Health inspection·May 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, interview, observation and record review, the facility failed to notify the resident's representative regarding a change in skin condition, for 1 of 3 sampled residents observed (Resident #1). The findings included: Review of the facility policy and procedure titled, Change in a Resident's Condition or Status, which was not dated, and provided by the Director of Nursing (DON), included: Our facility shall promptly notify the resident, his or her attending physician, and representative (or sponsor) of changes in the resident's condition and/or status. The nurse supervisor will record in the resident's medical record any changes in the resident's medical condition or status. Review of the facility policy and procedure titled, Trach Care, dated 02/2025, included: Prevention is the best medicine for the care of the skin around the trach and the neck. Meticulous care should be taken to assess the skin each shift and document findings. Skin care management plans should be initiated when the skin condition is less than optimal . Review of the facility policy and procedure titled, Pressure Ulcer Prevention and Managing Skin Integrity, dated 09/2023 included: Nursing, in collaboration with the health care team, will assess and manage skin integrity for all residents. Risk for pressure ulcer development will be evaluated upon admission. Skin inspections will be completed on admission and daily for all residents. Purpose: To promote prompt evaluation and intervention of any changes in skin integrity. The focus of the examination will be on the skin over the bony prominence and in skin fold/creases. Findings will be documented in the patient medical record (paper or electronic). Communication to the provider and other caregivers of a skin breakdown is essential. 1) Resident #1 was originally admitted to the facility on [DATE] with the following diagnoses which included: Disruption of Wound, , Cerebral Palsy, Hypertension, Epilepsy, Hypoplastic Right Heart Syndrome, Double Outlet Right Ventricle, Aphasia and Chronic Respiratory Failure. Resident #1 is medically fragile with a Ventilator and Tracheotomy in place and totally dependent on staff for care, nutrition and hydration. She had a Brief Interview Mental Status (BIMS) indicative of (severe impairment). During an interview conducted on 05/01/25 at 4:09 PM with the resident's mother, she verbalized that, on Friday 04-11-25 she went to visit Resident #1 and that's when she noticed that she had a hole/bedsore on the right side of her neck, which she described as having the smell of eggs and sewage Page 1 of 3 106110 106110 05/02/2025 Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was the size of a golf ball and deep. The mother indicated that she had spoken to the wound care doctor in the facility the same day and was told by him that Resident #1 also had sores on her neck, in the past, which she started getting in 2024. According to the mother, this was the first time that she heard anything about Resident #1 having sores on her neck. The mother went on to say that the staff members have her phone number, but hadn't called her at all, regarding this. The complainant ended by saying that the doctor apologized for not calling. On 05/02/25 at 10 AM an observation was conducted of Resident #1 who was resting in bed with her head elevated and with both her Ventilator and Tracheotomy in place. Resident #1 was not observed as having a hole/bedsore on the right side of her neck. The resident's neck did not smell like eggs and sewage. However, it was apparent from the two (2) healed, old discolored scars on the back and right side of the resident's neck that a former wound or sore, that had been treated and healed. Resident #1's mouth and teeth were clean, with no build-up, noted, at the time, and she was wearing her hand splints. (Photographic Evidence Obtained). Record review of the Resident #1's Tracheotomy Care plan initiated 03/07/19 indicated Focus: Resident #1 has Tracheotomy related to disease process. Interventions: Ensure that Trach ties are secured at all times .Trach care Q shift, cleanse neck with normal saline, inspect skin for any abrasion or redness, apply A & D as needed. Goal: Resident #1 will have no abnormal drainage around Trach site and will have no signs or symptoms of infection through review date. Record review of the Resident #1's Ulceration or Interference Care plan initiated 03/27/24 indicated Focus: Structural integrity of layers of skin to the right side of her neck caused by prolonged pressure related to: Trach collar and excess secretion. Interventions .Document on daily flow sheet: if skin is intact, mark Y. If skin is reddened or has open area; mark N. Report any new openings to Registered Staff Goal: There will be a reduction in size/stage of pressure ulcer and no signs of infection or complication during period of review. On 04/22/25 the Wound Care Doctor's Wound Evaluation documented that, .Patient has a Stage IV wound on her right lateral neck .pressure, duration (>) greater than twenty-two (22) days Wound size 1.0 x 1.2 x 0.2 cm Surface area 1.20 cm2, edges attached, moderate serous exudate, 100% granulation tissue, pain noted with grimacing, no signs of infection. Dressing Treatment Plan: Mepilex silicone Ag+ foam apply Q-shift and as needed if saturated, soiled, or dislodged. For nine (9) days secure under Trach strap. Computerized record review conducted of a late entry nursing note by Staff A, a Licensed Practical Nurse (LPN) in which he revealed that, on Friday 04/11/25 around 5:30 PM resident's mother came in to visit her daughter . She complained about wound she observed on the resident's neck. The Respiratory Therapist (RRT) explained to her that the physician was notified and ordered Tracheotomy care which included Mepilex to tracheotomy site twice a day. Resident's mother was informed about it, at that time. During an interview and side-by-side computerized record review conducted on 05/02/25 at 1:35 PM with Staff A, he revealed that neither he, nor any other nursing staff members, had recorded any documentation in the nurses' progress notes, prior to Friday 04/11/25, to indicate that he or they had spoken with the mother about any of the details, regarding Resident #1's current skin condition. A side-by-side record review was conducted with the DON in which it was noted that there was no documentation recorded in any of the Respiratory Therapists' notes, nurses' progress, the Dietary 106110 Page 2 of 3 106110 05/02/2025 Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nutrition notes (12/31/24, 01/08/25, 02/26/25 and 03/30/25), nor in the Care Plan meetings (01/08/25 and 04/09/25) and Transitional meeting (03/06/25), from 12/31/24 until Friday 04/11/25 (when the complainant entered the facility to discover her child's wounds herself), to specifically describe, in detail, the resident's current skin condition. Nor was there any documentation to describe the presence of any wounds. There was not any documentation to signify whether or not the resident's representative had been previously contacted and notified of the resident's current and on-going wound status , by the facility's nursing staff. The computerized last Skin Evaluation completed (prior to 04/11/25) had been dated 10/12/24. 2) Record review conducted for last year, 2024, also revealed that Resident #1 had developed a wound to her neck, which had been documented as treated and healed. However, there had still been no notation anywhere in the record to show that the resident's representative had been notified of this change in skin condition with treatment, between the dates of 03/28/24 until 04/23/24. A subsequent interview and side-by-side computerized record review was conducted on 05/02/25 at 4:57 pm with Staff A, one (1) of three (3) currently available staff members, who had also been working in the facility during dates of service (DOS) 03/28/24 until 04/23/24, regarding his nursing note entry on 04/12/24 at 08:05 AM. Staff A, acknowledged and revealed that neither he, nor any other facility nursing staff members, had made any documentations in the record of Resident#1's current skin condition at that time. Neither, had he made any contact with the resident's representative concerning such. The DON further recognized and acknowledged on 05/02/25 at 5:05 PM that the resident's representative should always be notified or contacted for any changes to the resident's skin status or condition. 106110 Page 3 of 3