Health inspection·September 9, 2022

REGULATION VIOLATION: Title 42 of the Federal Code of Regulations  483.25(d) Accidents. (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.  72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient.  72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.  72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. On June 27, 2022, at 4:03 pm, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Patient A sustaining "scattered redness" on his left hand and left abdomen after spilling hot coffee on himself. Patient A was served hot coffee by a Certified Nursing Assistant (CNA 3) on June 24, 2022, at around 7:00 AM. Patient A required set up and supervision with meals and was not assisted by CNA 3 who placed the cup of hot coffee on patient's overbed table but did not ensure the coffee was within patient's reach. This failure resulted in the cup of hot coffee sliding off the overbed table, which was slightly slanted, when Patient A tried to pull the overbed table closer to reach his coffee, causing scalding burns on patient's left hand, wrist, and the left side of his abdomen. The facility failed to: 1. Identify Patient A's care needs based on the initial written and continuing assessment of the status of Patient A's wounds from the scalding burn to his left hand, wrist, and the left side of his abdomen. 2. Notify the physician when there was a sudden change in Patient A's skin condition related to the scalding burns to his left hand, wrist, and the left side of his abdomen. 3. Review, evaluate, and update the patient care plan when there was a change in Patient A's burns to include blisters, swelling and skin peeling. 4. Administer the Silvadene cream (a medication used to prevent infections in burns) in a timely manner in accordance with physician's order, which presents a risk to the patient's health. 5. Follow its policy and procedure titled "Policy: Change of Conditions," when multiple nurses failed to call a physician upon Patient A's change of condition. Patient A, a 77-year-old male, was admitted to the facility on November 20, 2019, with diagnoses of transient cerebral ischemic attack (a brief episode during which parts of the brain do not receive enough blood), type 2 diabetes mellitus (high blood sugar), neuralgia (pain caused by damaged or irritated nerves) and neuritis (inflammation of a peripheral nerve or nerves, usually causing pain and loss of function). Patient A was alert, awake and verbally responsive (Spanish speaking only), he understood little English. Patient A has impaired ability for activities of daily living such as bed mobility, transfer, walking, locomotion, dressing, toilet use and personal hygiene. Patient A requires two persons assist and using a wheelchair is his primary mode of locomotion. Patient A requires set up and supervision for his meals (the person helping will place things within reach, open containers, assist to cut up food and provide verbal cues either continuously or intermittently during meals). A review of Patient A's Minimum Data Set (MDS) (a computerized monitoring tool) Section G, Functional Status, indicated Patient A requires supervision and set up during meals. Patient A also had limited range of motion on one side (left) of his upper extremity (shoulder, elbow, wrist, hand). A review of Nursing Care - Change of Condition (NC -COC)/ Assessment Form (SBAR) (Situation, Background, Assessment, Recommendation) (communication tool that helps provide essential and concise information) v (version)1.3: nursing notes dated June 24, 2022, written by a Licensed Vocational Nurse (LVN 1) (11:00 PM- 7:00 AM shift), indicated, "At around 7:00 AM resident called that he spilled his coffee on self. Half of the cup was spilled on him and his bed. No blisters noted to abdomen or left hand. Per resident he only feels some stinging. Cleaned area and provided towels. Resident comfortably(sic) at this time. Inform the physician, nurse practitioner. Responsible party aware. Endorsed continuation of care to oncoming (sic) nurse." A review of physician's order dated June 24, 2022, it indicated "Silvadene Cream 1% [Silver Sulfadiazine-a medication used to treat bacteria from open wounds, such as second- and third-degree burns]. Apply to affected area topically every day-shift for left hand redness for 1 week." A review of a second physician's order dated June 24, 2022, it indicated "Silvadene Cream 1%. Apply to affected area topically every day-shift for abdominal redness for 1 week." A review of NC-COC/ Assessment Form (SBAR) v1.1: nursing notes dated June 24, 2022, written by LVN 2 (7:00 AM - 3:00 PM shift), indicated, "with new order to apply cold compress to left hand and abdomen Q2hrs [every two hours] for 15 minutes for 24 hours and Silvadene cream1% to affected area qd [every day] for 7 days. Wife [name] was informed. Some redness on abdomen and redness and some peeling noted on the left hand." A review of NC Licensed Nurse Record COC v1.1: nursing notes dated June 24, 2022, written by LVN 3 (3:00 PM - 11:00 PM shift), indicated, "Some redness noted on abdomen and redness and some peeling noted on left hand." A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 24, 2022, written by LVN 1 (11:00 PM- 7:00 AM shift), indicated, "Resident continues with treatment order Silvadene cream 1% and cold compress x 24hrs to abdomen and left hand... No open skin noted. Some redness still noted." A review of the Treatment Administration Record (TAR) dated June 2022, it indicated that Silvadene Cream was started June 25, 2022, instead of on June 24, 2022, when the medication was initially ordered. A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 25, 2022, written by LVN 4 (7:00 AM - 3:00 PM shift), indicated, "Abdominal area is slight pink in color with no swollen areas noted. Left hand burn is swollen and red." A review of NC Licensed Nurse Record COC v1.1: nursing notes dated June 25, 2022, written by LVN 5 (3:00 PM- 11:00 PM shift), indicated, "Resident is on monitoring for burn to abdomen and left-hand wrists area. Abdomen area noted to pink and left hand noted with swelling." A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 25, 2022, written by LVN 1 (11:00 PM- 7:00 AM shift), indicated, "Redness still noted left hand with some peeling." A review of NC Licensed Nurse Record COC V 1.1: nursing notes dated June 26, 2022, written by LVN 4 (7:00AM- 3:00 PM shift), indicated, "Abdominal area is slight pink in color with no swollen or open areas noted. Left hand burn swollen and red." A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 26, 2022, written by LVN 3 (3:00 PM- 11:00 PM shift), indicated, "Continues monitoring for redness to abdominal area and left hand due to spilling coffee on self. Redness still noted to left hand with some peeling." A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 26, 2022, written by LVN 6 (11:00 PM - 7:00 AM shift), indicated, "Redness to his abdominal area and his left hand with some peeling. Continue with Silvadene cream." A review of NC Licensed Nurse Record COC v 1.1: nursing notes dated June 27, 2002, written by LVN 2 (7:00 AM - 3:00 PM shift), indicated, "On monitoring for redness to left arm and abdominal area. Redness with peeling noted on left arm and some redness throughout abdomen s/p spilling coffee on self ... Wife upset about the burn on resident's arm. Explained treatment order to family and treatment nurse also spoke with family." During a concurrent observation and interview on June 27, 2022, at 4:13 PM, with Patient A, he was in his room sitting in his wheelchair, and observed to have a bandage on his left hand. Patient A was observed to be unable to raise or move his left arm and hand, due to a previous "stroke" leaving him with a contracted left hand and left sided weakness. Patient A stated he spilled hot coffee on his left hand and abdomen as he tried to reach for the coffee that was slowly sliding from the edge of his bedside table. Observed table surface was not straight, but slightly slanting. During an observation on June 27, 2022, at 4:23 PM, in Patient A's room, the Director for Staff Development (DSD) explained what she was going to do before removing the dressing from the patient's left hand to observe the site of injury. The skin of the left hand was observed to be peeled off from the base of the thumb to the wrist, showing a beefy red wound bed, with some areas having white to greenish patches. The wound bed measured 7 x 3 centimeters (cm= 0.39 inches). The patient's abdomen where the hot coffee had spilled, had multiple scald burns the size of a dime, some with eschar (dead tissue) that were located from below the left nipple line through the left lower abdominal area. During an interview on June 27, 2022, at 4:45 PM, with CNA 1, CNA 1 stated on Friday, June 24, 2022, she worked her regular shift (3:00 PM-11:00 PM shift) and learned about the incident from the report given by her co-worker. CNA 1 did not see what happened to the left hand as it was bandaged, but saw Patient A had redness on his abdomen while changing his diaper. CNA 1 notified the charge nurse, but was informed that they were aware, and it was being treated. When asked how coffee was provided to patients, CNA 1 stated coffee was obtained for patients two ways. First was from the kitchen, and a cup with a lid was used because of the long walk from the kitchen to the patient's room. The second way was from the coffee cart that is used to deliver coffee to patients' rooms before meals. The coffee delivered from the coffee cart does not have a lid. During a concurrent observation and interview on June 27,2022, at 5:08 PM, with the Registered Nurse Supervisor (RN Sup), in the hallway, CNA 2 was observed pushing the coffee cart and offering coffee to patients. On this coffee cart was a large multi-cup coffee pot, colored plastic mugs and condiments. CNA 2 stated cup lids were not used because there was only a short distance from the cart to the patient's room. The RN Sup stated when the coffee comes directly from the kitchen, then the cup would have a lid because of the long walk from the kitchen to the patients' room. Upon request, CNA 2 poured a sample of the coffee into a colored plastic mug. The mug was cool to the touch, however, when the coffee temperature was measured using a thermometer it read 166.6 degrees Fahrenheit. The RN Sup stated, "That is hot." During an interview on June 28, 2022, at 2:10 PM, with CNA3, CNA 3 stated Patient A's daily routine was to request coffee at 7:00 AM and watch TV. CNA 3 stated on June 24, 2022, she got the patient a cup of coffee from the kitchen and placed it at his bedside table and left. CNA 3 also stated she left because Patient A was alert and only needed set-up. During an interview on June 27, 2022, at 5:53 PM, with the Wound Care Nurse (WCN), the WCN stated she assessed Patient A at 10:00 AM on Friday June 24, 2022. No skin discoloration or redness was seen initially on the left hand and abdomen, but when she reassessed Patient A between 3:00-4:00 PM, she saw blistering on the left hand, but nothing on the abdomen. However the, WCN admitted she did not document her findings. The WCN also stated, she was aware of the Silvadene cream order and assumed it was acquired from the pharmacy. WCN also stated, the physician ordered the Silvadene cream to "probably granulate and prevent burn." During an interview on July 6, 2022, at 2:35 PM with LVN3, LVN 3 was asked about her assessment on Patient A's injuries, and she stated, "Yes, I knew it was a burn." LVN 3 stated she did not document her assessment as burns because it "didn't seem like it was at that time," however, when she re-assessed Patient A, she stated she saw small blister like areas forming on the Patient A's left lower abdomen. During a concurrent interview and record review on July 6, 2022, at 2:10 PM with the Director of Nursing (DON), NC- Licensed Nurse Record COC v 1.1 dated June 25, 2022, (7:00 AM - 3:00 PM shift) and (3:00 PM-11:00 PM shift) was reviewed. The NC - COC v 1.1 indicated LVN 4 observed Patient A's left-hand burn was swollen and red. The DON stated "LVN 4 took it upon herself to document it was a burn and there was no documentation that she called the physician." While LVN 5 (registry nurse) observed Patient A's burn to the abdomen and left-hand wrist was swollen, the DON stated "there was no documentation that she called the physician." During a continued interview and record review on July 6, 2022, at 2:10 PM, with the DON, the facility policy titled, "Policy: Change of Condition," (undated) was reviewed. The policy indicated, "Definition: A change of condition is a sudden or marked difference in resident's: ...12. Bruises, lacerations, blister, rashes, or skin tears. 13. Skin condition (e.g., swelling or discoloration) ...Content: C. Upon Change in Condition for any reason, nursing staff members are to take the following actions ...b. Physician shall be called promptly." DON stated her staff did not follow the policy. Conclusion: In violation of the above cited standards, the facility failed to: 1. Identify Patient A's care needs based on the initial written and continuing assessment of the status of Patient A's wounds from the scalding burn to his left hand, wrist, and the left side of his abdomen. 2. Notify the physician when there was a sudden change in Patient A's skin condition related to the scalding burns to his left hand, wrist, and the left side of his abdomen. 3. Review, evaluate, and update the patient care plan when there was a change in Patient A's burns to include blisters, swelling and skin peeling. 4. Administer the Silvadene cream (a medication used to prevent infections in burns) in a timely manner in accordance with physician's order, which presents a risk to the patient's health. 5. Follow its policy and procedure titled "Policy: Change of Conditions," when multiple nurses failed to call a physician upon Patient A's change of condition. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.