Health inspection·June 5, 2024

The following reflects the findings of the California Department of Public Health during the Recertification Survey Event ID AS9T11 conducted on 3/25/24 to 3/28/24. Representing the Department: 35649, HFEN A deficiency was written for Recertification Survey at F-tag 687/ S/S G F687 §483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Based on observation, interview, and record review, the facility failed to ensure two licensed nurses Licensed Vocational Nurse [LVN] 2 and LVN 4) performed skin assessments through direct observations, licensed nurses developed a care plan for the condition of the feet, licensed nurses notified the attending physician the condition of the feet, Certified Nursing Assistants (CNAs) reported to the licensed nurse the condition of the feet, CNAs documented their observations of the resident's feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist provided appropriate foot care and treatment for one sampled resident (Resident 15). This failure resulted in pain, discomfort, and neglect of Resident 15's feet. Findings: On 3/25/24, an unannounced visit was conducted at the facility to conduct a Recertification Survey. Resident 15 was an 80 year-old male, admitted on 1/23/13 and readmitted on 2/29/24 after a hospitalization, with diagnosis including, Chronic Obstructive Pulmonary Disease (COPD- lung disease that causes airflow blockage and breathing-related problems), Type 2 Diabetes Mellitus (DM-characterized by high blood sugar) with Polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and development of foot ulcers), and hemiplegia (one-sided paralysis)/hemiparesis (loss of strength in the arm, leg, and face on one side of the body) affecting the left dominant side. During a concurrent observation and interview on 3/25/24 at 9:48 a.m. with Resident 15, in Resident 15's room, Resident 15 was lying in bed, awake and conversant, with the lower portion of the body covered with a blanket. Resident 15 was unable to move the left side of his body and complained of pain on the left knee. During a concurrent observation and interview on 3/25/24 at 9:50 a.m. with CNA 1, in Resident 15's room, CNA 1 pulled Resident 15's blankets off to look at the left knee. Resident 15 had foot drop (inability to lift the front part of the foot due to weakness of the muscles of the foot for movement) to his left foot. CNA 1 removed the socks and exposed both feet. Resident 15 had pain and discomfort when the left foot was touched. The left foot had a small wound on the top of the left 3rd medial phalanx (bone of the toe); had redness and swelling to the left foot and five toes; dry and scaly skin on the foot and toes; and blackish discoloration in between the toes. There was yellowish/blackish discoloration on the 4th toenail; long and yellowish discoloration of the 2nd, 3rd, and 5th toenails; thick, hard, deformed left big toenail with upward growth of the nail and a fungus-like appearance: discolored, thickened, and crumbled at the edge. Resident 15's right foot and toes also had dry, scaly, flaky skin, yellowish discoloration and long toenails on the right 2nd, 3rd, and 4th toes; the right big toenail was thick, yellowish in color, deformed with toenail growth upward, and fungus-like appearance. CNA 1 stated, "It looks like the feet have not been cleaned. I will call his nurse." During an interview on 3/25/24 at 9:52 a.m. with Treatment Nurse (TN) 1 and Licensed Vocational Nurse (LVN) 1, TN 1 stated, "I have not seen the resident's feet. The cart nurses (referring to the nurses who are responsible for administering the medication to the residents) do the weekly assessments of the residents." LVN 1 stated, "I also have not seen the resident's foot." TN 1 stated, "The feet have not been properly showered and cleaned. The right lower extremity has redness and dry skin. The right big toe is thick and has fungus-like appearance. [Resident 15] needs podiatry (treatment of disorders of the foot, ankle, and lower limb care, but podiatry is not covered by insurance. Podiatrist comes to the facility every three months." During an interview on 3/25/24 at 10:11 a.m. with CNA 2, CNA 2 stated she noticed Resident 15 had flaky skin on both lower extremities. CNA 2 stated she noticed the feet were red, but she did not check in between the toes. CNA 2 stated she did not document her observations regarding the resident's feet on the person figure of the CCNASRF, and she did not report her observation to the nurse. During an interview on 3/25/24 at 10:12 a.m. with Resident 15, Resident 15 stated it was about two to three months ago when his feet were cleansed. During a concurrent observation and interview on 3/25/24 at 10:13 a.m. with Director of Nursing (DON), in Resident 15's room, DON came to evaluate Resident 15's lower extremities. DON stated, "[Resident 15] had bilateral lower extremities redness, scattered. The skin was dry and with scabs on the shin, possible rash, and with unopened wound on the left lateral area of the left lower leg. The left foot has foot drop, with some redness and swelling. The nails were large, hypertrophic (thickening, excessive growth in cells/tissues), joints were getting contracted (hardening of muscles, tissues leading to deformity/rigidity of joints). The left 3rd toe, metatarsal (five long bones in the midfoot) had dry scab. [Resident 15] needs hygiene, definitely needs attention from wound care, and needs podiatry care." DON continued to evaluate Resident 15's right foot and stated, "There is redness, swelling, and dryness on the toes. The nails are large on the right big toe, 3rd, 4th, and 5th toenails. There are no wounds observed in between the toes. The left foot is worse than the right foot." DON stated the social worker is responsible for arranging podiatry visits for the residents. DON stated in the past, [Resident 15] had been seen by the podiatrist, but in looking at his feet, "it's not recent." During a concurrent observation and interview on 3/25/24 at 11 a.m. with TN 1, in Resident 15's room, TN 1 measured the thickness and the length of the toenails for both feet. The following were the toenail measurements for both feet: Left Foot Toenails: Big toenail: Length 1.4-centimeter (cm) Thickness 1.8 cm. 2nd toenail: Length 0.5 cm Thickness 1 cm 3rd toenail: Length 0.5 cm Thickness 1 cm 4th toenail: Length 1.7 cm Thickness 1 cm 5th toenail: Length 1 cm Thickness 0.7 cm Right Foot Toenails: Big toenail: Length 1.3 cm Thickness 2 cm 2nd toenail: Length 0.7 cm Thickness 0.5 cm 3rd toenail: Length 1.9 cm Thickness 0.6 cm 4th toenail: Length 1.9 cm Thickness 1 cm 5th toenail: Length 1 cm Thickness 1 cm During a concurrent interview and record review on 3/25/24 at 11:21 a.m. with Social Worker (SW), Resident 15's "Podiatric Evaluation and Treatment Form (PETF)," dated 3/20/24, was reviewed. The PETF indicated, "Chief Complaint: pain, edema (fluid retention in the body tissues). Skin: Check mark for Atrophy (decrease in size of tissue), Hydration, and Growth. Nails: Right and Left 1,2,3,4,5. Check mark for hypertrophic, yellow, brittle, thick subungual (under the fingernail/toenail) debris. With Pain: Check mark for pain. Edema: +2 (measurement of edema in tissue). Loss of protective sensation: Left. Check mark for: No other significant changes. Check mark for: Nails debrided (removal of infected, damaged, or dead tissue) to patient's tolerance only. PETF physician' signature was blank." SW stated Podiatry comes every 45-60 days and they see all the residents. SW stated the podiatrist was last here on 3/20/24 and saw [Resident 15]. SW looked at Resident 15's feet and stated podiatrist did not provide aggressive treatment for Resident 15's feet nor made any recommendations based on the documented podiatrist notes. SW verified the podiatrist did not sign the PETF dated 3/20/24. SW was unable to find other podiatrist PETF documentation on previous visits in the chart. During a review of Resident 15's Shower Schedule, dated 3/5/24, 3/12/24, 3/19/24, and 3/22/24. the shower schedule indicated, "[Resident 15] is scheduled every Tuesday and Friday." During a concurrent interview and record review on 3/25/24 at 2:18 p.m. with TN 1, Resident 15's Skin Monitoring: CCNASRF, dated 3/5/24, 3/19/24, and 3/22/24, were reviewed. The CCNASRF indicated, on 3/5/24, Resident 15 had completed shower and needed his toenails cut. No visual observation was documented on the person figure of the CCNASRF. On 3/19/22, Resident 15 refused to shower. CNA 2 documented Resident 15 needed his toenails cut. No documentation of CNA 2's skin observation on the person figure of the CCNASRF. On 3/22/24, Resident 15 had full shower, but refused to have lotion applied on the legs due to pain. No documentation of CNA 2's skin observation on the person figure of the CCNASRF. TN 1 verified the findings and stated the CNAs must document their skin observation on the CCNASRF. During a concurrent interview and record review on 3/25/24 at 2:30 p.m. with TN 1, Resident 15's Care Plan, dated 2/29/24 to 3/25/24, were reviewed. TN 1 was unable to find care plans for skin integrity, and the noted problems with the feet and toenails, and stated there were no care plans written. During a concurrent interview and record review on 3/25/24 at 2:40 p.m. with TN 1, Resident 15's Weekly Assessments, dated 1/10/24 to 3/22/24, were reviewed. The weekly assessments indicated the following: 1/10/24 Licensed Vocational Nurse (LVN) 2 documented toenails clean, no foot problem. No skin assessment performed. 1/16/24 LVN 2 documented toenails clean, no foot problem. No skin assessment performed. 1/22/24 LVN 2 documented no foot problem. No skin assessment performed. 2/4/24 LVN 3 documented no foot problem, no skin issue, toenails clean. 2/16/22 LVN 4 documented left lower leg front, no skin issues, toenails clean, no skin issues. 2/22/24 LVN 2 documented left lower leg no skin issues, fingernails/toenails clean, no foot problem. 3/10/24 LVN 2 documented left lower leg no skin issue, fingernails/toenails clean, foot problem, none. 3/16/24 LVN 4 documented fingernails/toenails clean, foot problems none, weekly assessment not completed. 3/22/24 LVN 2 documented foot problem none, fingernails/toenails clean. TN stated the documentation above were copied and pasted. During a concurrent observation, interview, and record review on 3/26/24 at 2:30 p.m. with Physician 2 and LVN 1, in Resident 15's room, Physician 2 examined Resident 15's feet. Physician 2 stated Resident 15 needs to be seen by another Podiatrist. Physician 2 verified Resident 15 has left foot edema and needs proper foot care. LVN 1 verified Resident 15 was on aspirin (medication with blood thinning properties). Physician 2 spoke with LVN 1 and verbally ordered to stop aspirin for two weeks due to presence of petechiae (pinpoint, round spots that form on the skin) on both lower extremities. A review of Physician's Progress Notes indicated Physician 2 did not document his evaluation of Resident 15's feet conducted on 3/26/24. During an interview on 3/27/24 at 2:59 p.m. with LVN 2, LVN 2 stated she reviews the Treatment Assessment Record (TAR) if there is any order for skin and wound issues, and if there is none, she documents no skin issues on her weekly assessment. During an interview on 3/27/24 at 4:32 p.m. with LVN 4, LVN 4 stated the weekly assessment is done whenever he passes his medications. The certified nursing assistants look at the residents' bodies when they give showers, and they notify the nurses of their observations. LVN 4 stated that's how he records his weekly assessment. LVN 4 stated, "It is impossible to do head-to toe assessments for all residents. I just copy and paste. They are the same findings." During a review on 3/27/24 at 10 a.m. with Minimum Data Set (MDS-resident assessment tool) Coordinator (MDSC) 1, Resident 15's Nursing Progress Notes, dated 3/1/24 - 3/22/24, were reviewed. MDSC 1 was unable to find documentation the attending physician was notified of Resident 15's skin and feet condition: red rash to bilateral lower extremities, edema, dry, flaky skin, yellowish discoloration, thick, hard, upward growth of nails on the left and right big toes, and unopened wound to the 3rd phalanx of the left foot, scabs on both shins, and unopened wound on the left lateral aspect of the lower extremity. During a review of the facility's policy and procedure (P&P) titled, "Grooming Care of the Fingernails and Toenails," dated 11/1/17, the P&P indicated, "XVlll. Report any changes in the color of the skin around the nail or nail bed to the attending physician. XlX. Document procedure in the resident's medical record and update resident's care plan as needed." During a review of the facility's P&P titled, "Showering a Resident," dated 11/1/17, the P&P indicated, "XVl. Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. XVll. Update the resident's care plan." In conclusion of the above cited, the facility failed to provide proper foot care when licensed nurses failed to perform skin assessments through direct observations, licensed nurses failed to develop a care plan for the condition of the feet, licensed nurses failed to notify the attending physician of the condition of the feet, Certified Nursing Assistants (CNAs) failed to report to the licensed nurse the condition of the feet, CNAs failed to document their observations of the resident's feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist failed to provide appropriate foot care and treatment for one sampled resident (Resident 15). This failure resulted in pain, discomfort, and neglect of Resident 15's feet. This violation presented had a direct or immediate relationship to the health, safety, or security of the resident and therefore constitutes a Class B citation.