Health inspection·January 7, 2021

Title 22 - 72315 (f) - Nursing Services - Patient Care Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Title 22 - 72311 (a)(2) - Nursing Services - General Nursing service shall include, but not limited to the following: Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this. On 10/27/2020 at 9:30 A.M., an unannounced visit was conducted at the facility to investigate a complaint alleging that Resident 1 was admitted to the hospital, from the facility, with a Stage IV pressure injury (full thickness skin and tissue loss with exposed or directly palpable muscle or bone in the ulcer). The facility failed to ensure nursing staff provided care to prevent pressure injury development for Resident 1, who was admitted with a knee immobilizer (a brace to prevent knee movement after an injury to the leg). The nursing staff failed to: 1. Assess Resident 1's skin underneath the knee immobilizer for 27 days. 2. Implement Resident 1's care plan intervention to monitor the skin integrity under the knee immobilizer. As a result, Resident 1 developed a painful Stage IV pressure injury on her right lateral calf that required graft reconstruction (surgical procedure that involves removing skin from one area of the body and moving it to a different area of the body). Resident 1 was admitted to the facility on 2/6/2020 after an open reduction and internal fixation (ORIF - repair of broken bone) of the right femur fracture (broken upper leg bone) per the History and Physical, dated 2/10/2020. A review of Resident 1's Discharge Summary, dated 11/6/2020, indicated the facility discharged Resident 1 to the hospital on 10/16/2020. The Minimum Data Set (MDS - assessment tool), dated 2/8/2020, was reviewed. The MDS Section C (Cognitive patterns) indicated Resident 1's BIMS (Brief Interview for Mental Status - use to evaluate a person's mental status) score was 12 (on a scale of 00 to 15, 12 is moderate impairment). The MDS Section M (skin condition) indicated Resident 1 was at risk for developing pressure injuries. The MDS Section G (Functional Status) indicated Resident 1 needed extensive assistance from staff with her activities of daily living. A review of Resident 1's Braden Scale for Predicting Pressure Sore Risk assessment (a tool used to measure a person's risk for developing pressure ulcer), dated 2/6/2020, indicated Resident 1 was at "low risk" for developing pressure ulcers. A review of Resident 1's Order Summary Report (Admission orders), dated 2/7/2020, indicated, "Keep Knee immobilizer (device that is worn to keep the knee from bending) on at all times every shift Check skin integrity (skin status)". A review of Resident 1's Care plan with initiation date of 2/13/2020 indicated, "Monitor skin integrity to right immobilizer and notify the nurse". A review of Resident 1's Treatment Administration Record (TAR) for February and March 2020 indicated, "Keep Knee immobilizer on at all times every shift Check skin integrity". The documentations from 2/8/2020 P.M. shift through 3/4/20 A.M. shift indicated the licensed nurses (LNs) checked Resident 1's skin integrity. On 10/27/2020 at 12:17 P.M., an interview with LN 3 was conducted. LN 3 stated she was one of the nurses that documented on Resident 1's TAR related to skin integrity checks. LN 3 stated Resident 1's TAR documentation meant that she checked the skin not covered by the knee immobilizer. LN 3 stated she did not check the skin covered by the immobilizer because she did not think she could remove Resident 1's immobilizer. LN 3 stated she did not clarify with the physician the removal of the immobilizer in order to conduct a skin integrity check. LN 3 further stated she should have clarified the order with the physician. On 10/30/2020 at 7:30 A.M., a telephone interview with LN 4 was conducted. LN 4 stated he was one of the nurses that documented on Resident 1's TAR related to skin integrity checks. LN 4 stated Resident 1's TAR documentation meant that he only checked the surrounding and exposed skin and did not check the skin covered by the knee immobilizer. LN 4 stated he did not clarify with the physician the removal of the immobilizer in order to conduct a skin integrity check. LN 4 further stated he should have clarified the order with the physician. A review of wound care consultation note, dated 3/5/2020, indicated, Resident 1 "had a f/u (follow up) with her surgeon and a medical device pressure injury was noted on the RLE (right lower extremity) where her immobilizer was." A review of Resident 1's LN Skin Pressure Ulcer Weekly note, dated 3/5/2020, indicated the resident's pressure ulcer on the right lateral calf was unstageable (full thickness tissue loss, base of the wound is covered by slough/eschar [dead tissue]). Per the same note, Resident 1's pressure ulcer had a measurement of 4.5 cm (length) x 3.0 (width) x 0.1 cm (depth). A review of Resident 1's IDT (interdisciplinary team) note, dated 3/6/2020, indicated orthopedic physician (Specialized in skeleton and associated structures) found wound on the RLE during Resident 1's appointment on 3/5/2020. On 10/27/2020 at 11:42 A.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated the orthopedic physician found Resident 1's knee immobilizer related pressure injury during the resident's appointment on 3/5/2020. The DSD stated nurses could have taken off the knee immobilizer to check the skin, but nurses misunderstood the knee immobilizer order. On 11/20/2020 at 9:58 A.M., a telephone interview with the Orthopedic surgeon was conducted. The surgeon stated the intent of his order was for the nurses to remove the knee immobilizer in order for Resident 1's leg to decompress (remove pressure), and for the nurses to check the resident's skin for reddened areas. The surgeon stated the nurses should have clarified the order, if the order was unclear. A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 3/12/2020 and 3/19/2020, indicated Resident 1 was experiencing moderate pain related to the resident's right lateral calf wound. A review of Resident 1's Wound Consult note, dated 3/31/2020, indicated a chief complaint of right lower extremity wound with "Patient (PT) is having increased pain in the wound, which has increasing DTI (Deep tissue injury, pressure related skin injury) surrounding it". A review of Resident 1's Wound Consult note, dated 4/7/2020, indicated chief complaint of right lower extremity wound with "PT has had increased pain and deterioration (decline) of wound". The note further indicated "debridement (procedure for treating a wound in the skin) to level of muscle/tendon performed today under local anesthesia..." A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 5/21/2020 and 6/25/2020, indicated Resident 1 was experiencing pain related to right lateral calf wound. On 12/1/2020 at 3:12 P.M., a telephone interview with the wound care physician was conducted. The physician stated removing the knee immobilizer to check the resident's skin was very important. The physician stated any skin breakdown could develop as early as one to two hours. The physician stated Resident 1 verbalized pain on her right leg wound. A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 4/2/2020, indicated the right lateral calf pressure ulcer's measurement was 8.3 cm (length) x 6.0 cm (width) x 0.3 cm (depth). A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 6/4/2020, indicated the right lateral calf pressure ulcer's measurements was 14 cm (length) x 8.1 cm (width) x 0.2 cm (depth). A review of Resident 1's LN Skin Pressure Injury Weekly note, dated 8/13/2020, indicated the right lateral calf pressure ulcer's measurement was 16.5 cm (length) x 7.0 cm (width) x 0.2 cm (depth). A review of Resident 1's Medication reconciliation discharge orders, dated 7/22/2020, indicated wound vac (vacuum assisted closure wound therapy to help wounds heal) on the right leg was ordered and applied to Resident 1. A review of Resident 1's Clinical Record (physician progress notes), dated 9/6/2020, was conducted. The document indicated Resident 1 underwent debridement (cleaning of the wound bed and removing of dead tissue) of the right leg wound and skin graft reconstruction (surgical procedure that involves removing skin from one area of the body and moving it to a different area of the body) on 8/31/2020. On 12/10/2020 at 10:05 A.M., a telephone interview with the DSD and the Interim DON (IDON) was conducted. The DSD stated the nurses should have removed Resident 1's knee immobilizer in order to check the skin under the immobilizer. The DSD also stated removing the knee immobilizer, to check the resident's skin, was important to prevent skin breakdown from developing. The DSD acknowledged that the nursing staff did not implement Resident 1's care plan related to skin checks. The IDON agreed with the DSD's statement. A review of the facility's policy and procedure titled Skin Care, dated June 2016, indicated, "It is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable ..." The policy also indicated, "... Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: a. Stabilize, reduce or remove any existing any [sic] underlying risks. B. Monitor impact of interventions ..." The policy indicated, "Monitoring: a. Daily via medication administration and treatment administration records. Confirm all orders have been implemented as ordered." The facility's policy titled, Care and Treatment, indicated "... the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident..." The facility's policy and procedure did not indicate care plan implementation procedures. In violation of the above cited standards, the facility failed to ensure that nursing staff provided care to prevent the development of a pressure injury for Resident 1. Additionally, Resident 1's care plan for skin checks was not implemented. These failures caused Resident 1 to develop a painful pressure injury and had to undergo skin graft surgery on the right leg. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.