Other·February 10, 2022

Health & Safety Code 1424 (d) (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 22 California Code of Regulations §72311 (Nursing Service - General ) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. §72313. Nursing Service - Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared, and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. (7) Patients shall be identified prior to administration of a drug or treatment. 72315. Nursing Service - Patient Care (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). 72523(a). Patient Care Policies and Procedures a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72523(c)(2)(D). Patient Care Policies and Procedures . . . (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. 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 8/27/2020 at 11:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care and Treatment. These regulatory violations occurred when the facility failed to ensure treatment was provided after a sacrococcyx (base of the spine and tailbone) wound was identified for Resident 1 which progressed into a three centimeter (cm, unit of measurement) x 2cm decubitus ulcer,including but not limited to: 1. Failure to assess and document the sacrococcyx wound size and condition accurately. 2. Failure to implement timely treatment as ordered by the wound physician. 3. Failure to notify the physician in accordance with the facility's policy and procedures regarding Resident 1's worsening sacrococcyx wound during weekly assessments of the wound. 4. Failure to offload (remove weight or pressure) Resident 1's sacrococcyx wound by not turning and repositioning every two hours. These deficient practices caused Resident 1 to develop a sacrococcyx wound that progressed into a three-centimeter (cm, unit of measurement) x two cm decubitus ulcer. Resident 1 was transferred to a general acute care hospital (GACH), on July 12, 2020, due to an increase in heart rate, decrease in blood pressure, and fluctuation in oxygen saturation. The GACH indicated that Resident 1 had experienced septic shock due to a bacterial infection likely from the pressure ulcer and noted a foul-smelling pressure ulcer with green-stained packing. The GACH also indicated a possible osteomyelitis (inflammation of bone or bone marrow due to infection) around the sacral wound. As a result, Resident 1 was expected to continue to have infectious complications in the future. Resident 1 was admitted to the facility on 7/25/2006 with the following diagnoses: 1) persistent vegetative state (a condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function), 2) chronic respiratory failure (inability to effectively exchange gasses in the lungs), 3) muscle weakness, 4) quadriplegia (paralysis of all four limbs), and 5) need for assistance with personal care. Review of Resident 1's medical record indicated Resident 1 was hospitalized on 7/12/2020 to 7/24/2020 due to sepsis (severe infection). Review of Resident 1's minimum data set (MDS, an assessment tool) dated 5/17/2020 indicated Resident 1 was in a persistent vegetative state and was at risk for developing a pressure ulcer. It also indicated Resident 1 was incontinent (no voluntary control) with urine and bowel movements. MDS also indicated Resident 1 had no pressure ulcer on her sacrococcyx. Review of Resident 1's Braden Scale (risk assessment for developing pressure ulcer) dated 5/16/2020 indicated Resident 1 had a score of 10 (a score of 10-12 represented a high risk for developing pressure ulcer). During a concurrent interview with licensed vocational nurse D (LVN D) and record review of Resident 1's SBAR (Situation, Background, Assessment, Response) Communication Form and Progress Note dated 5/26/2020, on 9/29/2020 at 2:58 p.m., LVN D stated she found the excoriation (scratch, a linear break in the skin surface) on Resident 1's sacrococcyx on 5/26/2020. It indicated in the SBAR on 5/26/2020 that the wound was superficial, round and was 1 centimeter (cm, unit of measurement for length) by 1cm. LVN D stated she did not speak with the physician to get a new order for wound dressing but notified Resident 1's physician via fax only. LVN D stated she did not put any dressing to cover or protect the wound and just applied a moisture barrier cream on the area. Review of Resident 1's Skin Observation Tool dated 5/26/2020 indicated 1 cm blanchable excoriation on sacrococcyx. No width, depth or description of wound bed was documented. Review of Resident 1's Skin Observation Tool dated 5/27/2020 indicated 1 cm skin excoriation on sacrococcyx. No width, depth or description of wound bed was documented. Review of Resident 1's Skin Observation Tool dated 5/28/2020 indicated 1.4 cm by 1.8 cm skin excoriation on the sacrococcyx. No depth was documented. Review of Resident 1's Skin Observation Tool dated 6/4/2020 indicated Resident 1 had a stage 1 pressure ulcer (intact skin with non-blanchable redness over a bony prominence) on the sacrococcyx. No wound measurement was documented. It also indicated the sacrococcyx wound was excoriated. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin). Review of Resident 1's Skin Observation Tool dated 6/16/2020 indicated Resident 1 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, usually cream or yellow in color) and/or eschar (dry, black and hard dead tissue) in the wound bed). It indicated the wound size as 1.4 cm by 1.8 cm. Depth was UTD (unable to determine). It also indicated that the skin at the sacrococcyx was excoriated and the wound remains unchanged. No wound bed description was documented. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was an unstageable pressure ulcer and the assessment that it was excoriated (open skin) and that there were no changes to the wound. The document did not indicate if a physician was notified. Review of Resident 1's Skin Observation Tool dated 6/23/2020 indicated Resident 1 had excoriated skin on the sacrococcyx and was also a stage 1 pressure ulcer. It indicated in the notes the wound was excoriated and granulated (granulation tissue, new connective tissue and tiny blood vessels that form on the surfaces of a wound). No wound length, width, depth or description of wound bed documented. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin) and had granulation. Review of Resident 1's Skin Observation Tool dated 6/24/2020 indicated Resident 1 had excoriated skin and a stage 1 pressure ulcer on the sacrococcyx. No wound length, width, depth or description of wound bed documented. It indicated the wound was deteriorating and has increased in size. It indicated Resident 1 will be referred to the wound physician. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin). Review of Resident 1's initial Wound-Weekly Observation Tool on 6/26/2020 indicated Resident 1 had a trauma wound (a severe break or injury in the soft tissue of the skin, may include abrasions, lacerations, crush wounds, penetration and puncture wounds) on the sacrococcyx. It indicated the wound was 1.4 cm by 1.8 cm. No depth was documented. It indicated UTD for tunneling or undermining (erosion under the wound edges, resulting in a large wound with a small opening). It indicated the wound bed was 20 percent (%) covered with slough. It indicated the treatment for Resident 1's sacrococcyx wound was medihoney (a honey-based wound dressing). Review of the Surgical Consult by the wound physician on 6/26/2020 indicated this was a new consult for Resident 1. It indicated the wound was 1.4 cm by 1.8 cm with a depth of UTD. It indicated the treatment plan was to apply medihoney as a dressing for Resident 1's sacrococcyx wound. It indicated Resident 1 needed offloading (removing weight placed on the wound to help prevent and heal ulcers) of the wound. Review of Resident 1's Order Summary Report dated 9/28/2020 and Treatment Administration Record (TAR) dated 6/2020 indicated an order 6/29/2020 to cleanse Resident 1's trauma wound to the sacrococcyx with normal saline, pat dry, apply medihoney, and cover with dry dressing every day and as needed if soiled. The treatment order was initiated three days after the wound physician saw the wound on 6/26/2020. Review of Resident 1's Skin Observation Tool on 7/1/2020 indicated Resident 1 had a pressure ulcer at the sacrococcyx. It indicated the wound was 1.4 cm by 1.8 cm and the depth was UTD. It indicated the wound was being cared for by the wound physician due to slow healing and a new treatment order was received. Review of Resident 1's Wound-Weekly Observation Tool on 7/3/2020 indicated Resident 1 had a trauma wound on the sacrococcyx. It indicated the sacrococcyx wound was worsening. The wound bed was covered with 50 % slough. The wound size was 1.8 cm by 2 cm. There was no documentation regarding the wound's depth or the presence of absence of tunneling or undermining. It indicated the peri-wound (skin surrounding the wound) was unhealthy. It indicated a physician was notified on 7/3/2020 but also indicated the wound physician was on vacation and was not available. Review of Resident 1's Skilled Charting on 7/3/2020, at 3:47 am, 1:40 pm, and 5:56 pm, indicated Resident 1 had no new changes to skin integrity. It also indicated no changes were noted to wound. No documentation a physician was notified regarding Resident 1's worsening sacrococcyx wound. Review of Resident 1's Skin Observation Tool dated 7/8/2020 indicated Resident 1 had an excoriation on the sacrococcyx. No wound length, width, depth or description of wound bed was documented. During an interview and record review of the Skin Observation Tool dated with DON on 11/17/2020 at 10:15 a.m., DON confirmed there was no documentation of Resident 1's wound size on 7/8/2020. Review of Resident 1's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients) Notes on 7/8/2020 at 9:30 a.m., indicated Resident 1 had a sacrococcyx excoriation. Wound measurements documented were from 6/26/2020 at 1.4 cm by 1.8 cm with depth as UTD and 20 % slough and 60 % granulation. It indicated to continue current treatment as ordered and monitor for effectiveness, weekly wound observation and weekly referral to wound doctor. The IDT notes did not include the most recent assessment on 7/3/2020 that Resident 1's wound was worsening. Review of Resident 1's Wound-Weekly Observation Tool dated 7/10/2020 indicated Resident 1's trauma wound on the sacrococcyx was worsening. The wound bed was 70% covered with slough and had an odor. The wound size was 3 cm by 3cm. Depth was UTD. Resident 1's wound had undermining at 3 cm in length at 12 o'clock, 3 o'clock, 6, o'clock and 9 o'clock. It indicated a new treatment order to cleanse the wound the with Dakin's solution (sodium hypochlorite, bleach that has been diluted) 0.125%, then lightly pack the wound with gauze moistened with Dakin's solution and cover with non-adherent dressing. Review of Resident 1's SBAR Communication Form and Progress Notes on 7/12/2020 at 4:54 pm, indicated Resident 1 had a change in condition and was experiencing an increase in hear