Other·January 26, 2023

Knolls West Post-Acute The following reflects the findings of the California Department of Public Health during a recertification survey GFZ311 Representing the Department, HFEN# 35183 State Citation B was written California Code, Health, and Safety Code - HSC 1424 (e)(1) Except as provided in paragraph (4) of subdivision (a) of Section 1424.5, class "B" violations are violations that the state department determines have a direct or immediate relationship to the health, safety, or security of long-term health care facility residents, other than class "AA" or "A" violations. Unless otherwise determined by the state department to be a class "A" violation pursuant to this chapter and rules and regulations adopted pursuant thereto, any violation of a patient's rights as set forth in Sections 72527 and 73523 of Title 22 of the California Code of Regulations, that is determined by the state department to cause or under circumstances likely to cause significant humiliation,indignity, anxiety, or other emotional trauma to a patient is a class "B" violation. A class "B" citation is subject to a civil penalty in an amount not less than one hundred dollars ($100) and not exceeding one thousand dollars ($1,000) for each citation. A class "B" citation shall specify the time within which the violation is required to be corrected. If the department establishes that a violation occurred, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. Title 22 of the California Code of Regulations s 72315. 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: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, 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). s 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. s 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. The facility was found to not follow the above regulations during a recertification survey from December 5, 2022, to December 13, 2022, when the following were identified regarding the care of Patient A and B's pressure ulcers: 1. The facility failed to implement its policy and procedure when it failed to document that Patient A, who had a Stage 4 pressure ulcer (a deep wound caused by prolonged pressure reaching the muscles, ligaments, or bones) on the sacrum (located above the tailbone) and a Stage 3 pressure ulcer (a deep wound caused by prolonged pressure that penetrates the top layers of skin and underlying tissue but not the bone or muscle) on the left hip, had been repositioned at least every two hours to prevent further pressure on the wounds. 2. The facility failed to implement Patient A's care plan which included assisting with turning or repositioning at least every 2 hours and as needed. 3. The facility failed to implement its policy and procedure when it failed to conduct a full assessment (which includes: Type of Ulcer, Location, Stage of Pressure Ulcer, Measurements, Non-viable tissue, Odor, Amount of Exudate [fluid], Type of Exudate, Wound bed, Description of surrounding skin/tissue, Description of wound edges, Progress towards healing, Nature and frequency of Pain and Signs of Infection) of a Deep Tissue Injury (DTI- a form of pressure ulcer. Pressure ulcers are localized areas of tissue damage that develop because of prolonged pressure on areas of bone that are close to the skin's surface) on Patient B's right heel at admission. 4. The facility failed to follow the physician's treatment order for the DTI on Patient B's heel for 64 days. 5. The facility, did not inform the wound care doctor of Patient B's DTI for 40 days. 6. The facility failed to implement its policy and procedure when it failed to conduct weekly wound assessments on Patient B for nine weeks. 7. The facility failed to implement its policy and procedure when the Registered Dietician (RD) did not include the DTI in Patient B's Nutritional Assessments from admission through November 9, 2022. As a result of these failures, Patients A and B, were placed at risk for infection, a decline in function (a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living), unnecessary pain and an increased risk of mortality (the state of being subject to death). Findings: On December 5, 2022, at 8:05 AM, the survey team entered the facility to conduct the annual recertification survey, Patients A and B had been selected during the initial tour. 1. A review of Patient A's "Admission Record"(contains demographic and medical information), undated, indicated Patient A was initially admitted to the facility on February 11, 2022, and readmitted October 20, 2022, with diagnoses that included metabolic encephalopathy (chemical imbalance in the brain), hemiplegia and hemiparesis following cerebral infarction (muscle weakness, inability to move one side of body as a result of blocked blood flow to the brain), dementia (a group of conditions affecting the ability to remember, think or make decisions), contracture of left and right knee (stiffening of the knee and inability to move the knee), blindness (inability to see), pressure ulcer of sacral region and pressure ulcer of left hip (localized damage to the skin on the hip). During a concurrent observation and interview on December 13, 2022, at 8:48 AM, with Patient A, who was lying in bed covered up with her legs turned to the right, Patient A stated she did not know how her wound developed or when it occurred, and the facility staff had not explained that to her. Patient A stated the treatment nurse puts a dressing on her wound, and she did not know if the wounds are getting better. Patient A stated the certified nursing assistant (CNA) would come twice a day to check the dressing on her wound. Patient A stated that she did not have pain in the wounds, but the wounds would sometimes itch and "I know I shouldn't scratch them." Patient A stated the certified nursing aides did not come in every two hours to assist with repositioning and that they used to come in more often but not so much anymore. Patient A was observed three times on December 13, 2022, at 8:48 AM, 10:30 AM, and 12:25 PM, and at all times she was lying in her bed, in the same position, on her back with legs turned to the right and under her blanket. A review of Patient A's "Braden Scale - For predicting pressure sore risk" (Braden scale is an assessment tool used to quantify a patient's degree of risk for developing a pressure ulcer based on the total of scores given in six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear), dated October 21, 2022, indicated Patient A was at high risk for pressure sore development with a score of 9 out of 23. (The lower the score, the increased risk for pressure sore development). A review of Patient A's "Long term care plan, Impaired skin/tissue integrity, chronic wound" (care plan) dated October 21, 2022, indicated the "plan/approach" included "assist with and/or encourage turning/repositioning at least every 2 hours and as needed." A review of Patient A's "MDS (minimum data set, a clinical assessment of all patients in nursing homes) 3.0 Section G" (MDS) dated November 18, 2022, indicated Patient A required total assistance (full staff performance every time) with one-person physical assist for bed mobility (how the patient moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). A review of Patient A's "IDT (interdisciplinary team- a group of clinical staff such as nursing, dietary, and activities), wound care committee" (IDT notes), dated November 11, 2022, indicated, "IDT recommendations" was to reposition/turn every 2 hours. During an interview with a Certified Nursing Assistant (CNA 2) on December 13, 2022, at 3:20 PM, CNA 2 stated she documented the cares she provided to each patient (cares outside of activities of daily living such as eating, bathing, and walking) in the "Nurse Assistant Additional Notes." CNA 2 stated every 2-hour turning was one of those cares she documented in the "Nurse Assistant Additional Notes." A review of Patient A's "Nurse assistant additional notes," was conducted. There was no documented evidence to show Patient A was turned or repositioned every 2 hours from October 20, 2022, through to December 13, 2022. During a review of the facility's policy and procedure titled, "Policy and Procedure on Pressure Ulcers," dated August 22, 2017, indicated, in section 1.8 "If bedbound, reposition every two hours; if chairbound reposition every hour." Section 5.3 indicated, "A resident [patient] who is dependent on staff for repositioning should have repositioning schedule to maintain skin integrity. Repositioning schedule may range from every 2 hours or more frequently depending on tissue tolerance." Section 5.7, indicated "Document implementation of repositioning schedule in the resident's [patient's] medical chart, e.g.,licensed progress notes, ADLS charting or medication administration record (MAR)." During an interview on December 13, 2022, at 5:06 PM, with the Director of Nursing (DON), the DON stated the intervention for pressure ulcers was expected to be every 2-hour turning and/or repositioning, which was not documented. The DON stated she made observations of [patients'] positions while lying in bed, throughout the day to ensure they were repositioned every two hours. The DON stated staff used a badge card to tell staff which way a [patient] should be facing at various times during the day while in bed. The DON stated that the CNAs and all staff have the same badge. The DON statedonly observations were completed, and there was no paper documentation to show that repositioning and/or every 2-hour turning was completed. 2. A review of Patient B's face sheet (a document that gives a summary of a patient's information), undated, indicated Patient B was admitted to the facility on September 27, 2022, with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), difficulty with walking, muscle weakness and lack of coordination. During an observation and interview with Patient B and her family member (FM 1) on December 5, 2022, at 11:23 AM, Patient B was in a wheelchair positioned beside her bed in her room, and FM 1 was sitting on Patient B's bed. FM 1 stated she found out that day Patient B had a blister on her right heel. Patient B's right ankle had a cushion fastened around the ankle and there was a sock on the right foot. FM 1 stated she was upset because it seemed Patient B had gone downhill since being admitted to the facility. FM 1 stated Patient B could no longer use the bathroom on her own, wore a diaper, and had a sore on her right foot. Patient B began to speak to FM 1, however Patient B's sentences did not make sense and did not relate to the subject being discussed. A review of Patient B's "Comprehensive Resident [(Patient)] Admission Assessment," dated September 27, 2022, indicated Patient B's skin was intact. Patient B's "Body Reassessment," dated September 28, 2022, indicated Patient B had a DTI to her right heel. The "Body Reassessment," did not indicate measurements of the DTI, condition, or appearance of the skin in and around the DTI, presence of pain or signs of infection if any. A review of Patient B's "ADL [(Activities of Daily Living)] Care Plan," dated September 28, 2022, indicated, Bed Mobility: extensive assist, Transfers: extensive assist, Walk in Room/Corridor: extensive assist and Locomotion On/Off Unit: extensive assist. "Pressure Ulcer/Skin Integrity Care Plan," dated September 28, 2022, indicated, "Pressure ulcers/skin breakdown, delayed/poor wound healing related to impaired mobility, impaired cognition, urinary incontinence and chairfast/bedfast most of the time." A review of Patient B's Long Term Care Plan titled, "Impaired Skin/Tissue Integrity, Chronic Wound," dated September 28, 2022, indicated, "Related to: DTI (R) [(right)] heel ... Plan/Approach: ... Assess and Document wound characteristics/dimensions initially, q [(every)] week and PRN [(as needed)] decline, Monitor wound progress; reevaluate wound Tx [(treatment)]/interventions q week and PRN, Use proper infection control procedures [(at)] all times to prevent cross contamination, Assess infection risk. Monitor for s/s [(signs and symptoms)] of wound infection and notify Dr. [(doctor)] ... Assess for pain [(secondary)] to wound or its treatment and manage appropriately, ... Monitor those dressings remain clean and intact between changes, replace PRN, ... Avoid pressure, friction, and shear to involved area(s) [(at)] all times, ... Suspend Feet/Heels(s) off bed surface w/ [(with)] pillow under calf as tolerated, ..." 3. A review of Patient B's treatment orders for the DTI indicated: a. September 28, 2022, "(R) heel DTI clnse [(cleanse)] c [(with)] NS [(normal saline)], pat dry, paint c iodine [(antiseptic)], cover c dry drsg [(dressing)], Qday [(every day)], x [(times)] 21 days, reeval [(reevaluate)] PRN [(as needed)]." b. November 4, 2022, "(R) heel blood filled blister. Cleanse c N/S, pat to dry. Apply betadine [(an antiseptic)], ABD [(abdominal)] pad & wrap c kerlix [(brand name)] wrap. Then re-eval x 21 days..." c. December 5, 2022, "D/C [(discontinue)] previous orders to R [(right)] heel ... [(change)] in etiology [(the cause of the condition)]. R heel st [(stage)] 3 PR [(pressure)] injury clnse c NS, pat dry, apply Medi Honey [(a brand name for an ointment that supports destruction of cells by their own enzymes, removal of damaged tissue and a moist wound healing environment)], cover c dry drsg, Qday & PRN x 21 days, then reeval." A review of Patient B's Treatment Administration Record (TAR) from September 28, 2022, to November 3, 2022, indicated Patient B's right heel DTI was being treated by cleansing with normal saline, patting dry, applying Medi Honey, and covering with dry dressing every day and as needed. Not per the order dated September 28, 2022, "(R) heel DTI clnse c NS, pat dry, paint c iodine, cover c dry drsg, Qday, x 21 days, reeval PRN." A review of Patient B's physician's orders did not indicate a Medi Honey treatment during this time period. Thirty-seven days passed without following the correct physician's order for wound treatment. A review of Patient B's Treatment Administration Record (TAR) from November 4, 2022, to November 30, 2022, indicated Patient B's right heel DTI was being treated by cleansing with normal saline, patting dry, applying Medi Honey, and covering with dry dressing every day and as needed. Not per the order dated November 4, 2022, "(R