Health inspection·January 22, 2025

723.11 § Nursing Services General (a) Nursing service shall include, but not be limited to, the following: (1) Planning patient care, which shall include at least the following: (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. The following reflects the findings of the California Department of Public Health during the 2024 Annual Recertification Survey conducted 11/18/24-11/21/24. Health & Safety Code 1424(e)(1) (e)(1) Except as provided in paragraph (4) of subdivision (a) of Section 1424.5, class "B" violations are violations that the department determines have a direct or immediate relationship to the health, safety, or security of long-term health care facility residents, other than class "AA" or "A" violations. Unless otherwise determined by the department to be a class "A" violation pursuant to this chapter and regulations adopted pursuant thereto, a violation of a patient's rights as set forth in Sections 72527 and 73523 of Title 22 of the California Code of Regulations, that is determined by the department to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient is a class "B" violation. A class "B" citation is subject to a civil penalty in an amount not less than one hundred dollars ($100) and not exceeding one thousand dollars ($1,000) for each citation. A class "B" citation shall specify the time within which the violation is required to be corrected. If the department establishes that a violation occurred, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. A deficiency was written for F-tag 686-G. 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. On 11/18/24, at 7 A.M., an unannounced visit was conducted at the facility for the 2024 Annual Recertification Survey. Resident 79 was a 95-year-old female with unspecified dementia with behavioral disturbance (group of symptoms affecting memory, thinking and social abilities severe enough to interfere with daily life), unspecified osteoarthritis (degeneration of joint cartilage and the underlying bone) admitted to the facility on 9/17/2024. Based on observation, interview, and record review, the facility failed to implement their policy and procedures (P&P) titled, "Prevention of Pressure Injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence)," for one of three sampled residents (Resident 79) when staff did not evaluate, report and document potential changes in the skin. This failure resulted in Resident 1 developing a facility acquired right heel injury which progressed to a pressure ulcer (open sore caused by poor blood flow or pressure) causing pain to Resident 1. Findings: During a review of Resident 1's "Admission Record (AR)," dated 9/17/24, the AR indicated, Resident 1 was admitted on 9/17/24 with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalance in the brain), type 2 diabetes mellitus (high blood sugar), end stage renal disease, (kidneys lose the inability to remove waste), dependence on renal dialysis (process of removing water, and toxins when kidneys no longer perform this function), neuromuscular dysfunction of bladder (when nerves and muscles don't work together properly), and hypertension (high blood pressure). During a review of Resident 1's "Minimum Data Assessment (MDS - standardized resident screening tool)," dated 10/10/24, the MDS, Section M - Skin Conditions indicated, "Is the resident at risk for developing pressure ulcers - 1. Yes." During a review of Resident 1's "Brief Interview for Mental Status (BIMS - assessment score of cognitive functioning)," dated 10/3/24, the BIMS indicated, Resident 1's BIMS (score 0-7 means severe cognitive impairment, 8-12 means moderate cognitive impairment and 13-15 means cognition intact) was coded as severe cognitive impairment with a score of 7. During a review of Resident 1's "Nursing/Readmission Evaluation/Assessment (NREA)," dated 10/2/24, the NREA indicated, "1.c. Resident has wounds or skin integrity concerns present on admission. a. yes - . . . 1.e. Description: L/R [Left/Right] heel blisters." During a review of Resident 1's "Treatment Administration Records (TAR)" dated, 10/1/24 -10/30/24, and 11/1/24 - 11/30/24, the TAR indicated, the last date of treatment to Resident 79's bilateral feet blisters was 10/17/24 (35 days ago). During a review of Resident 1's "Plan of Care (POC)," dated 9/17/24, the POC indicated, "Skin: Resident is at risk for skin breakdown related to fragile skin, old age, diabetes . . . Check skin during daily provisions. Notify physician of abnormal findings." During a concurrent observation and interview on 11/18/24 at 10:52 a.m. in the activities room, with Resident 1 and Infection Preventionist Nurse (IPN), Resident 1 was sitting in her wheelchair. Resident 1 had dressings on both feet with a date of 10/27. Resident 1 stated she has had problems with her feet for a while. During an interview on 11/21/24 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated treatment nurses take care of residents' wounds/dressings. During a concurrent observation and interview on 11/21/24 at 10:08 a.m. in Resident 79's room, with Resident 1 and Treatment Nurse (TN) 1, TN 1 stated, "There are no current orders for dressing changes to [Resident 1's] feet." TN 1 removed Resident 1's dressings on bilateral (both sides) heels. Resident 79 stated, "Duele [Spanish word for 'hurt']" while dressing was being removed. TN 1 stated the dressing had a date of 10/27 taped on the dressing which indicated her feet had not been assessed since 10/27. TN 1 stated Resident 1 had a possible "UTD [unstageable deep tissue injury]" on her right heel. During a concurrent observation and interview on 11/21/24 at 10:22 a.m. with Director of Nursing (DON) and TN 1, in Resident 1's room, DON stated Resident 1's feet had not been treated or assessed since 10/27/24. During a review of Resident 1's "Medication Administration Record (MAR)" dated 11/1/24 -11/30/24, the MAR indicated, Resident 1 had pain and "Norco Oral Tablet (pain medication)" was administered for pain level of 5 on a scale of 1-10 (score of 0 means no pain, score of 1-3 mild pain, score of 4-5 means moderately strong pain and a 6-9 means severe pain, 10 is the worst pain you have experienced) on 11/5/24 at 12 a.m., 11/18/24 at 10:39 a.m., 11/20/24 at 6:49 a.m. and on 11/21/24 at 10:28 a.m. During an interview on 11/21/24 at 12:30 p.m. with TN 2, TN 2 stated she is the weekend treatment nurse. TN 2 stated TN 1 is responsible for taking pictures of wounds and documenting progression of wound healing. TN 2 stated she recalled changing the dressing for Resident 1's feet on 10/27/24 (25 days ago). TN 2 stated she did not check the physician's order before changing the dressing or document the dressing change to Resident 1. TN 2 stated she should have called the doctor and documented Resident 1's dressing change. During a concurrent interview and record review on 11/21/24 at 12:35 p.m. with TN 2, a photo of Resident 1's right heel wound dated 10/21/24 was reviewed. TN 2 stated, "It looks like an unstageable pressure injury [type of bed sore that cannot be staged due to damaged tissue covering wound]." During a concurrent interview and record review on 11/21/24 at 12:38 p.m. with Certified Nursing Assistant (CNA) 1, Resident 79's "Resident Shower Log (RSL)," dated 11/13/24, was reviewed. The RSL indicated no skin issues. CNA 1 stated the process was to note skin issues during bathing of the residents and to document. CNA 1 stated she remembered giving Resident 1 a bed bath and did not recall any skin issues. During a concurrent interview and record review on 11/21/24 at 2:10 p.m. with TN 1, Resident 1's medical record (MR) was reviewed. The MR did not indicate a phone call to the doctor or any documentation of skin wounds. TN 1 stated there was no documentation of a phone call to the doctor or of the wounds and both should have been done. During a concurrent interview and record review on 11/21/24 at 3:22 p.m. with DON, Resident 1's "Nursing - Weekly Summary (NWS)," dated 11/2/24, 11/9/24, 11/16/24, and 11/18/24 were reviewed. The NWSs indicated, "C. Skin 4. No new skin issues this week. 5. Skin clear and intact." DON stated the expectation was for the nurse to do a complete head to toe skin assessment and for these assessments to be accurate and complete. During a review of Resident 1's "SBAR [Situation, Background, Assessment, Recommendation - written communication tool helps provide concise information]," dated 11/21/24 at 11 a.m., the SBAR indicated, "pt [patient] with skin issue to right heel 2.6x2.5x0, 1 cm (centimeter) surrounded by 1 cm callus, site previously had dried blister upon admission. contacted wound provider dr. [sic] who gave an initial order md ordered treatment." During a review of Resident 1's "Skin & Wound Evaluation (SWE)," dated 11/21/24 at 10:09 p.m., the SWE indicated the pressure injury was acquired in house on 11/21/24. During a review of Resident 1's "Progress Note Details (PND)," dated 11/24/24, the PND indicated, "Associated Signs and Symptoms: complaints of increased Pain 11/21/24 . . . initial exam- pt [patient] wound consulted and tx [treatment] in place . . . 11/24/24 pt with stable wound with arterial doppler study with significant findings consult for vascular eval [evaluation] placed." During a review of the facility's P&P titled, "Prevention of Pressure Injuries" dated April 2020, the P&P indicated, "Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition ... Skin Assessment. 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). B. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); d. Moisturize dry skin daily. Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis." During a review of the facility's P&P titled, "Pressure Injury Risk Assessment" dated March 2020, the P&P indicated, "Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment (s) conducted. 2. The date and time of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternative. Document family and physician notification of refusal. 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration noted with change of plan of care, if indicated. 12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated." In violation of the above cited standards, the facility failed to implement their policy and procedure titled, "Prevention of Pressure Injuries," when staff did not evaluate, report and document changes to Resident 1 right heel, resulting in a delay in treatment for a facility acquired right heel injury which progressed to a pressure ulcer causing pain to Resident 1. This violation presented had a direct or immediate relationship to the health, safety, or security of Resident 1 and therefore constitutes a Class B citation.