Other·December 15, 2021

California Code, Health and Safety Code-HSC 1424 (f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the Patient or the care or services provided. (3) "Willful material omission," as used in this section, means the willful failure to record any untoward event that has affected the health, safety, or security of the specific patient, and that was omitted with the knowledge that the records falsely reflect the condition of the Patient or the care or services provided. The following citation is written as a result of findings during a complaint investigation for #CA00737348. An unannounced visit was made to the facility on 6/2/21 to investigate an allegation of the patient's responsible party not being notified of a change in condition (development of pressure ulcers). The Department determined the facility failed to: Maintain accurately documented medical records in accordance with professional standards when licensed staff documented Patient 1's sacrococcyx (tail bone and lower back) was checked on 4/20/21, 4/21/21, 4/22/21, and 4/23/21, even though the task had not been physically completed by the licensed staff. This resulted in the delay of early identification and treatment of a pressure ulcer for Patient 1. Patient 1 developed an unstageable sacrococcyx pressure ulcer (full thickness tissue loss in which actual depth of the ulcer was completely obscured by slough (yellow, tan, gray, green, or brown dead tissue) and/or eschar (tan, brown, or black dead tissue in the wound bed)) which had been identified by the facility on the day shift of 4/24/21. The development of the pressure ulcer led to Patient 1's hospitalization on 5/5/21 and death on 5/9/21. Review of Patient 1's "ADMISSION RECORD" indicated Patient 1 was admitted to the facility on 3/30/21, with diagnoses which included end stage renal disease (final and permanent kidney failure), heart failure (a condition in which the heart cannot pump enough blood to meet the body's need), and obesity (an excessive amount of body fat). Review of Patient 1's "ADMISSION RECORD" indicated, "...Date of Discharge 05/05/2021...Discharged to...Acute care hospital..." Review of Patient 1's "BRADEN SCALE FOR PREDICTING PRESSURE SORE [ulcer] RISK," dated 3/31/21, indicated, "...Score: 15...SCORING: AT RISK 15 18..." The Braden Scale score indicated Patient 1 was at risk for developing pressure ulcers. Review of Patient 1's skin assessment, dated 4/8/21, indicated, "...Blanchable Redness to sacrococyx [sic]..." Review of Patient 1's care plan for skin integrity, initiated on 4/8/21, in the section "Focus," indicated, "...ALTERATION IN SKIN INTEGRITY: ACTUAL AS EVIDENCED BY: BLANCHABLE REDNESS SITE: SACROCOCCYX..." In the section "Interventions," indicated, "ASSESS SKIN DAILY AND AS NEEDED, MONITOR HEALING PROGRESS AND CALL MD [medical doctor] FOR TREATMENT CHANGE IF NOT HEALING...MONITOR AREAS FOR ANY SIGNIFICANT CHANGES AND REPORT TO MD IF NOTED..." During a concurrent interview and record review, on 6/9/21, at 1:31 p.m., with Wound Care Nurse (WCN) 1, Patient 1's treatment administration record (TAR), dated 4/21, was reviewed. Patient 1's TAR indicated, "BLANCHABLE REDNESS TO SACROCOCCYX: MONITOR Q [every] SHIFT AND NOTIFY MD FOR SIGNIFICANT CHANGES...every shift [three shifts every day-day shift, evening shift and night shift] ... Start Date 04 08 2021..." WCN 1 confirmed, a check mark and her initials were located in the box indicated for the day shift on 4/23/21. WCN 1 stated, she did not check Patient 1's sacrococcyx on 4/23/21 because she was busy and had relied on other staff to inform her if there had been a change in Patient 1's skin. During a concurrent interview and record review, on 7/6/21, at 1:49 p.m., with WCN 2, Patient 1's TAR, dated 4/21, was reviewed. In the section "BLANCHABLE REDNESS TO SACROCOCCYX: MONITOR Q SHIFT AND NOTIFY MD FOR SIGNIFICANT CHANGES...," WCN 2 confirmed a check mark, and her initials were located in the box indicated for the day shift on 4/20/21, 4/21/21, and 4/22/21. WCN 2 stated she did not physically check Patient 1's sacrococcyx on those days. WCN 2 stated a check mark on the TAR meant the sacrococcyx had been checked. WCN 2 stated, she could not confirm if anyone in the facility had checked Patient 1's sacrococcyx on the day shift of 4/20/21, 4/21/21, and 4/22/21, even though she had marked the sacrococcyx had been checked. During an interview, on 8/5/21, at 8:18 a.m., Licensed Nurse (LN) 1 stated, she did not recall if she looked at Patient 1's sacrococcyx on the night shift of 4/22/21 and 4/23/21. LN 1 explained she would look at Patients 1's sacrococcyx if the certified nurse assistant had requested assistance to change Patient 1's brief or to reposition him, but the certified nurse assistant had not requested assistance with Patient 1 very often. During an interview, on 8/5/21, at 10:54 a.m., LN 2 stated, she did not recall if she looked at Patient 1's sacrococcyx on the night shift of 4/20/21 and 4/21/21. LN 2 explained, if the shift was really busy she did not check Patient 1's sacrococcyx, but had relied on the certified nurse assistant to report if the skin was no longer blanchable (a sign of a stage 1 pressure ulcer skin no longer loses color when pressed briefly). During an interview, on 6/9/21, at 12:37 p.m., the Director of Nursing (DON) stated, the expectation was that if the licensed nurse documented a check mark on the TAR, the task had been completed. The DON confirmed it would not be possible for a pressure wound to go from blanchable redness to an unstageable pressure ulcer in one day. The DON confirmed WCN 1 documented Patient 1's sacrococcyx was assessed on 4/23/21. She acknowledged the documentation showed on 4/24/21 an unstagable pressure ulcer located on the sacrococcyx had been identified. Review of Patient 1's "WOUND EVALUATION," dated 4/24/21, indicated, "...Pressure Unstageable (Slough and/or eschar) Body Location: Sacrum [tail bone] New...: In house [at the facility] Acquired...DIMENSIONS...Length 8.13 cm [centimeter a unit of measurement equal to .39 inches] Width 6.47 cm [3.2 by 2.5 inches] ...Noted unstageable pressure injury to sacrococcyx extending to left and right buttock..." Review of Patient 1's "Progress Note Details," dated 4/30/21, indicated, "...[Patient 1] developed a large Stage 4 [1 to 4 stages, with stage 4 pressure ulcer defined as full thickness skin and tissue loss] ...ulcer [on sacrum]...Initial encounter measurements are 9.8 cm length x 11 cm width [or 3.8 by 4.3 inches] with no measurable depth...located on the sacrococcyx...debridement [the removal of dead (necrotic) or infected skin tissue to help a wound heal] ...was performed...Post Debridement Measurements: 9.8cm length x 11 cm width x 3.4 cm [1.3 inches] depth..." Review of Patient 1's Emergency Department (ED) medical record from the hospital titled "ED Note - Physician," dated 5/5/21, indicated, "...[Resident 1] presents to the emergency department for concern of altered mental status [a disruption in how your brain works that causes a change in behavior]...He was taken from his nursing home to dialysis center this morning and had approximately 2 hours of dialysis performed when he became altered per staff. Patient is unable to answer any questions or give further history...I am concerned the source of infection could be from his coccyx wound. This was cultured [a test to find germs (such as bacteria or a fungus) that can cause an infection]. Antibiotics [medication used to treat an infection] blood culture [a medical laboratory test used to detect bacteria or fungi in a person's blood] started in the emergency department...I am concerned for Fournier's gangrene [a rapidly progressing, tissue-destroying infection on the genitals and nearby areas]..." Review of Patient 1's "Discharge Summary" from the hospital, dated 5/9/21, in the section "Hospital Course," indicated, "...1. Septic shock [occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure] secondary to infected coccyx/sacral decubitus ulcer [also known as a pressure ulcer], osteomyelitis [infection in the bone], and underlying abscess [swollen body tissue that contains pus] not ruled out -CT [computerized tomography scan - a series of images taken from different angles around the body] Abd [abdomen - stomach]/Pelvis [hips] 5/5: Large decubitus ulcer posterior [situated at the back of or behind something] to the coccyx with subcutaneous [tissue beneath the skin] gas tracking superiorly [above] along the superomedial [above the middle] aspect of the right gluteal region [the area of the buttocks]. There is additional subcutaneous gas along the medial [near the middle] right gluteal fold extending into the base of the penis. Fournier's gangrene cannot be excluded..." In the section "Disposition," indicated, "Patient expired today [5/9/21]..." Review of Patient 1's "CERTIFICATE OF DEATH" dated 5/12/21, indicated, "...DATE OF DEATH...05/09/2021..." In the section "CAUSE OF DEATH" indicated, "...the chain of events diseases, injuries, or complications that directly caused death...Immediate cause (final disease or condition resulting in death) A. SEPSIS [A life threatening complication of an infection, chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body and can cause damage to multiple organ systems, leading them to fail, sometimes even resulting in death]....Sequentially, list conditions, if any, leading to cause on Line A. ENTER UNDERLYING CAUSE (disease or injury that initiated the events resulting in death)...B. SEVERE DECUBITUS [pressure ulcer] [of the coccyx and/or sacrum] ULCERS [damage to an area of the skin caused by constant pressure on the area for a long time which may lead to tissue damage and tissue death], ABSCESSES [a swollen, infected area within skin tissue, containing an accumulation of pus], WITH DISSECTION [tissue separation] TO PERINEUM [the area between the anus and the pouch of skin containing the testicles (the male sex glands)], SCROTUM/TESTES [a pouch of skin which contains the male sex glands] C. CARETAKER NEGLECT..." Review of The Joint Commission undated online article titled "Quick Safety 25: Preventing pressure injuries," indicated, "...Skin Care. Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 [reddened skin that does not blanch] sores early so they can be treated before they worsen...Inspect the skin upon admission and at least daily for signs of pressure injuries. Assess pressure points [bony areas of the body, such as the heels, ankles, hips and tailbone]..." (https://www.jointcommission.org/resources/news and multimedia/newsletters/newsletters/quick safety/quick safety issue 25 preventing pressure injuries/preventing pressure injuries/) Review of a facility policy and procedure (P&P) titled "Pressure Ulcer/Injury Risk Assessment," dated 7/17, in the section "Documentation," indicated, "The following information should be recorded in the resident's medical record...the name and title (or initials) of the individual that conducted the assessment...Any change in the resident's condition, if identified...The condition of the resident's skin..." Review of a facility P&P titled "Prevention of Pressure Ulcers/Injuries," dated 7/17, indicated, "...Inspect the skin on a daily basis when performing or assisting with personal care or ADLs [activities of daily living]..." Review of a facility P&P titled "Charting and Documentation," dated 7/17, indicated, "...Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate..." The Department determined the facility failed to: Maintain accurately documented medical records in accordance with professional standards when licensed staff documented Patient 1's sacrococcyx (tail bone and lower back) was checked on 4/20/21, 4/21/21, 4/22/21, and 4/23/21, even though the task had not been physically completed by the licensed staff. "The above facts indicate that there was a willful material falsification in the medical record for the patient(s)."