Health inspection·August 21, 2024

F686 §483.25(b) Skin Integrity §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. Tit. 22, § 72315 - Nursing Service-Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). On 4/17/24, an unannounced visit was conducted to investigate a complaint regarding a resident of the skilled nursing facility who was presented to the Emergency Department in the hospital with overall poor health condition. Resident 1 had pressure ulcers (damaged skin and underlying tissue over a bony prominence). Resident 1 was a 64-year-old male resident who was admitted to the skilled nursing facility on 3/14/24 with diagnoses that include Hemiplegia (loss of ability to move one side of the body) and Hemiparesis (muscle weakness of a side of the body), Reduced Mobility, and Need Assistance for Personal Care. Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, "Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention" for one of three sampled residents (Resident 1) when: 1. Resident 1 was not assessed for risk for developing pressure injuries upon admission. 2. Physician was not notified to obtain treatment for Resident 1's left heel redness. 3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness. 4. Interdisciplinary team (Team members from different disciplines working collaboratively with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting was not conducted to address Resident 1's left heel redness. These failures resulted in Resident 1 sustaining a facility acquired Stage 3 (Full-thickness loss of skin, in which adipose [fat] is visible) pressure injury to the left heel. Findings: During a review of Resident 1's "Admission Record" (AR) the AR indicated, Resident 1 was admitted on 3/14/24, with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), muscle weakness, and reduce mobility. During a review of Resident 1's "Nursing Admission Screening/History" (NASH) dated 3/14/24, the NASH indicated Resident 1 was alert and oriented to person, place, time, and situation and Resident 1's cognition (mental action or process) was intact. The NASH indicated, "Skin . . . Face . . . Dryness . . . (no other documented skin issues)." During a review of Resident 1's admission "Minimum Data Set" (MDS-an assessment tool) dated 3/20/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) a score of 12 (a score of 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), and sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), and Resident 1 was dependent (helper does all the effort) for chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair). 1. During a review of Resident 1's "Braden Scale for Predicting Pressure Sore Risk" (Braden-a medical instrument used to measure residents' risk of developing pressure injuries) dated 3/14/24, the document was noted blank. During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with Director of Nursing (DON), Resident 1's "Braden Scale for Predicting Pressure Sore Risk" dated 3/14/24, was reviewed. DON confirmed Resident 1 was admitted on 3/14/24. DON reviewed Resident 1's "Braden Scale for Predicting Pressure Sore Risk" dated 3/14/24, and DON stated the Braden Scale for Predicting Pressure Sore Risk was not completed. 2. During a review of Resident 1's "Skin Observation Tool," (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission). During a review of Resident 1's "Treatment Administration Record," dated 3/2024, the TAR indicated no documented treatment for Resident 1 left heel redness. During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's "SOT" dated 3/15/24 was reviewed. The SOT indicated Resident 1 left heel redness. DON reviewed Resident 1's medical record and stated the physician was not notified to obtain treatment for Resident 1's left heel redness. 3. During a review of Resident 1's "Skin Observation Tool," (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission). During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's "SOT" dated 3/15/24 was reviewed. DON confirmed the SOT indicated Resident 1's left heel redness. DON reviewed Resident 1's care plans and stated there was no care plan developed to address Resident 1's left heel redness. During a review of Resident 1's "Wound Weekly Observation Tool" (WWOT) dated 4/4/24 (20 days after the admission), the WWOT indicated, Resident 1 had a SDTI (suspected deep tissue injury-intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [small bubble on the skin filled with serum]) to the left heel. The WWOT indicated the SDTI was intact, measuring 20 mm (millimeters-unit of measure) in length by 20 mm in width. During a review of Resident 1's "WWOT" dated 4/10/24, the WWOT indicated Resident 1's SDTI to the left heel worsened to a Stage 3 pressure injury measuring 25 mm in length by 25 mm in width and 1 cm (centimeter-unit of measure) in depth. The WWOT indicated slough (yellow, tan, white, or stringy material noted in the wound) and necrotic (dead skin tissue-brown, black, leather, scab-like) tissue. During a concurrent observation and interview on 4/17/24 at 12:39 p.m. with Resident 1, in Resident 1 room, Resident 1 had his left foot elevated on a pillow. Resident 1 stated he was not admitted to the facility with pressure injury to the left heel. Resident 1 stated two weeks ago (4/4/24) a wound care provider took something off the bottom of his left foot, he stated the wound care provider "came in today and scrapped and scrapped at my left foot again." Resident 1 stated, "I was ready to go home but they won't let me go because of the wound [left heel]." During an interview on 4/24/24 12:32 p.m. with Treatment Nurse (TN), TN stated the facility process for new admitted resident identified with wounds was for the treatment nurse to measure the wounds, contact the physician to obtain treatment orders, develop a care plan, perform weekly wound assessment with the wound specialist, and update the treatment order and care plan as needed. During an interview on 5/15/24, at 11:25 a.m. with DON, DON confirmed Resident 1's SDTI to the left heel was now a Stage 3. 4. During a concurrent interview and record review on 5/20/24 at 11:56 a.m. with DON, Resident 1's medical record was reviewed. There was no IDT meeting noted to address Resident 1's left heel redness. DON stated Resident 1 did not have an IDT meeting to address Resident 1's left heel redness on the month of March 2024. During a review of facility's P&P titled, "Pressure Ulcer Prevention," revised 11/1/17, the P&P indicated, "Purpose To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. Policy: The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. Procedure I. Risk Identification and Assessment: A. The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. B. Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly and as needed. . . a. If the resident is identified as having wound upon admission, findings will be documented on the Resident Admission Assessment . . . and a Wound Monitoring Record . . . will be implemented. . . c. A Wound Monitoring Record will be implemented for each identified wound. II. Plan of Care: A. The Licenses Nurse will develop a Care Plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the following: i. Attending Physician ii. Interdisciplinary Team (IDT)- Skin Committee iii. Registered Dietician iv. Director of Rehabilitation Services B. Nursing Staff will monitor interventions for effectiveness and resident tolerance. C. The Care Plan will be revised as indicated. . . III. Ongoing Monitoring: . . .C. The Licensed Nurse will document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis." In violation of the Code of Federal Regulations §483.25(b)(1), the facility failed to ensure that the resident did not develop and acquire a pressure ulcer while in the facility. The Department determined that the facility failed to implement their policy and procedure (P&P) titled, "Pressure Ulcer Prevention" for Resident 1. These failures resulted in Resident 1 sustaining a facility acquired Stage 3 pressure injury to the left heel. This violation presented either imminent danger that serious harm would result or a substantial probability that death or serious physical harm would result and constitutes to "A" citation.