Other·December 1, 2023

The following reflects the findings of the California Department of Public Health during the investigation of annual recertification survey conducted at the facility from 11/6/23 to 11/9/23. Representing the Department, HFEN 48263. State Citation B was written. 42 CFR 483.25(b) Skin Integrity CFR 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. 22 CCR § 72523 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. 22 CCR § 72315 Nursing Services- Patient care. (f)(1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (4) Using pressure-reducing devices where indicated. The facility failed to ensure Resident 51 received interventions to prevent the development of pressure injuries in accordance with the physician's order. As a result, Resident 51 developed a new pressure injury on the sacral area (area below the lower back). Resident 51 was re-admitted to the facility on 09/28/23, per admission record, with diagnosis which included Coronary Artery disease (A major blood vessel [coronary arteries]) that supply the heart with blood, oxygen and nutrients to the heart muscle due poor circulation [the flow of blood]) and history of pressure ulcers to sacrum (area below the lower back) and upper back as documented per the progress note dated 08/22/23 written by a Nurse Practitioner (NP). A record review of Resident 51's document titled, "Braden Risk Assessment Flowsheet" (An assessment tool used to indicate pressure ulcer risk), dated 06/15/2023, indicated Resident 51 was at risk for developing pressure ulcers due to limited mobility " ...unable to make frequent or significant changes independently ..., and chairfast... Cannot bear own weight and/or must be assisted into chair or wheelchair." A record review of Resident 51's document titled, "Physician's Orders" dated 06/29/23 indicated, " ...Low Air Loss Mattress (LAL mattress - pressure relieving mattress that uses air that continues to flow through the mattress so that the user floats on the soft cushion of air relieving pressure to skin). for Wound Management ...", and " ...Turn Patient Strict L/R (Left/Right) turns only every 2 hrs (hours) to remove pressure from sacral ..." A review of Resident 51's care plan related to pressure injury, dated 09/23/23, indicated, "Stage 2 (an open wound with red or pink appearance sometimes may contain fluid filled blisters that are open or closed caused by pressure to the skin and is non-blanchable [reoccurrence]) location: sacrum ... Reposition q (every) 2 hours ..." A record review on Resident's 51's document titled, "Physician's Orders" dated 10/24/23 indicated, "Cleanse with NS (normal saline is a mixture of table salt and water for medical use) wound on Sacral and L (left) inner buttock with NS, pat dry, apply Medi-honey (wound paste to treat wounds) and cover with adaptic (non-stick wound dressing) and 4x4 gauze (loosely woven cotton surgical bandage) daily and PRN (as needed) ..." Observations of Resident 51 were conducted on following dates and times: 11/06/2023 at 10:56 A.M. and 1:00 P.M.- sat in an upright position in bed without a low air-loss mattress (LAL mattress - pressure relieving mattress that uses air that continues to flow through the mattress so that the user floats on the soft cushion of air relieving pressure to skin). 11/06/2023 at 2:51 P.M.- slightly turned to right (R) side while bottom half of the body laid directly on the bed. No LAL mattress. 11/06/2023 at 3:00 P.M.- slightly turned to L side while bottom half of the body laid directly on the bed. No LAL mattress. 11/07/2023 at 8:41 A.M.,10:41 A.M., and 12:53 A.M. - sat in an upright position in bed without a low air-loss mattress. 11/07/2023 at 1:57 P.M.- slightly turned to L side while bottom half of the body laid directly on the bed. No LAL mattress. 11/08/2023 at 8:30 A.M.- slightly turned to R side with wedge pillow (triangular pillow used for positioning while bottom half of the body laid directly on the bed. No LAL mattress. 11/08/2023 at 10:12 A.M.- slightly turned to R side with wedge pillow (triangular pillow used for positioning while bottom half of the body laid directly on the bed. No LAL mattress. 11/08/2023 at 10:38 A.M.- slightly turned to L side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. 11/08/2023 at 12:30 P.M and 1:45 P.M.- sat in an upright position in bed with wedge pillow set aside without a low air-loss mattress. 11/08/2023 at 3:30 P.M.- slightly turned to L side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. 11/09/2023 at 7:52 A.M.- sat in an upright position in bed with wedge pillow set aside without a low air-loss mattress. 11/09/2023 at 10:55 A.M- slightly turned to R side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. 11/09/2023 at 11:08 A.M.- CNA 50 repositioned Resident 51 to L side for wound treatment. An interview was conducted on 11/06/23 at 2:51 PM, with Certified Nurse Assistant (CNA) 42. CNA 42 stated residents who require extensive assistance with bed mobility such as Resident 51 should be turned every two hours and checked by all nursing staff. CNA 42 stated if there were skin issues or refusal of care, these issues would be reported to the licensed nurse (LN). A joint observation of Resident 51's wounds and interview of licensed nurse (LN) 46 was conducted on 11/07/23 at 2:52 PM. Resident 51's sacral area had two round open wounds. Below one of the open wounds, a round quarter-size reddish-purple discoloration was observed. LN 46 pressed on the reddish-purple discoloration and stated that the area was non-blanchable (a skin abnormality where the discoloration of the skin that does not turn white when pressed). An interview and joint record review of Resident 51's physician's order was conducted on 11/09/23 at 10:55 A.M., with LN 46. LN 46 stated Resident 51 was not on a LAL mattress because the resident had stage two pressure injuries. LN 46 stated that LAL mattresses were only ordered for stage three pressure injuries (an open wound caused by pressure that extends through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone and is non-blanchable). LN 46 reviewed Resident 51's physician's order and stated that the LAL mattress order was active and should have been provided to Resident 51. A joint observation of Resident 51's wounds and interview of LN 46 was conducted on 11/09/23 at 11:08 AM. A new open wound developed on Resident 51's sacral area, where the reddish-purple discoloration was observed on 11/07/23. LN 46 measured the new wound at 0.3 centimeters (cm) by 0.3 cm. LN 46 stated Resident 51 had histories of pressure ulcers and required assistance with bed mobility. LN 46 stated a LAL mattress would be beneficial due to Resident 51's high risk for developing pressure injuries. LN 46 stated it was important to reposition Resident 51 every 2 hours to help prevent the development of pressure ulcers. An interview with the Director of Nursing (DON) was conducted on 11/09/23 at 3:55 PM. The DON stated that the LAL mattress should have been provided to Resident 51 and that Resident 51 should have been repositioned every two hours as ordered to prevent skin breakdown. A review on the facility's policy, titled "Pressure Ulcer/Injury Prevention and Treatment" effective 07/12/23, was conducted. The policy defined a stage two pressure injury as "...Partial-thickness skin loss with exposed dermis (the layer of skin just underneath the part you can see and touch). The wound bed is viable (alive), pink or red, moist, and may also present as an intact or ruptured serum (clear liquid or yellowish fluid that does not clot from blood) -filled blister ..." and defined a DTI (deep tissue injury) as " ... Persistent non-blanchable deep red, maroon or purple discoloration ..." The policy section III under "Text" indicated "PUPT (Pressure Ulcer/Injury Prevention and Treatment) is designed to " ... 2. Define early interventions for prevention of pressure ulcer/injury. 3. Provide treatment options for Stages 1-4, Unstageable pressure ulcer/injury and DTI and 4. Define appropriate documentation of pressure ulcer/injury ..." These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.