduct the weekly interdisciplinary team (IDT) wound meetings to ensure the pressure ulcer was healing. These failures resulted in Resident 1's development of a worsening pressure ulcer and delayed healing. Review of the facility's policy and procedure (P&P) titled Wound Care revised 10/20, showed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation - 1. Verify that there is a physician's order for this procedure...Documentation - The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given...4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound...9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. According to the National Pressure Injury Advisory Panel, a pressure ulcer is defined as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The National Pressure Injury Advisory Panel redefined the definition of a pressure ulcers in 2016. They are as follows: - Stage 1 pressure ulcer - intact skin with a localized area of non-blanchable erythema (redness). - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). Closed medical record review for Resident 1 was initiated on 1/24/22. Resident 1 was admitted to the facility on 10/14/21, readmitted on 10/26/21, and discharged from the facility on 1/16/22. Review of the Re-Admission Braden Scale for Predicting Pressure Sore Risk dated 10/26/21, showed Resident 1's risk score was 17, which meant the resident was at risk for developing the pressure ulcers. Review of the untitled document dated 10/27/21, showed Resident 1's skin assessment showed a pressure injury (same as pressure ulcer) described as non-blanchable redness to the coccyx. Review of the Order Summary Report showed a physician's order dated 10/27/21, to apply zinc oxide ointment 20% to sacrococcyx topically every shift for non blanchable redness, wash with warm water and mild soap, pat dry, apply zinc oxide, and leave open to air every shift and as needed. Review of Resident 1's plan of care showed a care plan problem dated 10/27/21, addressing redness to Resident 1's sacrococcyx. The interventions included to perform the treatments as ordered. Review of the Wound Evaluation Flow Sheet dated 10/27/21, showed Resident 1 had a Stage 1 non-blanchable pressure ulcer to the sacrococcyx, measuring 4.0 centimeter (cm) x 4.0 cm (length x width). Further review of the Wound Evaluation Flow Sheet showed the last wound evaluation conducted for Resident 1 was documented on 12/23/21. Review of the Skin/Wound Progress Note dated 1/12/22, showed Resident 1's pressure ulcer regressed to a Stage 3 and noted few islands of partial thickness tissue loss, open areas over redness, close approximate to each other and the entire site, measuring 4.6 cm (length) x 5.6 cm (width) x 0.2 cm (depth). On 1/24/22 at 1130 hours, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated all CNAs were required to conduct daily skin checks for the residents. CNA 1 stated the skin checks occurred while providing care to the resident and the CNAs were required to report to the Charge Nurse if they observed any changes to the resident's skin. On 1/24/22 at 1150 hours, an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 1 was no longer at the facility. LVN 2 stated Resident 1 was readmitted to the facility with a Stage 1 non-blanchable ulcer on the sacrococcyx. LVN 2 stated Resident 1 had a physician's order for skin treatments to the wound. LVN 2 stated she was off from work and when she returned on 1/12/22, she assessed Resident 1's skin and found the resident's pressure ulcer had worsened. LVN 2 stated the pressure ulcer progressed from a Stage 1 to Stage 3. LVN 2 stated the facility's policy was to conduct skin wound assessments weekly, which included measurements, description, and location of the wound. On 1/24/22 at 1225 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 1 was alert and oriented, able to carry a conversation, and compliant with care. LVN 1 verified Resident 1 was admitted to the facility with a Stage 1 non-blanchable pressure ulcer and on 1/12/22, the pressure ulcer had worsened to a Stage 3. On 1/24/22 at 1237 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated the facility's policy for skin assessments included conducting skin assessments on the new residents upon admission. LVN 3 further stated CNAs should be conducting skin checks during the resident's shower days, peri-care, and bed baths. The CNAs were to report any changes to the charge nurse. LVN 3 stated Resident 1 was admitted with foot edema and redness on her coccyx. LVN 3 reviewed Resident 1's Treatment Administration Record and verified Resident 1 had a physician's order to apply zinc oxide ointment 20% to sacralcoccyx topically every shift for non-blanchable redness. LVN 3 stated the nurses who provided the treatments would document in the Treatment Administration Record and the nurse's initials would appear. Further review of Resident 1's Treatment Administration Record showed the following: * The Treatment Administration Record dated 10/1 to 10/31/21, showed blank, unsigned treatments on the following dates: - On 10/28/21 and 10/29/21, during the 11-7 shifts - On 10/30/21, during the 3-11 and 11-7 shifts - On 10/31/21, during the 11-7 shift A total of four treatments were missed for October 2021. * The Treatment Administration Record dated 11/1 to 11/30/21, showed blank, unsigned treatments on the following dates: - On 11/1/21, during the 3-11 and 11-7 shifts - On 11/4/21, during the 11-7 shift - On 11/6/21, during the 3-11 shift - On 11/8/21, during the 11-7 shift - On 11/9/21, during the 3-11 and 11-7 shifts - On 11/10/21, during the 3-11 shift - On 11/13/21, during the 11-7 shift - On 11/20/21, during the 7-3 shift A total of 10 treatments were missed in November 2021. * The Treatment Administration Record dated 12/1 to 12/31/21, showed blank, unsigned treatments on the following dates: On 12/2/21, during the 3-11 shifts On 12/12/21, during the 7-3 shift On 12/14/21, 12/19/21, 12/20/21 and 12/24/21, during the 3-11 shift On 12/25/21, during the 11-7 shift On 12/26/21, during the 7-3 and 3-11 shifts On 12/28/21, during the 3-11 shift On 12/30/21 and 12/31/21, during the 11-7 shift A total of 12 treatments were missed in December 2021. * The Treatment Administration Record dated 1/1 to 1/31/22, showed blank, unsigned treatments on the following dates: - On 1/1/22, during the 3-11 shift - On 1/2/22, during the 11-7 shift - On 1/3/22, Resident 1 did not receive treatments on each of the three shifts for the day - On 1/4/22, during the 3-11 and 11-7 shifts - On 1/5/22, during the 11-7 shift - On 1/6/22, during the 3-11 and 11-7 shifts - On 1/7/22, during the 3-11 shift - On 1/9/22 and 1/10/22 during the 7-3 shifts - On 1/11/22 during the 3-11 and 11-7 shifts - On 1/12/22, Resident 1's wound progressed to a Stage 3 and the new orders from the physician were received. A total of 14 treatments were missed in January 2022 prior to the discovery of Resident 1's Stage 3 wound. LVN 3 verified the blank boxes in Resident 1's Treatment Administration Record meant the treatments were missed and not provided to the resident. LVN 3 further stated the residents with a pressure ulcer must have had the weekly assessments documented in the electronic medical record or paper weekly wound assessments and must have had the weekly IDT wound management meetings. LVN 3 reviewed Resident 1's medical record and verified she could not find any weekly electronic skin/wound evaluation/assessments conducted for Resident 1. LVN 3 stated there were no weekly IDT wound management notes pertaining to Resident 1's Stage 1 pressure ulcer. LVN 3 verified an IDT wound management note was dated for 1/13/22, in regards to the in-facility development of Resident 1's Stage 3 pressure ulcer. On 1/24/22 at 1607 hours, an interview and concurrent medical record review was conducted with the Director of Nursing (DON). The DON verified Resident 1's Stage 3 pressure ulcer was discovered on 1/12/22. The DON reviewed Resident 1's medical record and stated an IDT meeting for the worsening of the wound was conducted on 1/13/22, but could not find other IDT wound notes relating to the pressure ulcer. On 3/1/22 at 1616 hours, a telephone interview was conducted with the (Director of Staff Development) DSD. The DSD stated the Treatment Nurses were expected to document and assess the wounds weekly, and the IDT wound management meetings should be conducted weekly for the residents as well. The DSD stated the assessments and meetings should be documented in the electronic health record; however, some treatment nurses still documented on paper record and those assessments were in the binder. On 3/3/22 at 1432 hours, a telephone interview and concurrent medical record review was conducted with the DON. The DON stated all physician's orders should be followed accordingly. The DON verified if a treatment was ordered every shift, then the order should be followed. If there was a discrepancy in the order, the physician should be notified and the order had to be clarified. The DON stated the nurses should be conducting skin assessments daily, especially when the nurse was providing a treatment, and the assessment should be documented. The DON reviewed Resident 1's medical record and verified the above findings on Resident 1's Treatment Administration Record for the months of October 2021 - January 2022, and verified there was a physician's order for zinc oxide ointment 20% to sacrococcyx topically every shift for non-blanchable redness. The DON verified the above treatments were missed and not documented. The DON verified the treatment orders should have been followed as per the physician's order, and the weekly wound evaluation and assessments should have been documented. This violation, jointly, separately, or in any combination had a direct or immediate relationship to the health, safety or security of patients or residents.