Other·August 9, 2023

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medical record review for Resident 1 was initiated on 7/5/23. Resident 1 was admitted to the facility on 12/5/22, transferred to emergency department on 6/29/23, and was admitted to the acute care hospital on 6/29/23. a. Review of the SOC 341 - Report of Suspected Dependent Adult/Elder Abuse dated 6/30/23, showed Resident 1 was transferred to the emergency department for a large mass on the left arm, presenting as early as April 2023. The SOC 341 reported Resident 1's responsible party had no knowledge of the large mass on Resident 1's arm. According to the report, the nursing facility staff had been aware of the progressively growing mass since April 2023 and were only providing daily dressing changes for it. The nursing facility did not arrange for Resident 1 to receive diagnosis and treatment until 6/29/23. The physician at the acute care hospital expressed concerns of possible medical neglect from the nursing facility due to the resident's wound and history of malignancy. Review of Resident 1's Emergency Department Note from the acute care hospital dated 6/29/23, showed Resident 1 had a history of basal cell skin cancer and squamous cell carcinoma in situ. On 7/5/23 at 1101 hours, a wound care observation for Resident 1 was conducted with LVN 1. Resident 1 had a dressing observed in place to the left forearm with a moderate amount of serosanguineous drainage noted. After removing the dressing, LVN 1 cleaned the skin mass with normal saline and patted the area dry. The mass appeared to be bright red, raw, was raised and had irregular borders, and was cauliflower-like in appearance. There was a moderate amount of active bleeding noted. LVN 1 verified the observation. Resident 1 denied having pain at the time, but stated the site was sometimes painful. LVN 1 measured the mass as 6.5 cm (length) X 5.5 cm (width) X 3 cm (depth). Review of Resident 1's Physician's Progress Notes dated 1/18/23, showed Resident 1 had a left upper extremity skin lesion and the physician recommended for the resident to consult the dermatologist for it. However, review of the physician's order dated 1/19/23, showed the order was transcribed as "may have dermatology consult" for the left forearm growth. A physician's order dated 1/27/23, showed Resident 1 could have a dermatology consultation as needed. Review of Resident 1's Progress Notes dated 1/27/23 at 1601 hours, showed Resident 1 was noted with a small, dry scab on the left anterior forearm measuring 1.0 cm (length) X 1.0 cm (width) X 0 cm (depth). After cleaning the area with normal saline, the scab fell off and left a lesion measuring the same size with noted light serosanguineous drainage (discharge that contains both blood and a clear yellow liquid known as blood serum). Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the following measurements of the resident's left forearm skin lesion/mass: - On 3/3/23, it was 2.0 cm (length) X 1.8 cm (width) X 0 cm (depth). - On 4/20/23, it was 2.5 cm (length) X 2.4 cm (width) X and 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. Review of the physician's order dated 4/21/23, showed to obtain a dermatology consultation for Resident 1 for the growing skin lesion on her left forearm. Review of Resident 1's medical record did not show Resident 1 was evaluated by the dermatologist. On 7/5/23 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 confirmed that he placed the dermatology consultation order dated 4/21/23, for Resident 1 after observing the growth of the skin lesion on her left forearm. LVN 1 also confirmed Resident 1 was not evaluated by the dermatologist as per the orders until she was transferred to the acute care hospital. LVN 1 stated it was the Case Manager's responsibility to arrange for the resident's consultation with the dermatologist. Upon reviewing Resident 1's Progress Notes, there was no documented evidence the facility had arranged a dermatology consultation for Resident 1 until 6/23 and 6/27/23. This was five months after the physician initially recommended it on 1/18/23, and two months after a second dermatology consultation was ordered on 4/21/23, when the lesion had already grown in size. On 6/9/23, the resident's forearm mass measured 4.5 cm (length) X 5.0 cm (width) and 5.0 "cm+" (depth). On 7/5/23 at 1147 hours, an interview and concurrent medical record review was conducted with the Case Manager. The Case Manager stated she started the position in March 2023 and was not aware of Resident 1's orders for the dermatology consultation until June 2023 when she was working with Resident 1's insurance carrier to obtain the authorization for unrelated matters. The Case Manager stated getting authorization for the dermatology consultation could take time, so it was best to start working on it as soon as there was an order. After reviewing her emails and Resident 1's medical record, the Case Manger verified the facility did not begin arranging for the resident's dermatology consultation until 6/23/23. The Case Manager confirmed that Resident 1 was not evaluated by the dermatologist as per the physician's orders until she was transferred to the acute care hospital. On 7/5/23 at 1215 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when he first saw Resident 1's skin lesion it looked like a skin tag. However, when he saw the lesion again sometime in June 2023, it had grown in size and resembled neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) prompting the resident's transfer to the emergency department on 6/29/23, for further evaluation. The DON verified the Physician's Progress Notes dated 1/18/23, indicated Resident 1 had a skin lesion on the left upper extremity and the physician recommended a consultation with a dermatologist. The DON stated the physician's order for the dermatology consultation transcribed on 1/19/23, should not have been written as a PRN (as needed) order. The DON verified the Case Manager should work on arranging any consultations ordered as soon as there was an order for it as to not delay the resident's care. The DON confirmed Resident 1 was not evaluated by the dermatologist as per the physician's orders until she was transferred to the acute care hospital. Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the following measurements of the resident's left forearm skin lesion/mass: - On 4/20/23, it was 2.5 cm (length) X 2.4 cm (width) X 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. - On 5/4/23, it was 2.7 cm (length) X 2.5 cm (width) X 0.6 cm (depth). - On 5/19/23, it was 3.3 cm (length) X 3.5 cm (width) X 3.7 cm (depth), growing significantly in length and width and more than six times the size in depth from the previous assessment. - On 5/26/23, it was 3.8 cm (length) X 4.2 cm (width) X and 4.2 "cm+" (depth). - On 6/2/23, it was 4.3 cm (length) X 4.7 cm (width) X 4.8 "cm+" (depth). - On 6/9/23, it was 4.5 cm (length) X 5.0 cm (width) X 5.0 "cm+" (depth). Review of Resident 1's Transfer Form dated 6/29/23 at 1354 hours, showed Resident 1 had an unplanned transfer to the emergency department due to the progressively worsening of the left arm skin growth. Review of Resident 1's Emergency Department Note from the acute care hospital dated 6/29/23, showed Resident 1 presented with a left forearm large fungating mass measuring approximately 12 cm in diameter with slow oozing of blood. The dermatologist consulted recommended surgical consultation for possible removal of the mass. The CT scan was reviewed by the radiologist who noted a concern for the large soft tissue dermal mass concerning for malignancy. Review of Resident 1's Surgical Pathology report from the acute care hospital showed a shave biopsy on the left forearm mass was performed on 6/29/23. The result available on 7/5/23, revealed the presence of invasive moderately differentiated squamous cell carcinoma. On 7/7/23 at 0753 hours, an interview was conducted with Physician 1, the consulting dermatologist at the acute care hospital. Physician 1 emphasized that the rapidly growing and bleeding nature of the lesion was a clear indication to seek evaluation from a healthcare provider. Physician 1 stated the biopsy results confirmed the presence of squamous cell carcinoma; clinically, the skin mass measured at least 4 cm, indicating a high-risk feature that increased the resident's risk of both local and distant metastasis. Additionally, the delayed care will result in the resident undergoing a more extensive surgical procedure to remove the cancer and experiencing a longer healing time. b. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol (undated) showed the licensed staff will evaluate the wound and document weekly the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. Wound status will be relayed to the physician for appropriate updated treatment. Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the resident's left forearm skin lesion/mass was not measured and evaluated weekly as per the facility's P&P as evidenced by: - On 3/3/23, it measured 2.0 cm (length) X 1.8 cm (width) X 0 cm (depth). However, there were no weekly wound evaluation performed for next three weeks until 3/27/23. - On 3/27/23, it measured 2.0 cm (length) X 1.8 cm (width) X 0.4 cm (depth). - On 4/5 and 4/12/23, it measured 2.2 cm (length) X 2.0 cm (width) X 0.5 cm (depth). - On 4/20/23, it measured 2.5 cm (length) X 2.4 cm (width) X 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. There was no weekly wound evaluation performed for a week until 5/4/23. - On 5/4/23, it measured 2.7 cm (length) X 2.5 cm (width) X 0.6 cm (depth). However, there was no weekly wound evaluation performed for a week until 5/19/23. - On 5/19/23, it measured 3.3 cm (length) X 3.5 cm (width) X 3.7 cm (depth), growing significantly in length and width and more than six times the size in depth from the previous assessment. - On 5/26/23, it measured 3.8 cm (length) X 4.2 cm (width) X 4.2 "cm+" (depth). - On 6/2/23, it measured 4.3 cm (length) X 4.7 cm (width) X 4.8 "cm+" (depth). - On 6/9/23, it measured 4.5 cm (length) X 5.0 cm (width) X 5.0 "cm+" (depth). However, there were no weekly wound evaluation performed for next three weeks until Resident 1 was transferred to the acute care hospital on 6/29/23. On 7/5/23 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings and confirmed he was supposed to conduct the weekly wound evaluations on Resident 1's left arm skin lesion/mass. On 7/6/23 at 0945 hours, an interview was conducted with the Administrator and DON. Both the Administrator and DON verified the weekly wound evaluations were required upon admission/readmission, weekly thereafter, for any change of condition, and annually. The DON explained the purpose of these evaluations was to monitor the wound's progress, assess whether it was improving or deteriorating, and adjust the treatment plan if necessary. On 7/12/23 at 1454 hours, a follow-up telephone interview was conducted with the DON. The DON stated that previously the Case Manager was solely responsible for obtaining authorizations for any consultations ordered and had no oversight to ensure it was being worked on. The DON stated moving forward, all ordered consultations will be discussed in the morning meetings to ensure they were carried out as ordered. Additionally, the DON stated only pressure-related wounds were audited to ensure the weekly wound evaluations were completed, but moving forward, the audits will include all wounds. This violation had a direct or immediate relationship to the health, safety or security of the client.