Health inspection·July 10, 2024

Santa Cruz Post Acute The following reflects the findings of the California Department of Public Health during the investigation of Complaint # CA00883551 Event ID: NJ5K11 Representing the Department, HFEN 36623 State Citation B was written F686 §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 2/9/24 at 10:10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment. Resident 1 was admitted to the facility on 11/6/23 and the initial nursing assessment indicated Resident 1 did not have any wounds. When Resident 1 was transferred to a hospital's emergency department (ED) on 11/17/23, an unstageable pressure injury (unable to determine the stage; staging/classification system uses depth to classify ulcers) to the coccyx (tailbone) and deep tissue pressure injury (intact or non-intact skin with persistent, deep red, maroon, or purple discoloration) to the left ankle were identified in the ED upon initial physical assessment. The facility failed to ensure care and services were provided in accordance with professional standards of practice in performing accurate skin assessment to help prevent pressure ulcers (injury to skin and tissue below the skin caused from prolonged pressure on the skin) and provide necessary pressure treatment when staff failed to identify the presence of pressure ulcers for Resident 1. This failure resulted in Resident 1 not receiving pressure ulcer treatment and nursing interventions to aid in wound healing. Review of Resident 1's face sheet (summary page of a patient's important information), printed 2/9/24 indicated Resident 1 was admitted to the facility on 11/6/23 with diagnoses including meningitis (infection and inflammation of the membranes surrounding the brain and spinal cord) and neuromuscular dysfunction of the bladder (loss of bladder control due to brain, spinal cord, or nerve problems). Review of Resident 1's Nursing - Admission/Readmission Evaluation/Assessment, dated 11/6/23 indicated Resident 1 did not have wounds or skin integrity (condition of skin's barrier) concerns present on admission. Review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 11/6/24 indicated the resident's score was 17. A score of 15-18 indicated she was "at risk" for developing a pressure sore. Review of Resident 1's IDT (interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents) Conference Notes, dated 11/8/23 indicated the resident had no pressure ulcers and she was at risk for skin breakdown due to age and immobility. Review of Resident 1's Nursing - Daily Skilled Charting Forms (documentation including symptoms review [head to toe review of any symptoms a person is experiencing] and assessment of the body systems [such as neurological (mental status and alertness), cardiovascular (examination of the heart), respiratory (examination of lungs and breathing), skin (examination of color, skin integrity), etc.], dated 11/7/23 to 11/16/23, documented by Licensed Vocational Nurse A (LVN A) indicated the Outcomes of Physical Assessment/Observation (performing a physical assessment includes the techniques of inspection [to look at something carefully], palpation [the method of using fingers or hands to touch and feel to examine a body part], percussion [the technique of examining body parts by tapping it with the fingers or an instrument to produce a sound/vibration], and auscultation [listening to the sounds of the body] to gather data) were the following: -Respiratory: breath sounds, clear; -Digestive Status: Bowel sounds, present; -Integumentary (skin) Status: Not Applicable (N/A); Further review of the Daily Skilled Charting forms dated from 11/7/23 to 11/16/23, documented by LVN A, the daily assessments did not indicate Resident 1 had skin issues. There were no check marks on the following check boxes to describe Resident 1's skin status: skin color normal, warm, dry, cool, chills, intact, cyanosis (bluish discoloration due to lack of circulation or oxygen), redness, jaundiced (yellow discoloration), pallor (pale appearance), clammy (moist/sweaty), flushing of skin (reddening of the face or neck area), rash/itching, edema (swelling), burns, and wounds. The only box checked for skin status was "N/A." Review of Resident 1's progress notes from 11/6/23 to 11/17/23 indicated there was no documented evidence staff identified any skin issues or pressure ulcers for Resident 1. There was no documented evidence staff implemented nursing interventions to treat skin issues or pressure ulcers to aid in wound healing. Review of Resident 1's Order Summary Report, date range 11/6/23 to 11/17/23 indicated there were no orders for pressure ulcer treatment. Review of Resident 1's SNF (Skilled Nursing Facility) to Hospital Transfer form, dated late entry (documented on a later date) on 11/28/23, indicated the resident was transferred to the hospital on 11/17/23 (time not specified) due to hypotension (low blood pressure) and tachycardia (increased heart rate). The form also indicated Resident 1 had no pressure ulcers/injuries. Review of Resident 1's hospital Emergency Department (ED) Physician Notes, dated 11/17/23 at 5:31 p.m., indicated the "Physical Examination" identified Resident 1 had a decubitus ulcer (pressure ulcer). Review of Resident 1's hospital History and Physical (formal document created by a physician based on patient interview, physical exam, and summary of tests) dated 11/17/23 indicated, "[Patient 1] came to [hospital] ... pressure ulcer on sacrum [bone at the base of the spine] noted on admission, nursing will photograph." Review of Resident 1's hospital Wound Care Photo, dated 11/17/23 indicated three pictures were taken of Resident 1's coccyx wound in the ER (emergency room, ED) on 11/17/23. Review of Resident 1's hospital Wound Care Photo, dated 11/17/23 indicated one picture was taken of Resident 1's left outer ankle wound in the ER on 11/17/23. Review of Resident 1's hospital Wound Care Note, dated 11/18/23 indicated Resident 1 had two wounds discovered on 11/17/23: -Resident 1's "Wound 1" was an unstageable pressure injury on the coccyx, measuring 2.5 centimeters (cm, unit of measurement) by 3.5 cm x 0.2 cm. The wound bed had "slough [dead tissue], peeling skin, dark non blanchable [discoloration of the skin that does not turn white when pressed] tissue and clean non gran [absence of granulation, which is an important component in the wound healing process] pink tissue." -Resident 1's "Wound 2" was a deep tissue pressure injury to the left lateral ankle. "Wound 2" was described as "Dark non blanchable tissue over Lat [lateral, to the side] malleolus [ankle bone] with boggy [soft, abnormal texture of tissue] blistered center." During interviews from 3/18/24 to 3/28/24 with LVNs and certified nursing assistants (CNA) who cared for Resident 1, the LVNs and CNAs stated they did not remember pressure ulcers identified for Resident 1. During an interview with LVN A on 4/2/24 at 3:22 p.m., LVN A confirmed she completed the Daily Skilled Charting Forms for Resident 1 on the above dates remotely (not physically present, working from a location other than the place where the residents currently reside), including the skin assessments. LVN A stated she was not physically present in the facility when she documented Daily Skilled Chartings for Resident 1 and other residents since November 2023. LVN A also stated she based her assessment documentations including the symptoms review (head to toe review of any symptoms a person is experiencing), assessment of the body systems (such as respiratory [examination of lungs and breathing], skin [requires inspection and palpation to determine color, skin integrity], etc.) and pain assessments from the previous progress notes of nurses, MD (doctor of medicine), and PT/OT (physical therapy and occupational therapy). LVN A acknowledged that the assessment should not be based on the documents of others, but she should be physically present to perform the resident's assessment herself. During an interview on 5/16/24 at 2:42 p.m. with the human resources/payroll manager (HRPM), the HRPM stated LVN A is a regional minimum data set (MDS) nurse. The HRPM stated LVN A's work is done remotely. When asked whether LVN A had a signed job description for the regional MDS nurse, HRPM stated there was none. During an interview on 5/16/24 at 3:40 p.m., the director or nursing (DON) stated when doing a physical assessment, including documentation for Daily Skilled Charting, it should be done while staff was present in the facility. During an interview on 6/4/24 at 1:40 p.m., the DON acknowledged Resident 1's Daily Skilled Charting Forms, dated 11/7/23 to 11/16/23 indicated N/A was checked for integumentary status for Resident 1. She also stated she would not be documenting breath sounds and bowel sounds without physically assessing the resident. The DON further stated if Resident 1 had any problems that day, she expected it to reflect in the Daily Skilled Charting documentation. Review of an article from the National Library of Medicine, "Physical Assessment Competencies for Nurses: A Quality Improvement Initiative," published 4/17/22 indicated, "Physical assessment is a basic but essential nursing skill. Being able to assess the patient's current condition can help identify early changes. Knowledge of a patient's clinical status and usual behaviors gained through a full (head-to-toe) physical assessment is a key influence on a nurse's ability to recognize subtle changes in a patient's condition." Review of an article, "LVN Scope of Practice in California 2024: A Comprehensive Guide," dated 3/7/24 from the National Career College website indicated, "While LVNs can perform basic health assessments, conducting comprehensive physical examinations and developing care plans are the responsibilities of RNs [Registered Nurses] and physicians." Review of the facility's policy, "Charting and Documentation," dated 2001 indicated, "All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) condition, shall be documented in the resident's medical record ... The following information is to be documented in the resident medical record: a. Objective observations ... Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate." Review of the facility's "Job Description: MDS Coordinator LPN [Licensed Practical Nurse]/LVN," dated 7/2020 indicated, "The primary purpose of you job position is to provide direct nursing care to residents ... Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident ... Perform charting duties as required and in accordance with established charting and documentation policies and procedures." In violation of the above cited standards, the facility failed to ensure care and services were provided in accordance with professional standards of practice in performing accurate skin assessment to help prevent pressure ulcers (injury to skin and tissue below the skin caused from prolonged pressure on the skin) and provide necessary pressure treatment when staff failed to identify the presence of pressure ulcers for Resident 1. This failure resulted in Resident 1 not receiving pressure ulcer treatment and nursing interventions to aid in wound healing. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.