Other·October 17, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number 839572. The inspection was limited to the specific Complaint investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 38993, HFEN A deficiency was written for Complaint #839572 at F-tag/S/S F684/G. 42 Code of Federal Regulations, part 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. Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on "Change in a Resident's Condition or Status" when the facility failed to notify the physician of a non-healing bruise (an injury appearing as an area of discolored skin on the body) and blister (a small bubble on the skin filled with serum and caused by friction, burning or other damage) to the left lateral shin which was sustained after a fall incident for one of three sampled residents (Resident 1). This resulted in Resident 1 developing cellulitis (bacterial infection involving the inner layers of the skin), requiring hospitalization and the need for surgical intervention. Findings: On 5/10/23, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident not receiving wound care at the facility and requiring hospitalization for a diagnosis of cellulitis. Resident 1 is a 65-year-old female who was admitted to the facility on 3/6/23. Resident 1 sustained a fall that caused a bruise and blister. The facility did not notify the physician of the non-healing bruise and blister to the left lateral shin, and this resulted in Resident 1 needing surgical intervention to the area. During a review of Resident 1's "Admission Record" (AR), undated, the AR indicated, Resident 1 diagnoses included encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), weakness, other symptoms and signs involving the musculoskeletal system (consists of the body's bones, muscles, tendons, ligaments, joints, and cartilages) morbid obesity (clinically severe obesity-overweight) due to excess calories and diabetes mellitus type II (elevated blood sugar levels). During a review of Resident 1's "Minimum Data Set" (MDS - a standardized comprehensive assessment tool), dated 5/25/23, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status - evaluates cognition, the ability to remember and think clearly) score of 11 (scores range from 0 - 15 and a score between 8 - 12 demonstrates moderately impaired cognition). During an interview on 5/24/23, at 4:31 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she was working when Resident 1 fell out of the Hoyer lift (commonly used brand of mechanical lift which is used as an assistive device that allows a caregiver to lift a resident and transfer them with minimal physical support) and hit her left leg on the Hoyer lift on 4/5/23. Resident 1 was sent to the Emergency Room (ER) for evaluation and returned from the ER on 4/6/23. LVN 3 stated, Resident 1 sustained a bruise and a blister to the left lateral shin after the fall incident and was being monitored (regularly checking for the development or condition of the resident) for 72-hours (from 4/6/23 to 4/9/23). LVN 3 stated, the 72-hour monitoring was completed on 4/9/23. On 4/26/23, (16 days later) Resident 1's left lateral shin was noted with "swelling and noticed draining." LVN 3 stated, the facility should have notified the physician after the 72-hour monitoring was completed on 4/9/23, because the bruise and the blister were still present, and the monitoring for the bruise and blister should have been continued until there was an improvement. During a review of Resident 1's "Progress Notes" (PN), dated 4/5/23, at 11:23 a.m., the PN indicated, "While doing med [medication] pass at around 8:35 p.m., this writer was notified by CNA [Certified Nursing Assistant] that resident fell. . .She [Resident 1] stated 'I hit my left leg on the base of the Hoyer lift, and it is hurting a lot. I don't think it's broken but I'm sure it will be bruised tomorrow' . . . MD [Medical Doctor] was notified and gave an order to send resident [1] to ER [Emergency Room] for evaluation and x-ray." During a review of Resident 1's "ER General RME [Rapid Medical Evaluation]/HPI [History of Present Illness]" dated, 4/5/23 (day of the fall incident from the Hoyer lift), the RME/HPI indicated, "Chief complaint: Fall. . .lower left leg pain s/p [status post] fall. . .Extremities: Ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to the lateral (towards the side) shin. . .she does have a contusion (injured tissue or skin in which blood capillaries have been ruptured) on her leg [left] and was returned to the nursing home for management of bruise. . .Referrals: [Primary Physician] -in 1 week. . .Additional Instructions: Follow-upy [sic] . . .primary doctor as need." During a review of Resident 1's PN, dated 4/6/23, at 5:53 a.m., the PN indicated, "Resident came back from ER visit. Resident has a contusion to L [left] leg (left lateral shin) with blister. . .Resident to follow up with MD." During a review of Resident 1's "Care Plan" (CP), dated 4/6/23, the CP indicated, "[Resident 1] had an actual fall [4/5/23] with minor injury. . .contusion to left leg (left lateral shin). . .Goal. . . [Resident 1]'s contusion to left leg will resolve without complications. . .Interventions. . .Monitor/document/report PRN (as needed) x (times) 72h [hours] to MD for s/sx [signs and symptoms]: bruises. . ." During a review of Resident 1's PN, dated 4/6/23, at 8:51 a.m., the PN indicated, "IDT [Interdisciplinary Team-group of healthcare professionals that create an individualized plan of care] met in regards to resident having a staff assisted fall on 4/5/23. . .resident was sent to the ER [4/5/23] for eval [evaluation]. . . Resident returned from ER @ [at] 4/6/23 @ approx [approximately] 5:53 a.m., no fracture noted to resident, resident noted to have a contusion to left leg (left lateral shin) with blister. . ." During a review of Resident 1's PN, dated 4/26/23, at 5:46 a.m., [21 days after the fall incident] the PN indicated, "Resident noted. . .wound to L lower leg (left lateral shin) noted to have non-purulent (drainage without pus) drainage. Redness around site with discoloration observed, skin is warm to touch." During a review of Resident 1's "Order Summary Report" (OSR), dated 5/1/23, the OSR indicated, "Keflex [antibiotic] Oral Capsule 500 MG [milligrams-unit of measurement] [Cephalexin-generic name for Keflex] Give 1 capsule by mouth three times a day for Cellulitis to L.L.E. [left lower extremity] (left lateral shin) for 10 days until finished. . .start date 4/26/23." During a review of Resident 1's PN, dated 5/1/23, at 10:59 a.m., the PN indicated, "[Wound MD] was made aware of wound to left lower leg (left lateral shin). [Wound MD] stated it is a DTI [Deep Tissue Injury-persistent non-blanchable (skin does not turn white when touched with finger) purple or maroon area of intact skin or blood-filled blisters caused by damage to under lying tissue]." During a review of Resident 1's "Integumentary [body's outer layer] Assessment Sheet" (IAS), dated 5/1/23, completed by [Wound MD], the IAS indicated, "Pt [patient] s/p fall mid-March [sic] with ER Eval [Evaluation] & dx [diagnosis] of contusion to left lateral calf [left lateral shin] area. End of April Pt developed cellulitis to area. . .I was consulted May 1st [2023]." During a concurrent interview and record review, on 5/10/23, at 1:10 p.m., with LVN 2, Resident 1's PN dated 4/9/23, at 12:20 p.m., documented by LVN 2, was reviewed. There was no documentation of the physician being notified and no documentation the injured area at the left lateral shin was being monitored between 4/10/23 and 4/25/23 (16 days). LVN 2 stated, Resident 1 had a bruise and a blister to the left lateral shin, and it was being monitored from 4/6/23 to 4/9/23. LVN 2 confirmed there was no documented evidence the physician was notified of the non-healing bruise and blister after the 72-hour monitoring which ended on 4/9/23. LVN 2 stated, when the 72-hour monitoring was completed (4/9/23) and the bruise and blister were still present, the physician should have been notified, and the licensed nurses should have continued monitoring the bruise and blister. During a concurrent interview and record review, on 5/10/23, at 1:28 p.m., with Director of Nursing (DON), Resident 1's PN's were reviewed. There was no documentation noted of Resident 1's bruise or blister between 4/10/23 to 4/25/23. DON confirmed the findings and stated, Resident 1 sustained a bruise and a blister to her left lateral shin after a fall incident (4/5/23) and the areas did not resolve. DON stated, Resident 1 developed cellulitis to the same area (left lateral shin) on 4/26/23 (21 days later). DON stated, "After the 72-hour monitoring was completed [4/9/23] and the bruise and the blister were still present, the physician should have been notified and the monitoring should have been continued due to a potential change in condition." During a concurrent interview and record review, on 6/8/23, at 8:28 AM, with Assistant Director of Nursing (ADON), ADON reviewed Resident 1's OSR (Order Summary Report), dated 5/1/23. The OSR indicated, "DTI to left outer ankle (left lateral shin): Cleanse area with wound cleanser, pat dry, apply Medi honey (wound and burn gel) to wound bed, cover with ABD (abdominal gauze pad), wrap with Kerlex [sic] (a white gauze dressing), QD [every day] or PRN [as needed] if soiled or falls off. Notify Md [sic] of any changes. . .order date 4/27/23." ADON stated, the left lateral shin wound (bruise and blister) was discovered on 4/26/23. ADON stated, Resident 1's physician classified the wound as a DTI due to the wound being caused from Resident 1's fall incident (4/5/23) and gave treatment orders for the wound. During a review of Resident 1's PN dated, 5/2/23, at 1 p.m., the PN indicated, "Resident requested to be sent out to hospital, resident c/o [complain of] . . . not feeling right. . .resident sent to [acute hospital] ER for evaluation." During a review of Resident 1 ' s "History of Present Illness" (HPI), dated 5/2/23, from [acute hospital], the HPI indicated, "Chief complaint: Left lower leg pain. . .Per patient's [Family Member 1 and Family Member 2]. . .she has not received proper care for left lower leg (left lateral shin) wound sustained after sling [Hoyer lift] fall [4/5/23] during patient's stay. . .Extremities: 6x8cm [centimeter-unit of measurement] LLE [left lower extremity] tender, necrotic (death of most or all the cells in tissue due to disease, injury, or failure of the blood supply), open wound with serous [thin watery fluid]/clotted drainage noted. . .Assessment and Plan. . .LLE [left lower extremity] necrotic ulcer. . .LLE cellulitis. . .Reason for hospitalization. . .cellulitis" During a review of Resident 1's "History of Present Illness" (HPI), dated 5/3/23, from [acute hospital], the HPI indicated, "Consult details. . .Left leg open wound. . .[Resident 1] noted to have a large open wound with skin necrosis. . .Left leg with large open wound and skin necrosis with underlying hematoma [localized bleeding outside of blood vessels due to either disease or trauma including injury and may involve blood continuing to seep from broken capillaries] but continues to be unstable medically. . .Plan. . .will require medical optimization prior to debridement (the removal of damaged tissue or foreign objects from a wound). . ." During a review of Resident 1's "Wound Care Note" (WCN) dated 5/5/23, at 11:56 a.m., from [acute hospital], the WCN indicated, "[Hospital MD] rounding. Per MD pt [patient] needing surgical debridement of hematoma." During a review of the facility policy and procedure (P&P) titled, "Change in a Resident's Condition or Status" dated, 2/2021, the P&P indicated, "The nurse will notify the resident's attending physician or physician on call when there has been a(an). . .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly. . .A "significant change" of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. . .b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. . ." This violation has a direct relationship to the health, safety, or security of the resident, other than class "AA" or "A" violations and therefore constitutes a Class "B" Citation.