Other·October 11, 2023

California Code of Regulations, Title 22, section 72311. Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, section 72523 (a) 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. Code of Federal Regulations, Title 42, 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. It was determined based on observation, interview, and record review; the facility failed to provide consistent wound treatment for Patient 1's open wound on the left side of the forehead. In addition, the facility failed to reassess and monitor weekly the status of the open wound on Patient 1's forehead. These failures resulted in the Patient 1's wound on the left forehead to deteriorate as evidence by maggot infestation (parasitic skin infestation caused by the larvae [maggots]of certain fly species) on May 20, 2023; and the patient had to be transferred to the general acute care hospital (GACH) for evaluation. In addition, the patient was diagnosed with cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) to the left forehead open wound (the area infested with maggot) while at the GACH on May 20, 2023. On May 23, 2023, at 10:20 a.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Patient 1's facility admission notes, dated October 6, 2022, at 12 p.m., indicated the patient was admitted to the facility with a head wound measuring four x (by) six. The admission notes further indicated the patient was admitted with melanoma (skin cancer typically appears as a brown or black raised lump with dark, irregular colors and borders). A review of Patient 1's care plan titled, "Actual Alteration in Skin: Related to squamous cell carcinoma (type of skin cancer)," dated October 6, 2022, indicated, "Interventions... Inspect skin weekly and PRN (As needed); Report lack of progress toward healing after two weeks to MD (medical doctor) & change treatment as ordered ... Educate resident regarding consequences of non-compliance behavior ..." A review of Patient 1's progress notes dated March 8, 2023, indicated, " Physician notified of worsening large skin lesion to left (L) side forehead. Wound is malodorous, yellow/brown with uneven boarders. New orders (N.O.) received to transfer resident to (name of GACH) emergency room (ER) for evaluation..." A review of Patient 1's physician order dated March 8, 2023, indicated the physician gave an order for the patient to be transferred to the GACH for non-healing forehead lesion (any damage or abnormal change in the tissue of an organism). A review of Patient 1's consultation physician assessment from the GACH dated March 8, 2023, at 1:49 p.m., indicated, "...brought in from the nursing home for a chronic draining wound (skin wound not healing) on the forehead. The patient states that it's been present for about a year and that he does not have a diagnosis as to the etiology ... Physical Examination...on the forehead there is approximate 7 x (by) 4 cm. (centimeters)...exudative (has drainage seeping out of the wound) and not purulent (pus)...He has multiple other small lesions on his head..." A review of the physician order dated April 4, 2023, indicated Patient 1 would have a surgery on April 5, 2023, for debridement (removal of damaged tissue from a wound) of the open wound located on the left side of the forehead. A review of the dermatologist's (medical practitioner specializing in the diagnosis and treatment of skin disorders) notes from the GACH dated April 5, 2023, indicated Patient 1 had his forehead wound assessed by the dermatologist, and came back with treatment orders for, "... Saline (mixture of sodium chloride and water used to clean wounds) moist to dry 4 x (by) 4 gauze dressing (Twice a day) ...Bacitracin/Neosporin (topical medication used to treat minor skin injuries, including cuts, scrapes, and burns) and Dry 4 x 4 after washing head, every (day)... (Follow-up dermatologist visit) next month ..." A review of Patient 1's skilled nursing facility progress notes titled, "Skin Wound Progress Report," related to the patient's open wound on the left forehead indicated the following: a. April 6, 2023, "...size: 4 x 4; color of drainage: yellow; wound bed: red; no undermining (separation of the wound edges from the surrounding healthy tissue) and no tunnelling (wound extends deeper into the tissue) ..." b. April 12, 2023, " size: 4 x 5; color of drainage: yellow; wound bed: red; no undermining and no tunnelling..."; and c. April 19, 2023, "... 4 x 4 (cm); color of drainage: none, wound bed: Pink; No undermining/tunneling ..." Further review of Patient 1's skin/wound progress notes for April 2023, indicated no other wound assessment was conducted after April 19, 2023. A review of Patient 1's Treatment Administration Record (TAR), dated April 2023, indicated Patient 1 received treatment of normal saline to the open wound on the left side of the forehead from April 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, and 17, 2023. The TAR indicated the patient did not receive treatment on April 10 and 18, 2023. Further review of the TAR dated April 2023, indicated Patient 1 did not receive treatment of normal saline for his open wound on the left side of the forehead after April 18, 2023. A review of Patient 1's "Nurses Treatment Notes," dated April 2023, indicated Patient 1 had refused treatment to the open wound on the left forehead on April 10 and 18, 2023. A review of Patient 1's "Nurses Treatment Notes," dated May 2023, indicated Patient 1 had refused treatment to the open wound on the left forehead on May 2, 2023. A review of Patient 1's a care plan titled, "Refusal of Care/Demanding of Staff," dated, November 2, 2022, indicated, "... Goal: Will not have a negative impact on medical status (related to) refusals of care ... Interventions... Keep head wound clean and covered at all times ...Educate resident related to the results of refusing ..." A review of Patient 1's dermatologist's follow-up notes dated May 4, 2023, at 2:30 p.m., indicated, "... Per RN (Registered nurse), refusing wound care, dressing changes ... (Diagnosis) Squamous Cell (Cancer) ... Recommend wound care if resident agrees; plastic surgery (surgical specialty involving restoration of a body or tissue defect) consult should resident become compliant; this will not heal without treatment..." A review of Patient 1's "Licensed Nurse Record," dated May 7 and 14, 2023; indicated, "...Skin: Please refer to the skin assessment and/or Weekly Wound progress report, for size/location, staging ... Open lesion ..." A review of Patient 1's "Skin Assessment and/Weekly Wound Record," for the month of May 2023, indicated no assessments on Patient 1's forehead open wound was documented on May 7, and 14, 2023. A record review of Patient 1's progress note, dated May 20, 2023, at 6:30 a.m., indicated, "... had maggots crawling on his head wound (open wound on the left forehead) ... multiple maggots were crawling in [sic] resident's head ... Resident (Patient 1) to be sent out to acute care hospital for evaluation..." A record review of Patient 1's GACH Admission/discharge note, dated May 20, 2023, at 2:50 p.m., indicated, "... Disheveled in appearance with large lesion on scalp oozing pus and has maggots crawling everywhere from his head ... multiple scrapes and has large lesion on forehead with lots of maggots eating his flesh ... Discharge (Diagnosis): Cellulitis (Skin infection) of scalp, Maggot infestation..." A review of Patient 1's skin/wound progress report on a cellulitis on the left forehead open wound dated May 20, 2023, indicated the wound was measured 6 x 5.5 x .5. A review of Patient 1's Physician's orders dated May 21, 2023, indicated," Cleanse cellulitis with maggot infestation left forehead, cleanse with normal saline (NS) and H2O2 (hydrogen peroxide-mild antiseptic used on the skin to prevent infection) important disinfectant and bleach and is currently manage (treatment) 50/50 mix (half normal saline and half hydrogen peroxide mixture). apply clean dry dressing Q evening x 14 days until 6/2/2023." On May 23, 2023, at 10:50 a.m., Patient 1 was observed lying in bed inside his room, with a bandage partially covering the left side of his forehead. Patient 1's head was observed to have a loose-fitting gauze, covering the wound on the left side of the forehead. In addition to the forehead open wound, Patient 1 was observed to have an uncovered open wound on top of his head. On May 23, 2023, at 11:12 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed removing Patient 1's bandage on the the patient's forehead, revealing a forehead open wound which appeared pink and granulated (roughened surface) with clear discharge. LVN 1 stated the weather had been hot and the inevitable happened. She stated Patient 1's forehead open wound got infested with maggots. LVN 1 further stated, Patient 1 went to the GACH on May 20, 2023, for wound debridement (removal of damaged tissue or foreign objects from a wound), after maggot infestation occurred on Patient 1's open wound on the left side of the forehead. On May 23, 2023, at 1:17 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Patient 1 was not receiving wound care treatments to the open wound on the forehead between the dates of April 19, 2023; and May 20, 2023; due to the patient's refusals of wound treatments. On May 24, 2023, at 1:45 p.m., during an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated on May 20, 2023, at approximately 5:30 a.m., CNA 1 saw maggots on Patient 1's forehead. CNA 1 further stated she reported the situation to the LVN (LVN 3), and the licensed nurse (LVN 3) called 911 for transport to the GACH emergency room. On July 21, 2023, at 4:46 p.m., an interview was conducted with the DON. The DON stated LVN 2 discussed the dermatologist's recommendation on May 4, 2023, with Patient 1 and a family member. The DON stated the patient and the family member refused treatments and she stated at that point the wound treatment for the patient's head was just not being done until the maggot infestation was discovered on May 20, 2023. On August 25, 2023, at 4:03 p.m., during an interview, the DON was asked on how often the treatment nurse conducted wound assessment. She stated the wound would be assessed daily during wound treatment; and the Treatment (Tx) Nurse would measure the extent of the wounds weekly. The DON stated the Tx Nurse would document the measurement of the wound and would conduct an assessment if further treatment was needed during the weekly wound assessment. However, there was no consistent weekly wound assessment completed for April and May 2023, since the patient would sometimes refuse wound treatment. A review of the facility policy and procedure titled, "Wound Care," revised December 2010, indicated, " ...6. Record in the resident's medical record the type of wound care given and the date and time the wound care was given. 7. Notify the supervisor if the resident refuses the wound care. 8. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer (an injury that breaks down the skin and underlying tissue) to the supervisor." It was determined based on observation, interview, and record review; the facility failed to provide consistent wound treatment for Patient 1's open wound on the left side of the forehead. In addition, the facility failed to reassess and monitor weekly the status of the open wound on Patient 1's forehead. These failures resulted in the Patient 1's wound on the left forehead to deteriorate as evidence by maggot infestation (parasitic skin infestation caused by the larvae [maggots]of certain fly species) on May 20, 2023; and the patient had to be transferred to the general acute care hospital (GACH) for evaluation. In addition, the patient was diagnosed with cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) to the left forehead open wound (the area infested with maggot) while at the GACH on May 20, 2023. This violation had a direct or immediate relationship to the health, safety, or security for Patient 1.