Health inspection·September 4, 2024

The following reflects the findings of the California Department of Public Health during the investigation of a complaint CA00906845. Event ID: 567Y11 Representing the Department, HFEN #3184 State Citation B was written. F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 7/5/24, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment: Resident Safety The facility failed to ensure the safety of Patient 1 when the facility did not investigate thoroughly the root causes of the incidents of skin tears during transfers from bed to wheelchair and transfer to wheelchair after using the bathroom. This failure led to four recurrent incidents on 2/24/24, 4/2/24, 5/17/24, and 6/10/24 that resulted to lower legs skin tears for Patient 1. Review of Patient 1's medical record indicated she was admitted on 12/30/23 with diagnoses that included peripheral vascular disease (PVD, narrowing of blood vessels that cause poor blood flow to the legs and feet), osteoarthritis (a disorder due to aging that caused wear and tear on a joint) of bilateral knee, muscle weakness and abnormalities of gait and mobility. Review of Patient 1's Minimum Data Set (MDS, a comprehensive resident assessment tool) dated 1/6/24, 4/4/24 and 7/2/24 indicated her Brief Interview for Mental Status (BIMS, a mental status test that measures orientation, learning and memory) was 12, a score of 8-12 indicates her cognition (mental process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. Further review of Patient 1's MDS dated 1/6/24, 4/4/24 and 7/2/24 indicated she had no impairment on both sides of her upper and lower extremities. She required partial/moderate assistance (helper does less than half of the effort) during chair/bed to chair transfer and toilet transfer. During an interview with Patient 1 on 7/19/24 at 8:22 am, she stated sometime in February 2024 her right leg was caught in the wheelchair when CNA transferred her from bed to wheelchair. During an interview with Certified Nursing Assistant A (CNA A) on 7/19/24 at 9:02 a.m., she stated Patient 1 was alert and oriented to time, person, and place and was able to verbalize her needs. During an interview with Licensed Vocational Nurse B (LVN B) on 7/19/24 at 10:58 a.m., she stated Patient 1 was alert and oriented to time, person, and place. Review of Patient 1's Nursing Care Plan (NCP, a plan that provides direction on the type of nursing care the patient may need) for at risk of skin breakdown dated 1/1/24 indicated, to assess for any skin breakdown during activities of daily living (ADLs). Notify nurse immediately for any new areas of skin breakdown. Review of Patient 1's NCP for Fall/Injury Risk dated 1/1/24 indicated, "Provide with equipment/wheelchairs brakes that are intact." Review of Patient 1's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps healthcare teams share information about patients) dated 2/24/24 indicated, sometime after 5:30 p.m. after dinner, Patient 1 was observed with active bleeding to the right lateral side of the leg measuring 4.5 centimeter (cm, unit of measurement) by 0.5 cm. Pressure was applied to the affected site and first aid rendered. Patient 1's physician and Patient 1's friend was notified of the incident. During an interview with LVN C on 7/19/24 at 11:13 a.m., she stated Patient 1 informed her that her right lateral side of her leg was hit at "something." LVN C stated she did not know the exact cause of Patient 1's right leg skin tear on 2/24/24. Review of Patient 1's NCP dated 2/24/24 indicated, skin tear on lateral side of right leg will resolve without complications. Monitor for signs and symptoms of infection and notify the physician if symptoms present. Treatment as ordered. During a concurrent interview and record review with the Director of Nursing (DON) on 8/9/24 at 11 a.m., she confirmed there was no documentation in Patient 1's medical record regarding a follow-up investigation on how and what was the exact cause of Patient1's right leg lateral skin tear on 2/24/24 incident. The DON acknowledged it should have been investigated and followed-up on what was the reason and exact cause of Patient 1's skin tear on her right leg. Review of Patient 1's SBAR dated 4/2/24 indicated, Patient 1 was noted with skin tear on the right lower leg. Patient 1 verbalized it got caught on the wheelchair from transferring from bed to wheelchair. Pressure and steristrip (a thin and sticky bandages that are used to closed small wounds and cuts) applied then covered with xeroform (non-adherent dressing that maintain a moist wound environment) and dry dressing. Patient 1's physician and friend were notified. During an interview with CNA D on 7/29/24 at 2:43 p.m., she stated she was the assigned CNA for Patient1 on 4/2/24 morning shift. CNA D stated she could not remember how Patient 1 sustained the skin tear on her right leg. During an interview with Treatment Nurse E (TN E) on 7/29/24 at 3 p.m., she stated the CNA called her and reported that CNA was helping Patient 1 to transfer from bed to wheelchair then the right leg was caught in the wheelchair. TN E stated she did not know how and what was the exact reason Patient 1's leg was caught in the wheelchair on 4/2/24. Review of Patient 1's NCP on skin tear on right lower leg dated 4/2/24 indicated, "Check wheelchair for any sharp edges. Identified potential causative factors and eliminate/resolve them when possible. Treatment as ordered." Review of the SBAR dated 5/17/24 at 4 p.m. indicated, noted left lower leg skin tear 2.5 by 6 cm. Cleansed with normal saline, pat dry and applied steristrip. Patient 1 claimed she sustained the skin tear when her left leg caught the wheelchair brake handle. During an interview with CNA F on 8/7/24 at 3:12 p.m., she stated on 5/17/24 she assisted Patient 1 in the bathroom and assisted her to sit on the wheelchair. The wheelchair was positioned behind Patient 1 and her left leg was caught in the wheelchair during the transfer. During an interview with the DON on 8/14/24 at 10:56 a.m., she stated on 5/17/24 Patient 1 hit her left leg on the wheelchair handle break. The DON confirmed there was no documentation in the Patient 1's medical record regarding how the incident happened. Review of Patient 1's NCP for skin tear on left lateral lower leg dated 5/17/24 indicated, wheelchair brake handle was padded with plumber tube and other areas of wheelchair to minimize recurrence. Review of the SBAR dated 6/10/24 at 10:30 a.m. indicated, the CNA was transferring Patient 1 from bed to wheelchair and Patient 1 right leg got caught on wheelchair and sustained skin tear on right lateral leg measuring 3 cm by 1.5 cm with minimal bleeding. Treatment was provided. During an interview with TN E on 7/29/24 at 3 p.m., she stated the CNA [no longer work at the facility] reported to her that CNA was assisting Patient 1 transferring from bed to wheelchair and Patient 1's right leg was caught in the wheelchair. TN E stated she did not know the exact cause and how Patient 1 sustained the skin tear on 6/10/24. Review of Patient 1's NCP for skin tear on the right lateral leg dated 6/10/24 indicated, to ensure Patient 1 was wearing pants and to handle Patient 1 gently. Treatment as ordered. During an interview with the DON on 8/14/24 at 10:56 a.m., she confirmed there was no documentation in the SBARs and Patient 1's medical record regarding a follow-up investigation on how and what was the exact cause of Patient 1's right leg lateral skin tear on 2/24/24, 4/2/24 and 6/10/24. She also acknowledged the initial investigation on how Patient 1 sustained left lower leg skin tear on 5/17/24 should have been documented in Patient 1's medical record. The DON further stated Patient 1's incident of sustaining skin tears on 2/24/24, 4/2/24 and 6/10/24 should have been investigated and followed-up. Patient 1 sustained skin tear on 2/24/24, 4/2/24, 5/17/24 and 6/10/24, however there was no documentation the facility discussed the incidents on how or what was the cause of the skin tear/incidents. During a concurrent interview and record review with the DON on 8/9/24 at 11 a.m., she reviewed the facility's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who work together to provide person-centered care to patients) record signed and dated 4/11/24, 5/15/24 and 6/11/24. The DON confirmed there was no detailed discussions of Patient 1's four repeated incidents where she sustained skin tear during transfers from bed to wheelchair and after using the toilet. Review of the facility's revised policy and procedures dated 09/2013 titled "Skin Tears-Abrasions and Minor Breaks, Care of: Documentation" indicated, "Record the following information in the resident's medical record: 1. "Complete in-house investigation of causation." Review of the facility's undated policy and procedures titled "Investigating Resident Injuries" indicated, "All resident injuries are investigated. The Director of Nursing services or a Designee assesses all resident injuries and document findings in the medical records." Review of the facility's undated policy and procedures titled "Registered Nurse (RN) Job Description indicated, "Initiate investigations of accidents and unusual occurrences and makes the necessary written report to the Director of Nursing Services (DNS). Review of the facility's revised policy and procedures dated 3/2022 titled "Care Plans, Comprehensive Person-Centered" indicated, "1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident ... 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying sources (s) of the problem area(s) and not just the symptoms or triggers ...12. The IDT team reviews and updates the care plan ... when the desired outcome is not met. The facility failed to ensure the safety of Patient 1 when the facility did not investigate thoroughly the root causes of the incidents of skin tears during transfers from bed to wheelchair and transfer to wheelchair after using the bathroom. This failure led to four recurrent incidents on 2/24/24, 4/2/24, 5/17/24, and 6/10/24 that resulted to lower legs skin tears for Patient 1. The violations of this regulation had a direct or immediate relationship to resident health, safety, or security.