Other·May 13, 2022

The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for FACILITY REPORTED INCIDENT CA00774325 which resulted in Dual Enforcement, a Class B Citation (Event ID ROFJ11). Representing the California Department of Public Health: Surveyor 39629, HFEN. 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, including but not limited to the following: On 2/28//22 at 0820 hours, an unannounced visit was conducted by the California Department of Public Health at the facility to investigate a facility report incident on a resident who sustained a laceration on the right hand. The facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained or maintained their highest practicable physical well-being. * Resident 1 was found with a deep laceration to her left hand which was covered with a dressing. CNA (Certified Nursing Assistant) 1, who was providing care to Resident 1 when the laceration was sustained, covered the laceration with a dressing and failed to report the incident to the licensed nurses. This failure resulted in Resident 1 ' s transfer to the acute care hospital and required sutures to repair the left-hand laceration. Findings: Medical record review for Resident 1 was initiated on 2/28/22. Resident 1 was admitted to the facility on 9/22/14, and readmitted on 2/23/22. Review of the History and Physical Examination dated 2/25/22, showed Resident 1 did not have the capacity to understand and make decisions. Review of the MDS (Minimum Data Set) dated 12/6/21, showed Resident 1 required total assistance on staff for bed mobility, transfers, dressing, bathing, and personal hygiene. Review of the Nurses Notes dated 2/18/22 at 1710 hours, showed at 1430 hours, the resident was noted with a left thumb dressing with blood. The dressing was removed, and Resident 1 was noted to have a laceration between the left thumb and left index finger, measuring 5.0 centimeters (length) x 1.0 centimeters (width) x 0.05 centimeters (depth). Review of the Nurses Notes dated 2/18/22 at 1735 hours, showed at 1537 hours, the physician was informed of Resident 1 ' s change of condition, and a new order was obtained to transfer the resident to the acute care hospital emergency department for further evaluation of the laceration sustained in between the left thumb and left index. Review of the acute care hospital 's History and Physical examination dated 2/19/22, showed the resident was admitted to the acute care hospital on 2/18/22. The documentation showed Resident 1 was found to have a left hand laceration, which required suturing. Further review of the hospital History and Physical examination showed the etiology of the laceration was unknown per the Skilled Nursing Facility's (SNF) nursing staff. Review of the SNF ' s Physician Order List for February 2022 showed a physician ' s order dated 2/23/22, for the left-hand laceration with five sutures: cleanse with sterile saline, pat dry, apply a Xeroform dressing (a type of wound dressing), and cover with a dry dressing daily for 21 days. On 2/28/22 at 0930 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 1 was non-verbal and required one-person total assistance with ADL care. CNA 3 stated she worked on 2/18/22, but was not assigned to Resident 1. CNA 3 stated when the licensed nurses were assessing Resident 1, she observed a big cut on Resident 1's left hand. CNA 3 stated CNA 1 was assigned to Resident 1 and CNA 1 did not request for assistance when providing care to Resident 1. On 2/28/22 at 0942 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he was assigned to Resident 1 on the day of the incident (2/18/22). CNA 1 stated Resident 1 required one-person total assistance with ADL care and repositioning. When asked to provide details of the incident, CNA 1 stated he could not provide any information, other than the cut was "... already there when his shift started. " On 2/28/22 at 1007 hours, an observation and concurrent interview was conducted with Resident 1 and her family member (Family Member 1). Resident 1 was observed sitting up in bed watching television. Resident was non-verbal and a bandage was observed to the left hand. Family Member 1 stated the Resident could not speak and required assistance with ADL (Activities of Daily Living) care. Family Member 1 stated he visited the resident daily, normally between the hours of 1000 and 1100. Family Member 1 stated the facility notified him on 2/18/22 at approximately 1600 hours, regarding Resident 1 ' s needs to be transferred to the acute care hospital for a hand injury. Family Member 1 stated on 2/18/22, he noticed Resident 1 ' s bilateral arms and hands were underneath the blanket. Family Member 1 stated normally her hands were draped and uncovered. Family Member 1 stated he thought Resident 1 was cold and did not remove her arms and hands from underneath the blanket. On 2/28/22 at 1020 hours, an interview was conducted with the Receptionist. The Receptionist stated Family Member 1 visited Resident 1 approximately at the same time daily and stayed in the facility for 30 to 40 minutes. On 2/28/22 at 1045 hours, an interview was conducted with LVN (Licensed Vocational Nurse) 2. LVN 2 stated Resident 1 sustained a hand laceration and required wound care treatments. On 2/28/22 at 1050 hours, an observation of the Resident 1's wound was conducted with LVN 2. LVN 2 removed Resident 1's bandage. Resident 1 was observed with five sutures between the left thumb and index finger. On 2/28/22 at 1121 hours, an interview was conducted with LVN 3. LVN 3 stated she worked the day Resident 1 sustained the hand laceration. LVN 3 stated she was the desk nurse on 2/18/22. LVN 3 stated on 2/18/22 at 1430 hours, LVN 4, who was the charge nurse assigned to Resident 1 observed a wet bloody bandage on the left hand of Resident 1. On 2/28/22 at 1359 hours, an interview was conducted with the DSD (Director of Staff Development). The DSD stated LVN 4 discovered Resident 1's wound during her rounds on 2/18/22, because Resident 1's blanket had a red colored stain which looked like blood on her blanket. The DSD stated CNA 1 did not report a change of condition to any licensed nurses. The DSD stated the CNAs were to conduct the skin checks when care was provided to the residents and report any changes immediately to the licensed nurses. On 2/28/22 at 1415 hours, an interview was conducted with the DON (Director of Nursing). The DON stated she was notified by RN (Registered Nurse) Supervisor 1, Resident 1 sustained an injury to the left hand on 2/18/22. The DON stated when LVN 4 and RN Supervisor 1 assessed Resident 1, they discovered Resident 1 had a bandage covering the laceration to the left hand. The DON stated LVN 4 and RN Supervisor 1 denied treating the wound and laceration to the left hand. The DON stated during the facility's investigation of the injury, CNA 1 admitted to placing the bandage on Resident 1's hand and failed to report the injury/change of condition to the licensed nurses. On 2/28/22 at 1557 hours, an interview was conducted with Administrator 1. Administrator 1 stated during the facility's investigation regarding Resident 1's injury to the left hand, CNA 1 was interviewed multiple times and his story kept changing. Administrator 1 stated during the facility's investigation, she reviewed the facility's surveillance videos, and CNA 1 was observed leaving Resident 1's room and retrieved gauze, tape, and bandages from the treatment cart. Administrator 1 stated CNA 1 admitted the resident sustained an injury to the left hand while he was repositioning the resident and admitted to placing the bandage on Resident 1's hand to cover the wound. Administrator 1 stated CNA 1 failed to report the injury immediately. Administrator 1 stated Resident 1 needed an evaluation by a physician based on the severity of the laceration. On 3/16/22 at 1027 hours, a telephone interview was conducted with RN Supervisor 1. RN Supervisor 1 stated LVN 4 reported Resident 1's hand laceration to her and asked her to assess Resident 1's hand. RN Supervisor 1 stated she was very shocked and surprised when no one other than LVN 4 had reported the cut because it was a very deep cut. RN Supervisor 1 stated Resident 1 was sent to the acute care hospital to be evaluated. RN Supervisor 1 stated Family Member 1 reported the resident's arms and hands were underneath the blanket when the family visited that morning. RN Supervisor 1 stated CNA 1 did not report any injuries that Resident 1 might have sustained on the day the laceration was discovered. RN Supervisor 1 stated the CNAs should report immediately if they noticed any changes to the resident's skin or anything different with the resident. On 3/16/22 at 1051 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 1 did not speak and was not able to communicate. LVN 4 stated she was assigned to Resident 1 on 2/18/22. LVN 4 stated when she assessed Resident 1, prior to the medication administration between 0800 to 0900 hours, she did not observe a bandage on Resident 1's hand. LVN 4 stated there was no endorsement from the night shift regarding Resident 1 sustaining an injury. LVN 4 stated after the medication administration, she rounded on Resident 1 and observed Resident 1's bilateral arms and hands were underneath the blanket. LVN 4 stated when she rounded on Resident 1 between 1400 to 1430 hours, she discovered a wound dressing on Resident 1's left thumb and saw visible blood outside of the wound bandage and blanket. LVN 4 stated she proceeded to open the saturated bandage and observed a cut on the left hand and saw visible blood. LVN 4 stated she applied a temporary wound dressing and immediately reported to the RN Supervisor 1. LVN 4 stated the assigned CNA to Resident 1 was CNA 1. LVN 4 stated CNA 1 did not report a change of condition or any injuries Resident 1 sustained during the shift. LVN 4 stated when she questioned CNA 1, he stated the injury occurred on the night shift. LVN 4 stated CNA 1 continued to deny the injury was sustained during care of Resident 1. LVN 4 stated she was informed by Administrator 1, CNA 1 confirmed Resident 1 sustained a laceration during repositioning and admitted he placed the bandage on Resident 1's hand to cover up the wound. LVN 4 stated CNA 1 should have reported the incident immediately instead of trying to hide it. This violation had a direct or immediate relationship to the health, safety, or security of the client.