Health inspection·August 20, 2024

Windsor Elmhaven Care Center The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00907842 Survey Event ID: QWE011 Representing the Department, HFEN #43943, HFES #44260 State Citation B was written. Code of Federal Regulations, Title 42, Section §483.25. Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: California Code of Regulations, Title 22, Section §70215. Planning and Implementing Patient Care. (a) A registered nurse shall directly provide: (1) Ongoing patient assessments as defined in the Business and Professions Code, section 2725(b)(4). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area. (2) The planning, supervision, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation. (3) The assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. Any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient. (b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission. (c) The nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient. On 7/16/24 at 9:50 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care and resident rights. The Department determined the facility failed to ensure Patient 1 received quality of care (health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice (a set of principles, goals, and expectations that describe the rights and responsibilities of professionals in a specific practice) when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time to more easily visualize the veins for blood removal needed for testing) was left around Patient 1's right arm for approximately three days and the nursing staff did not perform a detailed skin assessment of Patient 1's skin. This failure resulted in Patient 1 with severe swelling (collection of fluid under the skin) and an open full thickness skin wound (sore) on the right arm. During a review of Patient 1's clinical record titled, "Admission Record," indicated Patient 1's diagnosis included quadriplegia (inability to move or have feeling in the arms and legs). A review of Patient 1's clinical record titled, "Lab [Laboratory - department in medicine that examined blood and other test results] Results," indicated the [LABORATORY NAME AGENCY] drew blood from Resident 1 on 6/6/24, at 3:52 p.m. A review of Patient 1's clinical record titled, "Progress Notes," dated 6/9/24, at 11:08 a.m., by Licensed Nurse (LN) 4, indicated, "Noted with open wound in the Right Upper arm with + [over] edema [buildup of fluid under the skin - edema was rated 1 through 4, with 4 the most severe form of edema]. Res [Resident] stated the Phlebotomist [a healthcare professional who collected blood samples from the resident for testing] forgot to remove the tourniquet in my arm last Thursday [6/6/24]..." A review of Patient 1's clinical record titled, "Situation Background Assessment Recommendation [SBAR] Communication Form," [a form used to communicate the resident's important information with other care givers] dated 6/9/24, at 12 a.m., by LN 1, indicated, "...noted with open wound in the Right Upper arm with + 4 edema...Primary Care Clinician Notified...Recommendations of Primary Clinician ...new orders...Cleanse [clean] with NS [normal saline] pat dry, apply Leptospermum honey [cream used to promote wound healing], and cover with boarder dressing [water resistant band-aid used to help protect the wound from dirt or germs]..." A review of Patient 1's clinical record titled, "Wound Evaluation & [and] Management Summary," dated 6/11/24, at 12:31 p.m., by the Wound Medical Doctor (WMD), indicated Patient 1 had a full thickness (damage extended below the epidermis (outermost layer of skin) and dermis (layer of skin found beneath the epidermis) wound of the right arm that was related to trauma (physical injury of sudden onset and severity which required immediate medical attention). The measurement of the wound was 3.0 centimeters (cm - unit of measurement) in length (L), 25 cm wide (W), and 0.1 cm deep (D). The surface area (SA - size of the wound on the surface) was 75.0 cm. There was 100 percent (% - unit of measurement) granulation tissue (the development of new skin during the healing process) and light serous drainage (clear yellow fluid that leaked from the wound). A review of Patient 1's clinical record titled, "Braden Scale For Predicting Pressure Sore Risk Original," (an assessment tool used to predict a resident's risk for pressure ulcers (an injury that breaks down the skin when an area of the body was placed under pressure), dated 3/16/24, indicated Patient 1's risk score was 12 (high risk for pressure ulcers) related to complete immobility, often moist, and confined to a bed. A review of Patient 1's MDS (a resident assessment tool), "Section GG," (assessment of the resident's usual abilities) dated 6/21/24, at 7:31 p.m., indicated Patient 1 needed maximum assistance with eating, oral hygiene (brushed teeth), toileting hygiene (clean up after voiding (urine) or having a bowel movement (stool), shower or bath, upper and lower body dressing, and put on or take off footwear. The record further indicated Patient 1 was dependent on staff to roll him to the left and right while in bed. A review of Patient 1's clinical record titled, "Care Plan," dated 3/15/24, indicated Patient 1 was dependent on the nursing staff for bathing, personal hygiene (body kept clean every day), dressing, eating, bed mobility (movement in bed), transfer (move from one location to another), and toileting related to paralysis (inability to move or feel areas of the body) of all extremities (arms and legs). An intervention included monitoring for complications of immobility, such as pressure ulcers. A review of Patient 1's clinical record titled, "Daily Skin Inspection and Shower Check," dated 7/1/24, signed by a Certified Nursing Assistant (CNA) and Licensed Nurse (LN), indicated Patient 1's skin was intact with no discoloration, skin tears, ulcers (sores) or reddened areas. The diagram of a human body did not have any areas circled on the front or back of the body indicating skin breakdown. A review of Patient 1's clinical record titled, "Daily Skin Inspection and Shower Check," dated 7/11/24, signed by a CNA and LN, indicated Patient 1's skin was intact with no discoloration, skin tears, ulcers, or reddened areas. The diagram of a human body did not have any areas circled on the front or back of the body indicating skin breakdown. The record did not indicate if a shower, tub, or bed bath was given. During an interview on 7/16/24 at 12:35 p.m., with CNA 1, CNA 1 stated Patient 1's skin should have been assessed every time the nurse provided care (repositioning, toileting, brushing teeth, etc.), which was every two hours. During an interview on 7/16/24, at 3:20 p.m., with Patient 1, Patient 1 stated the phlebotomist had left the tourniquet on his right arm for three days. Patient 1 stated his diagnosis included quadriplegia, and he was unable to feel the tourniquet cutting off blood flow to his arm. Patient 1 stated, "The nurses missed it when providing care." During an interview on 7/16/24, at 3:25 p.m., with the WMD, WMD stated the tourniquet was on Patient 1's right arm for three days and restricted the blood flow to the arm. WMD further stated if Patient 1 would have been an older man, he could have needed the arm amputated (surgical removal of the dead arm). WMD stated Patient 1 was not able to feel the tourniquet around his arm due to his diagnosis of quadriplegia. WMD further stated Patient 1 was dependent on the staff to meet all his physical and medical needs. During an interview on 7/16/24, at 3:30 p.m., with the Wound Nurse (WN), WN stated it was reported to her that Patient 1 had two open wounds above his right elbow and a brown circular wound around the circumference (closing of a circle) of his right arm where the tourniquet had been left in place for approximately three days. WN further stated all nursing staff should have assessed Patient 1's skin while providing care (changing a soiled diaper or repositioning the resident). WN stated, "it's crazy that a tourniquet was left on for three days." WN further stated Patient 1 could have had a very serious injury to his right arm due to the decreased circulation (blood flow). WN stated it was the facility's responsibility to ensure Patient 1 received quality care from all health care professionals. During a phone interview on 7/16/24, at 3:40 p.m., with the Medical Director (MD), MD stated the facility was responsible for the care Patient 1 received from the phlebotomist. MD further stated the nurses were responsible for daily assessments of Patient 1. MD stated the facility should have noticed that the tourniquet was still in place after the blood draw was completed and there was no excuse for the discovery to take nearly three days. MD further stated the tourniquet on Patient 1's right arm was discovered on 6/9/24 after the staff had turned Patient 1 in bed. During a phone interview on 7/16/24, at 4:20 p.m., with [LABORATORY NAME DIRECTOR - LD], LD stated it was their lab technician that left the tourniquet on Patient 1's arm after completing the blood draw. LD stated this resulted in decreased blood flow and skin damage to Patient 1's right arm. During an interview on 7/16/24, at 4:27 p.m., with the Director of Nursing (DON), DON stated the staff should have assessed Patient 1's skin every two hours while providing care and they should have noticed the tourniquet was left on the right arm. The DON verified the tourniquet remained on Patient 1's right arm for approximately three days before it was discovered. During an interview on 7/16/24, at 4:50 p.m., with LN 2, LN 2 stated he was alerted by a CNA that Patient 1's arm did not look good. LN 2 further stated Patient 1's arm had 4+ swelling and looked like a balloon. LN 2 stated there was a skin tear (open sore) above Patient 1's right elbow and yellow liquid coming out of the intravenous (IV - inside the vein) site near the inside of the elbow. LN 2 further stated the area behind Patient 1's elbow was yellow from a rubber burn. LN 2 stated, "Everyone missed it, including me." LN 2 stated he took a photo of the wound and sent it to the doctor, but the photo had since been deleted. During an interview on 7/16/24, at 4:55 p.m., with CNA 2, CNA 2 stated Patient 1's skin should have been assessed every two hours when providing care to the resident. CNA 2 further stated when she went into the room, she asked Patient 1's if there were any problems, and he denied any problems. CNA 2 stated she should have looked to see if Patient 1 had any problems with his skin and not just asked him if he was ok. CNA 2 acknowledged Patient 1 could not feel or move his arms and legs and was dependent on staff to meet his needs. During a phone interview on 7/17/24, at 9 a.m., with LN 3, LN 3 stated Patient 1 was a very vulnerable (a person in need of special care, support, or protection because of disability) patient due to his inability to feel his body from the neck down and was dependent on staff to care for all his needs. LN 3 stated skin checks should have been done every time the nurse provided care to the patient. LN 3 stated Patient 1's hospital gown should have been changed every day, and if the gown would have been changed, the staff would have seen the tourniquet around Patient 1's arm. LN 3 stated Patient 1 would have benefited from more frequent skin checks due to his immobility (unable to move independently). During a phone interview on 7/17/24, at 12:08 p.m., with Patient 1's family member (FM), FM stated a tourniquet was left on Patient 1's arm for three days. FM stated she was very upset when she saw the condition of Patient 1's arm and was afraid for his health and safety while at the facility. FM stated the facility was not taking good care of Patient 1. During a phone interview on 7/17/24 at 1:30 p.m., with LN 4, LN 4 stated Patient 1 was supposed to be repositioned every two hours. LN 4 stated Patient 1's arms and the legs were supposed to be floated (lifted on pillows or foam wedge) to have the pressure relieved off the bony areas of the body (heels, elbows, backbone). LN 4 stated he was not sure how the tourniquet got missed by the nurses if Patient 1 was repositioned every two hours. LN 4 stated he was surprised Patient 1's right arm did not get amputated due to the lack of blood flow through the veins. During a joint phone interview on 7/19/24, at 8:10 a.m., with the Administrator (ADM) and the DON, the ADM stated she became aware of the incident in which a tourniquet was left on Patient 1's right arm when the [DEPARTMENT] arrived at the facility for a complaint investigation on 7/16/24. The DON stated she was unsure why the ADM was not made aware of the situation sooner but stated it had been a busy month. The ADM stated she should have been informed of the incident prior to the [DEPARTMENT]'s complaint investigation. The DON and ADM acknowledged Patient 1's skin injury related to the tourniquet left around his right arm was a preventable injury and the nursing staff should have assessed the skin more thoroughly. The DON and the ADM acknowledged Patient 1 was at high risk for skin breakdown related to the inability to feel anything from the neck down. The ADM stated the facility had the ultimate responsibility to ensure Patient 1 received safe quality care from the contracted staff (health care providers hired by the facility). The DON stated the process for skin assessments was that the LN completed a full body skin assessment once a week and both the CNAs and LNs observed residents daily for any sores or discoloration on the skin when a resident got dressed, cleaned, or repositioned in bed. The DON and the ADM stated Patient 1 was at risk for a right arm amputation due to the lack of blood flow to the arm while the tourniquet remained tied around the right arm. During a phone interview on 7/22/24, at 12:48 PM, with the facility's Vice President of Operations (VPO), the VPO stated the nursing staff should have noticed the phlebotomist forgot to remove the tourniquet when the nurses provided care to Patient 1. The VPO further stated there was no excuse for them to miss the tourniquet on Patient 1's right arm. The VPO stated Patient 1's diagnosis included quadriplegia and he should have received additional skin checks due to the high risk of skin breakdown (sores). The VPO further stated it was absolutely not acceptable that the tourniquet was missed by the facility staff. During a joint concurrent interview and record review on 7/17/24, at 4 p.m., with the ADM and the DON, the u