Health inspection·March 19, 2021

§ 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. On 12/28/2020 at 8:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment. The facility failed to provide care and services in accordance with professional standards of practice when: 1. For Resident 1, staff did not document admission and weekly wound skin assessments, did not provide treatment as ordered by the physician, did not have a Skin Care Plan (a care plan identifies residents' concerns and outlines the care and services needed to meet their needs) on readmissions, did not have the Interdisciplinary Team (IDT, team members from different departments involved in a resident's care), and did not have a wound consult ordered. 2. For Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17, treatment was not provided as ordered by the physician. These failures had the potential to negatively affect the residents' health and well-being. 1. Review of Resident 1's medical record indicated he was readmitted to the facility twice on 10/9/2020 and 11/14/2020. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) dated 12/17/2020, indicated he was transferred to the general acute care hospital (GACH) due to labored breathing, and elevated heart rate. Review of Resident 1's GACH History and Physical dated 12/17/202 indicated "decreased responsiveness and elevated white blood cell count, has bullous pemphigus [rare skin condition causing large, fluid-filled blisters, usually appears on the belly, chest, arms, legs, groin, or armpits. The risk of developing this condition increases with age and symptoms include fluid-filled blisters that are often located along creases in the skin. Affected skin may be itchy. Steroid pills and topical steroid creams and ointments can help the skin heal and relieve itching] with multiple skin ulcerations associated with erythema [superficial reddening of the skin]". The Inpatient Medicine Progress Note dated 1/8/2021, indicated "Pemphigoid-diffuse bullous pemphigoid, [Resident 1] needed a steroid [type of medication to reduce redness and swelling] treatment, stable but generalized bullous pemphigoid persistent". Review of the facility's Detail Admission/Discharge Report, indicated that on 10/9/2020, Resident 1 was readmitted to the facility. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 10/14/2020, indicated he had short and long term memory problems, and needed one person physical assistance with toilet use and personal hygiene. Resident 1 had urinary and bowel incontinence. Review of Resident 1's physician order dated 10/9/2020, listed the following skin problems: a. coccyx stage 2 [partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed], cleanse with normal saline [NSS], pat dry, apply medihoney [type of treatment] 100% paste and cover with foam dressing QD [daily] b. right lateral foot opened blister, apply no string barrier and cover with dry dressing QOD [every other day]. Notify MD [medical doctor] if change c. left dorsal foot opened blister, cleanse with NS [normal saline], pat dry apply Xerofoam [an occlusive dressing that keeps air out, which can help to protect the area while also promoting a moist environment for healing] 5"x 9" gauze strip QOD d. mid abdomen opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD e. left abdomen lateral side opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD" f. right clavicle opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD g. left lateral chest intact blister, clean with NS, pat dry apply no string barrier film wipe QOD h. right ankle blood filled blister, no string barrier film wipe and cover with dry dressing QOD i. left upper side of the back stage 2, cleanse with NS, pat dry apply MediHoney 100% paste and cover with foam dressing QD j. right buttock two sites stage 2, cleanse with NSS, pat dry apply MediHoney 100% paste and cover with foam dressing QD k. left buttock stage 3 [sores have gone through the second layer of skin into the fat tissue] cleanse with NSS, pat dry apply MediHoney 100% paste and cover with foam dressing QD Review of the Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report dated 10/9/2020 and 10/16/2020, identified Resident 1's skin issues. However, after 10/16/2020, Resident 1 did not have done the Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report. Review of the facility's Detail Admission/Discharge Report, indicated on 11/14/2020, Resident 1 was readmitted to the facility. Review of Resident 1's physician order dated 11/14/2020, listed the following skin problems: a. left lateral hip opened blisters, cleanse with NS, pat dry, and apply Xerofoam petrol 5 "x 9 dressing on wound bed. Cover with dry dressing QD b. mid abdomen opened blisters two sides, cleanse with NS, pat dry, apply Xerofoam petrol 5" x 9" dressing over wound bed then cover with dry dressing QOD c. right lateral foot blister, apply no sting barrier and cover with dry dressing QOD. Notify MD if change d. left abdomen lateral side opened blister, cleanse with NS, pat dry apply Xerofoam 5x9 gauze strip QOD e. left dorsal foot opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD f. mid abdomen opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD g. right clavicle opened blister, cleanse with NS, pat dry apply Xerofoam 5"x 9" gauze strip QOD h. left lateral chest intact blister cleanse with NS, pat dry apply no sting barrier film wipe QOD i. right ankle blood filled blister, no sting barrier film wipe and cover with dry dressing QOD j. coccyx open wound, cleanse with NSS, pat dry apply MediHoney 100% paste and cover with foam dressing QD k. right buttock open two sites open wound, cleanse with NSS, pat dry apply MediHoney 100% paste and cover with foam dressing QD l. left upper side of the back of the wound, cleanse with NSS, pat dry apply MediHoney 100% paste and cover with foam dressing QD. Review of the Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report did not have documentation of Resident 1's skin issues on 11/14/2020 and every week after. Review of Resident 1's treatment administration record (TAR) for November and December 2020 indicated there were no treatments documented on the following dates: a. 11/15/2020, 11/30/2020 on left lateral hip opened blisters b. 11/29/2020, 11/30/2020 on mid-abdomen opened blisters, left upper side of back wound, coccyx open wound, right buttock open wound c. 11/30/2020 on left abdomen lateral side opened blister, left dorsal foot opened blister, left lateral chest intact blister, mid-abdomen opened blister, right ankle blood blister, right clavicle opened blister, right lateral foot blister d. 12/5/2020, 12/6/2020, 12/14/2020, 12/15/2020, 12/16/2020, 12/17/2020 on left lateral hip opened blisters e. 12/2/2020, 12/6/2020, 12/8/2020, 12/10/2020, 12/14/2020, 12/16/2020 on mid-abdomen blisters f. 12/14/2020, 12/15/2020, 12/16/2020, 12/17/2020 on left upper side of the back wound, coccyx open wound, right buttock open wound g. 12/14/2020, 12/16/2020 on left abdomen lateral side opened blisters, left dorsal foot blister, left lateral chest intact blister, mid-abdomen opened blister, right ankle blood blister, right clavicle opened blister h. 12/4/2020, 12/14/2020, 12/16/2020 on right lateral foot blister Review of Resident 1's Skin Care Plan dated 3/30/2020 and 10/8/2020 respectively, indicated Resident 1 had pressure ulcers (also known as pressure sores or bed sores, localized damage to the skin and/or underlying tissue that usually occur over a bony prominence) but did not include blisters. The Skin -Short Term Non-Pressure Ulcer Care Plan dated 9/29/2020 did not include blisters. The facility did not provide evidence that Resident 1 had a Skin Care Plan initiated on the readmissions. Further review of Resident 1's medical record indicated there was no IDT in place. During a telephone interview with certified nursing assistant A (CNA A) on 2/2/2021 at 10:05 a.m., CNA A stated Resident 1 had blisters all over and the blisters were fluid like. CNA A said Resident 1 would moan sometimes whenever she changed him because of the blisters his body, and it was hard to change his diaper because "the diaper sticks on skin, sometimes the blisters were not all covered". During a telephone interview with registered nurse B (RN B), on 2/2/2021 at 10:35 a.m., RN B stated Resident 1 had multiple wounds, and some were blisters. RN B acknowledged she missed providing Resident 1's treatment on 12/5/2020. During a telephone interview with RN C on 2/2/2021 at 11:00 a.m., she acknowledged on 12/17/2020, she took care of Patient 1. RN C stated Patient 1 had blisters, open wounds, intact blisters even on face. Prior to sending Patient 1 to GACH on 12/17/2020, RN C stated she did not see if Patient 1 had dressings on his body but "visually, I can see dressings on his arms, it was taped on both arms, and it has a smell of a wound." RN C said Patient 1 wounds were not healing, the blisters would dry up, and then a new one would come out. RN C stated, they did not have a treatment nurse since mid of November 2020 and she was not sure if there was a wound referral done. During a telephone interview with licensed vocational nurse D (LVN D) on 2/3/2021 at 11:30 a.m., LVN D stated he was assigned as the full time treatment nurse sometime in June or July 2020. He reduced his working hours to two times a week sometime in November 2020. LVN D said Resident 1 was the last resident whose Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report he did on October 2020. LVN D stated he was not in charge of doing the Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report after reducing his working hours to two times a week. LVN D said he remembered Resident 1 had many generalized blisters, fluid like, and open areas on the coccyx. LVN D also stated he started a skin care plan upon admission. During an interview and concurrent record review with LVN E on 2/3/2021 at 12:07 p.m., LVN E stated Resident 1 had "lots of wounds, it's generalized", the wound-like blisters never healed since readmitted on 10/2020. LVN E confirmed she did not provide Resident 1's treatments on 12/15/2020, 12/16/2020, and 12/17/2020. During an interview and concurrent record review with the assistant director of nursing (ADON) on 2/3/2021 at 12:28 p.m., the ADON stated the treatment nurse was responsible for completing the Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report. The ADON further stated they have a skin IDT committee. The ADON confirmed they did not have a treatment nurse from 11/1/2020 to 1/2/2021. The ADON acknowledged she could not provide evidence that Resident 1 received the following: Weekly Skin Problem Progress Report and Weekly Pressure Injury/Ulcer Progress Report after 10/16/2020 and on 11/14/2020, and weekly; Skin Care Plan was initiated to show all skin problems upon the readmissions, and the skin committee IDT involvement. The ADON stated Resident 1's physician order was not followed as evidenced by multiple missing licensed nurses' signatures on the November and December 2020, TARs. The ADON acknowledged she could not provide documentation that Resident 1's treatments were effective and the wounds healed. The ADON stated a wound consultation should have been ordered but she could not provide evidence it was done. During a telephone interview with Resident 1's attending physician (AP) on 2/3/2021 at 1:09 p.m., he stated he knew about Resident 1's skin issues, and about the blisters, but Resident 1 would need a dermatologist to diagnose bullous pemphigus. AP confirmed he did not order a referral for dermatology. 2. For Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17, treatment was not provided as ordered by the physician. a. Review of Resident 2's TAR dated 10/15/2020, indicated triamcinolone 0.1%, apply topically to affected areas every shift for itching, scratching, and on dry scabs. There were no treatments documented on the following dates and shifts: 11 p.m. to 7 a.m. (night shift) on 01/01/2021, and 01/21/2021 through 01/31/2021; 7 a.m. to 3 p.m. (morning shift) on 1/1/2021, 1/2/2021, 1/3/2021, 1/15/2021, 1/19/2021,1/20/2021,and 1/21/2021; and 3 p.m. to 11 p.m. (evening shift) on 1/26/2021, and 1/31/2021. b. Review of Resident 3's TAR dated 11/26/2020, indicated cleanse right lateral leg with normal saline (NS), pat dry, apply triple antibiotic QD (everyday) and open to air until healed. There were no treatments documented on the following dates: 1/1/2021, 1/2/2021, 1/3/2021, 1/19/2021, 1/20/2021, 1/21/2021, 1/25/2021, 1/26/2021, 1/28/2021, and 1/29/2021. Review of Resident 3's TAR dated 12/10/2020, indicated cleanse left lateral opened cellulitis (a common and potentially serious bacterial skin infection) area with NSS, pat dry, apply bacitracin (a type of antibiotic), cover with dry dressing QD until healed. There were no treatments documented on the following dates: 1/1/2021, 1/2/2021, 1/3/2021, 1/9/2021 1/19/2021, 1/20/2021, 1/21/2021, 1/25/2021, 1/26/2021, 1/28/2021, and 1/29/2021. c. Review of Resident 4's TAR dated 9/10/2020, for the months of November 2020, December 2020, and January 2021, indicated there were no treatments documented on the following dates: 1) Hydrocortisone (anti-itch medication) 2.5% ointment, apply to affected areas to scaly areas on face, neck, groin twice daily on 11/15/2021, 11/25/2020, 12/20/2020, 12/23/2020,12/25/2020, 12/28/2020, 12/20/2020, 01/3/2021, 01/7/2021 to 01/11/2021, 01/13/2021, and 01/14/2021. 2) Mupirocin (a type of antibiotic) 2% ointment, apply to affected areas to yellow , crusty, open skin twice daily on 11/3/2020, 11/4/2020, 11/9/2020, 11/10/2020, 11/15/2020, 11/25/2020, 12/20/2020, 12/23/2020, 12/25/2020, 12/28/2020, 12/30/2020, 01/7/2021 to 01/11/2021, 01/13/2021, and 01/14/2021. 3) Triamcinolone (a type of medication that helps reduce inflammation) 0.1% ointment, apply to affected areas to red, scaly area on body two times a day for eczema (a condition wherein patches of skin become inflamed, itchy, cracked, and rough), do not use on face, trunk or extremities, on 11/06/2020, 11/15/2020, 11/25/2020, 12/20/2020, 12/23/2020, 12/25/2020, 12/28/2020, 12/30/2020, 01/07/2021 through 01/11/2021, 01/13/2021, and 01/14/2021. d. Review of Resident 5's TAR for the months of December 2020 and January 2021, indicated there were no treatments documented on the following dates: 1) Order dated 11/27/2020; cleanse left above knee blister with NS, pat dry then cover with dry dressing until resolved, missing for 12/20/2020, 12/23/2020, 12/25/2020, 12/27/2020, 12/28/2020, and 12/30/2020. 2) Order dated 1/12/2021; left hip stage 3 wound #3 clean with NS, pat dry, apply MediHoney and cover with foam dressing daily and as needed missing on 1/14/2021. 3) Order dated 1/12/2021; apply hydrocortisone 1% cream to generalized body rash bid (twice a day), notify MD for any changes missing on 01/14/2021, 01/25/2021, 01/26/2021, 01/29/2021, and 01/31/2021. e. Review of Resident 6's TAR for the months of December 2020 and January 2021, indicated there were no treatments documented on the following dates: Order dated 12/22/2020; open wound on right buttock, cleanse with NS, pat dry, apply MediHoney 100% paste and cover with dry dressing Q (every) AM (morning ) and prn if soiled on 12/23/2020, 12/25/2020,12/20/2020, 01/1/2021, 01/3/2021, 01/07/2021 through 01/11/2021, 01/13/20