Other·September 12, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number CA00761629. Representing the Department, HFEN 32717. State Citation B was written CLASS B CITATION - PATIENT CARE F 686 CFR §483.25(b)(1)(i)(ii) 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 02/08/22, an unannounced visit was conducted at the facility to investigate a complaint of patient care. The facility failed to ensure Resident 1 was assessed, monitored, and treated for a new pressure ulcer on the left buttock and an existing Stage II (partial thickness skin loss that involves the deeper layers of the skin, may appear as a shallow crater) pressure ulcer (otherwise known as bed sore, a skin injury that result from unrelieved pressure on a body part, usually on a bony prominence like the tailbone, buttocks, and hips) on the coccyx (tailbone). This resulted in Resident 1's coccyx pressure ulcer to worsen from Stage II to Stage IV (full thickness skin loss with extensive destruction, tissue necrosis [tissue death], or damage to bone, muscles or tendons), and Resident 1 to develop a new Stage II pressure ulcer on the left buttock. Resident 1 was a 72 year-old female, admitted to the facility on 09/04/19. She had diagnoses that included Dementia (memory loss), low back pain and osteoarthritis (protective tissue at the end of the bones wear down, causes pain in the hands, neck, lower back, knees, and hips). Resident 1 was not alert and oriented. Resident 1 was nonverbal. During a review of the clinical record for Resident 1, the Situation, Background, Appearance, Review (SBAR, a communication tool among health practitioners) Communication Form and Progress Note, dated 12/19/20, indicated, Resident 1 was transferred to the acute hospital due to low oxygen saturation (amount of oxygen in the blood) level reading of 81 percent (%, normal range is 95% to 100%) at room air. The Progress Note indicated Resident 1 had a primary diagnosis of COVID 19 (a respiratory infection caused by a coronavirus that could have severe or life threatening complications). During a review of the clinical record for Resident 1, the Nursing Admission Screening/History, dated 12/27/20, indicated Resident 1 was re admitted to the facility from the hospital with a Stage II pressure ulcer on the coccyx. The Nursing Admission Screening/History did not indicate measurement of Resident 1's pressure ulcer on the coccyx. Resident 1 was re admitted on hospice care (compassionate care focusing on the quality of life so that the person's last days may be spent with dignity and quality). During an interview and concurrent review of Resident 1's Nursing Admission Screening/History, dated 12/27/20, and Weekly Wound Observation Tool, dated 1/19/21, with Registered Nurse Consultant (RNC), on 2/8/22, at 2:56 p.m., RNC stated, Resident 1's pressure ulcer should have been measured for the staff to know the baseline and to be able to monitor whether the wound is worsening or improving, that way, appropriate treatment, and intervention could be provided. RNC stated, aside from the Weekly Wound Observation assessment dated 1/19/21, Resident 1's clinical record did not indicate a wound assessment was done after 1/19/21. RNC stated there should have been a weekly wound assessment for every pressure ulcer. During a review of the clinical record for Resident 1, the Braden Scale for Predicting Pressure Sore Risk, dated 12/27/20, indicated Resident 1 was at "High Risk" for developing pressure ulcer. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 1/5/21, indicated Resident 1 had a Stage II pressure ulcer and was at risk of developing pressure ulcer. During an interview and concurrent review of Resident 1's clinical record with Treatment Nurse (TN), on 2/8/22, at 11:20 a.m., TN stated, there was no pressure ulcer care plan to address Resident 1's pressure ulcer despite a high pressure sore risk based on Braden Scale assessment and MDS assessment. TN stated licensed staff should have developed a pressure ulcer care plan. During a review of the clinical record for Resident 1, the Skin Impairment Assessment by Hospice Nurse (HN) 1 dated 12/27/20, indicated, Resident 1's Stage II pressure ulcer on the coccyx measured 2.1 centimeters (cm) x 1.4 cm x 0.1 cm. The skin assessment indicated, "Noted with [Stage II] pressure injury to coccyx treatment initiated cleanse pressure injury to coccyx with NS [normal saline] pat dry apply med honey [medihoney, used to treat partial to full thickness pressure ulcers with moderate amount of drainage] cover with [dry] dressing daily until healed." During a review of the clinical record for Resident 1, the Treatment Administration Record (TAR) for December 2020 indicated there was no treatment done on Resident 1's coccyx pressure ulcer for three days from 12/27/20 to 12/29/20. The TAR indicated that treatment order for medihoney, as initiated by HN 1 on 12/27/20 was not carried out. Review of a telephone visit by Hospice Nurse 4 (HN 4), titled, "Visit Note LVN," dated 12/28/20, indicated current treatment for Resident 1's coccyx pressure ulcer was to apply wound gel and cover with dry dressing. Further review of Resident 1's TAR for December 2020 indicated wound gel treatment order for the coccyx pressure ulcer, as indicated in hospice "Visit Note LVN" dated 12/28/20, was not initiated until 12/30/20. During a review of the clinical record for Resident 1, the Medication Review Report for January 2021 indicated an order dated 12/27/20 to "Apply skin barrier to peri area (between genitals and anus) as preventative measure every shift". Another order dated 12/30/20 indicated, "Sacral [a large, triangular bone at the bottom of the spine and between the two hip bones] coccyx: Cleanse with NS, pat dry, apply wound gel (treatment of choice for minor, superficial/partial thickness wounds such as a Stage II pressure ulcer), cover with a dry dressing every day shift". The report did not indicate the treatment initiated by HN 1 on 12/27/20 (day of re-admission) to apply medihoney on the pressure ulcer. During an interview and concurrent review of Resident 1's clinical record with TN, on 2/8/22, at 1:09 p.m., another Braden Scale for Predicting Pressure Sore Risk dated 1/7/21 indicated Resident 1's pressure sore risk went down from "High Risk" (from 12/27/20 assessment) to "Moderate Risk". TN stated the assessment of Resident 1's sore risk was not accurate and written by "Maybe one of the registry nurses who would just throw in numbers". TN stated, Resident 1's Nutritional Screening dated 1/6/21 indicated Resident 1 had poor appetite and consumed only soups during meals, an information that would have increased Resident 1's risk. During a review of the clinical record for Resident 1, the RD (Registered Dietician) Note dated 1/7/21 indicated, under skin, "Pressure ulcer. No pressure injuries and no edema per nursing weekly summary 5/6." RD's recommendation was for monthly weight monitoring per hospice protocol. There was no recommendation for nutritional intervention to address an existing pressure ulcer. During an interview and concurrent review of Resident 1's Weekly Wound Observation Tool, dated 1/19/21, with TN, on 2/8/22, at 1:09 p.m., the observation tool indicated Resident 1's pressure ulcer on the sacrococcyx (fused tailbone and sacrum, the triangular bone just above the tailbone) area was a Stage II that measured 3.5 cm x 3.5 cm, unable to determine depth. The tool indicated Resident 1's wound was "Worsening" and had slough (yellow, tan, white stringy tissue). TN stated, the pressure ulcer should not have been a Stage II because of the presence of slough that indicated wound is worse than a Stage II. The tool listed the current treatment plan as; cleanse with normal saline, pat dry and apply medihoney to wound bed and cover with dry dressing. The licensed staff who completed the observation tool and signed off on the TAR was not available for interview. During a review of the clinical record for Resident 1, the "Visit Note LVN" dated 1/19/21, indicated "[HN 4] Spoke with tx [wound treatment] nurse. New left buttock wound deteriorating." During a review of the clinical record for Resident 1, the Physician's Order from hospice dated 1/19/21 indicated to change the treatment to Resident 1's left buttock and coccyx pressure ulcers to; "Cleanse with NS, pat dry, and apply medihoney. Then cover with a foam dressing daily." During a review of the clinical record for Resident 1, the TAR for January 2021 indicated physician ordered treatments from hospice for the existing pressure ulcer on the coccyx and the new pressure ulcer on the left buttock were not provided from 1/19/21 to 1/31/21. During a review of the clinical record for Resident 1, the TAR for February 2021 indicated the physician ordered treatment from hospice for Resident 1's left buttock pressure ulcer was not provided from 2/1/21 to 2/11/21. During a review of the clinical record for Resident 1, the Skin Impairment Assessment by Hospice Nurse (HN) 2 dated 2/9/21 indicated Resident 1 had two pressure ulcers, one with an open date of 12/27/20, and a new one with an open date of 2/9/21. The assessment indicated the following: #1, open date 12/27/20, coccyx area, Stage IV pressure injury that measured 3.5 cm x 3.5 cm x 0.4 cm. #2, open date 2/9/21, left buttock area, Stage II pressure injury that measured 2.5 cm x 1.7 cm x 0.1 cm. During a telephone interview with Registered Nurse Supervisor (RNS) on 3/14/22 at 2:53 p.m., RNS stated Resident 1's clinical record did not have any documentation of a new open area on left buttock. During a review of the clinical record for Resident 1, the Health Status Notes dated 2/12/21 indicated Resident 1died on 2/11/21. During a telephone interview with Hospice Nurse (HN) 3 on 2/9/22 at 3:02 p.m., HN 3 stated, on 2/11/21, when Resident 1 died, Resident 1's pressure on the sacrococcyx area looked "big and really bad" and had odor to it. HN 1 also stated, there was part of the ulcer that was black. During an interview and concurrent review of the facility's undated "T time" (turning schedule, when residents are turned and repositioned) schedule with TN on 2/8/22 at 1:09 p.m., TN stated, for all residents who had pressure ulcers, T Time was implemented. TN stated all staff, licensed nurses and Certified Nursing Assistants (CNAs), made rounds every two hours to make sure residents were in a certain position while in bed (i.e., at 2:00 p.m., residents were to face the window, at 4:00 p.m., the residents were to be on their back, etc.). TN stated, because T time was universal for all residents regardless of where the pressure ulcer was located, it was not applicable for Resident 1 because of the location of the ulcer. TN stated, Resident 1 was to be positioned on the back only to eat, otherwise, Resident 1 should be on either side to reduce pressure on the buttock area and tailbone. Review of the facility's T time would have Resident 1 positioned on the back, two hours at a time, for a total of over nine hours a day. During an interview with Restorative Nursing Assistant (RNA) 1 on 2/8/22, at 2:48 p.m., Resident 1 was one of the residents who was turned and repositioned every two hours because Resident 1 required total assist with all activities of daily living (like turning and repositioning while in bed). RNA 1 stated, around lunch time, residents that included Resident 1, needed to be on their back, after two hours, they were repositioned to face the window. During a review of the facility's policy and procedure (P&P) titled, "Wound and Skin Management," released on 9/1/08, the P&P indicated all staff are responsible for the prompt reporting of any skin related problems and any resident who has pressure sores will receive the necessary treatment and services to promote healing and prevent ulcers from developing. The P&P indicated under assessments, the procedures included, licensed nurse will assess each resident's skin condition weekly and document findings in the weekly progress notes and/or the skin sheet. Interdisciplinary team (IDT, a group composed of individuals representing different departments of the facility) and licensed nurse will assure care plans and progress notes reflect resident's status and appropriate interventions. Licensed nurse will refer newly identified pressure ulcer to IDT for further assessment and care planning. The P&P also indicated, licensed nurses will document pressure ulcer status at least every seven days and should record the status of the ulcer, location, size, and stage. IDT will enter all skin related issues on the resident's care plan and there will be an interdisciplinary approach to skin care. In violation of the above cited standards, the facility failed to ensure Resident 1 was assessed, monitored, and treated for a new pressure ulcer on the left buttock and an existing Stage II (partial thickness skin loss that involves the deeper layers of the skin, may appear as a shallow crater) pressure ulcer (otherwise known as bed sore, a skin injury that result from unrelieved pressure on a body part, usually on a bony prominence like the tailbone, buttocks and hips) on the coccyx (tailbone). This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.