Other·November 20, 2023

REGULATION VIOLATIONS: Title 22 72311(a) Nursing Service General (a) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Title 22 72315(f)(7) 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: (7) Carrying out the physician's orders for treatment of decubitus ulcers. The facility shall notify the physicians, 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 October 2, 2023, an unannounced recertification survey was conducted at the facility. A 69 years old female patient (Patient 21) was admitted to the facility on August 7, 2020, with diagnoses of gangrene (dead tissue caused by an infection or lack of blood flow), methicillin resistance staphylococcus aureus infection (an infection that is difficult to treat because of resistance to antibiotics), and hemiplegia (a condition which causes weakness to one side of the body). Patient 21 was found to have multiple skin tissue injuries and was not receiving care and treatment for her left contracted (tightening of muscle, tendons, ligaments, or skin which prevent movement) foot. The facility failed to: 1. Identify care needs based upon an initial written and continuing assessment for Patient 21. 2. Provide care to prevent formation and progression of decubiti, contractures and deformities for Patient 21. 3. Obtain physician's orders for treatment of Patient 21's left contracted foot skin tissues injuries. These failures resulted in a delay in the treatment for skin injuries to Patient 21's contracted left foot. A review of Patient 21's "Admission Record" (contains demographic and medical information) indicated Patient 21 was admitted to the facility on August 7, 2020, with diagnoses which included: Gangrene (Dead tissue caused by an infection or lack of blood flow), Methicillin Resistance Staphylococcus Aureus Infection (an infection that is difficult to treat because of resistance to antibiotics), hemiplegia ( A condition which causes weakness to one side of the body) and hemiparesis (paralysis of partial or total body function on one side of the body). A review of Patient 21's, "Braden Scale - For Predicting pressure sore Risk," dated, August 30, 2023, the Braden Scale indicated Patient 21 was at high risk for pressure sore development with score of 8 out of 23 score. (A low score indicates increased risk for pressure sore development.) A review of Patient 21's, "care plan" dated, August 1, 2022, Patient 21's care plan indicated, "Risk for developing pressure sore, and other types of skin breakdown related to: Aging Process, fragile skin, hx [history of] skin alteration, immobility, impaired cognition, incontinence of (bowel, bladder) ...Goal: Minimize the risk for breakdown / pressure sore daily...Interventions...Provide good skin care q shift [every shift] Assess skin integrity during care...Notify MD of any changes..." During a concurrent observation and interview on October 3, 2023, at 9:01 AM, with Licensed Vocational Nurse 3 (LVN 3) Patient 21 was observed lying on her back while in bed. Patient 21 was wearing a left heel boot. Upon removal of the left boot by LVN 3 the following was noted to Patient 21's left contracted foot: A. The lateral (outer side) area of the left foot, distal from the 5th toe, noted with purple color blister characterized by skin elevation, (1.5cm x 1.5 ci) B. The left 5th toe pressure tissue injury with partial thickness loss of dermis (thickest layer of the skin) and red/pink wound bed. (approx. 2 cm length) C. The 4th left foot toe had circular, dry and cracked skin (approx. 2 cm length) D. The 3rd left foot had circular dark cracked skin. E. The left great toe had a circular area (approx. 1 cm x 1 cm) on the bottom of the toe which was dark in color. F. Between the great toe and 3rd toe of the left foot, there was dark colored skin tissue and dryness. LVN 3 stated Patient 21 did not have any treatment for Patient 21's skin tissue injuries to the left contracted foot. During an interview on October 4, 2023, at 12:21 PM, with the Director of Nursing (DON), the DON stated she was not aware Patient 21 had multiple skin tissue injuries to her left foot. A review of Patient 21's physician's orders for the month of September 2023, there were no orders for the treatment of any skin injuries to Patient 21's left contracted foot. A review of Patient 21's physician's orders for the month of October 2023, there were no orders for the treatments of any skin injuries to Patient 21's left contracted foot. A review of Patient 21's physician's orders, dated August 25, 2023, indicated, "left foot heel protector (boot like device which us used to help prevent the development of pressure injuries on the foot) while in bed and wheelchair for skin integrity. Every 12 hours for wound prevention." A review of Patient 21's "Treatment Administration Record," (TAR- document used to record treatments administered to the Patient), dated September 1, 2023, through October 5, 2023, the documents indicated there were 9 days (September 22, 25, 28 and 29, 2023 and October 1,2, 3, 4, and 5, 2023) without documented evidence that the heel protector was applied as specified by the physician's orders. A review of Patient 21's "Skin & Wound - Total Body Skin Assessment" dated September 3, 2023, at 10:12 PM, indicated, "1. Skin Assessment, 1. Turgor [skin elasticity] poor elasticity, [skin ability to stretch] ..., Enter the # [number] of new wounds" [injury to the tissue] 0 [no indication of new wounds was noted] A review of Patient 21's "Skin & Wound - Total Body Skin Assessment" dated September 17, 2023, at 10:52 PM, indicated, 1. Turgor, 2. Poor Elasticity..., Enter the # [number] of New Wounds, 6. New Wounds 0" [No indication of new wounds was noted] A review of Patient 21's "Weekly Summary V2.1" dated September 17, 2023, at 10:49 PM, indicated, "Mobility / Ambulation, 2. How much assistance is required 5. Total Dependence [needs maximum of assistance] ..., I, Skin Condition, 1. Is the resident free of any open areas? A. Yes...4. Are other skin condition (s) present? B. No, 5. Additional documentation (treatments, pressure reducing devices etc.)" [no documentation noted] A review of Patient 21's "Weekly Summary V2.1" dated September 24, 2023, at 11:48 PM, indication, "Skin Condition, 1. Is the Patient free of any open areas? A Yes, 5. Additional documentation (treatments, pressure reducing devices, etc.) [No documentation noted] A review of Patient 21, "Weekly Summary V2.1" dated October 1. 2023, at 11:22 PM indicated "I. Skin Condition, 1. Is the resident free of any open areas? A. Yes...5. Additional documentation (treatments, pressure reducing devices, etc.) NA"[NA-meaning not applicable] A review of the facility's policy and procedure titled , "Pressure Injury Risk Assessment" dated September 28, 2023, indicated, the purpose of this procedure is to provide guidelines for the structured assessment and identification of resident at risk of developing a new pressure or worsening of existing pressure injuries (PIs) The purpose of pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addresses...h. Impaired perfusion, oxygenation or circulation deficit... or lower extremity arterial insufficiency;...4. Conduct a comprehensive skin assessment with every risk assessment. B. Once inspection of skin is completed document the findings on a facility approve skin assessment tool, c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin...Documentation....1. The type of assessment (s) conducted. 2. The date and time and type of skin care provided, if appropriate..., 4. Any change in the resident's condition, if identified..., 12. Documentation in medical record addressing MD notification if new skin alteration noted..." In violation of the above cited standards, the facility failed to: 1. Identify care needs based upon an initial written and continuing assessment of Patient 21's left foot. 2. Development of an individual, written patient care plan for Patient 21 which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. 3. Provide care to prevent formation and progression of decubiti, contractures and deformities for Patient 21. 4. Obtained physician's orders for treatment of Patient 21's left contracted foot skin tissues injuries. These violations has a direct or immediate relationship to the health, safety and security to Patient 21 and would result and constitutes a class "B" violation.