Health inspection·December 19, 2024

Community Care and Rehabilitation Center Class A Citation Event ID: 2JJU11 California Code of Regulation Title 22, Section 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 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). California Code of Regulation, Title 22, Section 72523(a) – 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 Regulation § 483.25 Treatment/Services to Prevent/Heal Pressure Ulcers 483.25(b) Skin Integrity 483.25(b)(1)(i) Pressure Ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that— (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable. On October 22, 23, and November 4, 2024, unannounced visits to the facility were conducted to investigate a complaint. It was determined that the facility failed to ensure facility practices were in place to prevent and identify the development of a pressure injury (PI - bed sore, decubitus ulcer) for Patient 1, when an open area of the skin on Patient 1’s sacrum (a large, triangular bone at the base of the spine; tailbone area) identified on August 30, 2024, was not assessed and was not provided treatment. These failures resulted in Patient 1 developing a stage 3 PI (full -thickness tissue loss, exposing fat tissue) on the sacrum which was identified on September 13, 2024. A review of Patient 1's admission record on October 22, 2024, indicated Patient 1 was an 85-year-old female admitted to the facility on June 19, 2021, with diagnoses which included paraplegia (inability to move the lower parts of the body), post-polio syndrome (a condition that causes gradual muscle weakness and muscle loss that can affect people who have had polio-polio a virus that causes paralysis), bullous pemphigoid (a rare skin condition that causes blisters on the skin), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life ). A review of Patient 1's care plan titled, "#16 CAA: PRESSURE INJURY/ULCER," dated June 23, 2021, indicated, "...The resident (patient) has potential/actual for pressure injury development/worsening r/t (related to) disease process...limited mobility, incontinence (no control of bowels and/or bladder), episodes of refusing showers, episodes of scratching/picking skin and episodes of refusing to have fingernails trimmed, refusal to get OOB (out of bed), prefers to be positioned in bed in high fowler's (head of the bed raised up to 90 degrees) while awake placing resident at risk for shearing (occurs when the skin moves in one direction while the tissue underneath moves in another)..." The care plan goal dated November 1, 2021, with June 21, 2024, as the latest revision date, indicated, "...The resident will have intact skin, free of redness, blisters, or discoloration by/through review date...Target Date: December 10, 2024." The care plan interventions included, "...administer medications as ordered...educate the resident as to causes of skin breakdown; including transfer/positioning requirements...encourage resident to shift weight in bed as necessary for pressure relief...monitor/document/ report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage..." A review of Patient 1's "History and Physical," dated June 7, 2024, indicated Patient 1 can make needs known but cannot make medical decisions. A review of Patient 1’s "Braden Scale for Predicting Pressure Ulcer," dated June 21, 2024, indicated she was at high risk for developing PI. During an interview with Certified Nurse Assistant (CNA) 1 on October 22, 2024, at 12:28 p.m., CNA 1 stated the patients’ skin condition is monitored every day when their briefs are changed and during showers; and that newly skin condition concerns are reported to the charge nurse. CNA 1 stated Patient 1 required total care, two-person-assist with most ADLs (activities of daily living), was incontinent, and she often refused care. CNA 1 stated Patient 1 had a wound on her buttocks area that "looked and smelled very bad." CNA 1 stated she was not sure when Patient 1 developed the wound. During an interview with Licensed Vocational Nurse (LVN) 1 on October 22, 2024, at 12:58 p.m., LVN 1 stated the CNAs would report abnormal skin conditions to the licensed or the treatment nurses (TXN) and would document on the shower sheets. During an interview with TXN 1 on October 22, 2024, at 1:44 p.m., TXN 1 stated patients are assessed for risks of developing skin conditions upon admission. TXN 1 stated the facility conducted skin sweeps where all patients are checked for their current skin condition. TXN 1 stated Patient 1 had a stage 3 PI identified on September 13, 2024, and it did not make sense to her that the PI was at a stage 3 when it was initially identified. TXN 1 stated there were different CNAs assigned to patients for each shift and someone should have noticed something. During a concurrent interview and record review on October 23, 2024, at 1:09 p.m., TXN 2 stated the following: a. The facility conducts skin sweeps weekly or biweekly, depending on staff availability. b. The skin inspection (shower sheet) dated August 10 and August 30, 2024, indicated Patient 1's skin was not intact and a skin problem was identified by the CNA on the buttocks area and sacral area. c. The physician's orders, progress notes, and Treatment Administration Record (TAR), for August 2024, did not have documentation reflecting Patient 1’s skin issues identified on August 10 and August 30, 2024. Also, the TAR did not reflect treatment was initiated. d. A skin sweep was conducted on September 13, 2024, when Patient 1's stage 3 PI on the sacrococcyx extending to the right buttock was discovered. A review of Patient 1's weekly summaries on October 23, 2024, indicated a weekly summary was not completed on August 31, 2024, to reflect the status of the skin issue on the sacral area identified on August 30, 2024, during skin inspection. During an interview and concurrent record review with the Director of Nursing (DON) on October 23, 2024, at 4:16 p.m., the DON stated the CNAs checked the patients’ skin when they change them and during showers. The DON stated the CNAs would use shower sheets to document any skin issues and they would verbally communicate any skin issues with the LVNs. The DON stated when CNAs report skin issues, the charge nurse would need to look at the patient and verify the skin issue. The DON stated if the skin issue was verified, the charge nurse communicates with the TXN so that the TXN can re-evaluate the patient. The DON stated the TXNs conducted a skin sweep for all patients monthly to ensure that no skin issue was missed. The DON stated the TXN conducted weekly skin evaluation, and the charge nurses conducted weekly summary where the patients’ skin is assessed as well. The DON verified that Patient 1 did not have a weekly summary for August 24 and 31, 2024. The DON stated the nurses should be conducting their weekly summaries to document a summary of the patients’ condition. On November 4, 2024, at 11:28 a.m., during a concurrent interview with CNA 2 and a review of Patient 1’s "Skin Inspection" dated August 30, 2024, CNA 2 stated it was her signature on the document and she identified Patient 1 had redness on her right arm and a small open wound on her sacral area. CNA 2 stated she reported her findings to the charge nurse and treatment nurse that same day (August 30, 2024). A review of the "Skin Only Evaluation," dated September 13, 2024, indicated Patient 1 was noted with a stage 3 (full-thickness loss of skin tissue that appears as a crater-like sore, with dark patches of skin around the edges) pressure injury on her Sacro coccyx (tailbone area) extending to the right buttock after conducting a skin sweep. The wound measured 5.5 cm (centimeters; length) x 2.5 cm (width) x 0.2 cm (depth), the wound bed was 80% slough (yellow/white material on the wound bed) and 20% granulation tissue (a new connective tissue that forms in a wound during the healing process) with minimal serous drainage (clear fluid that leaks out of wounds), peri (around) wound is erythematous (inflamed skin). A review of Patient 1's physician's orders, dated September 14, 2024, indicated a treatment order of "...Wound type: Stage 3 PI Wound site: Sacro coccyx Cleanse with: NS (normal saline), Pat dry Apply Santyl (an ointment) and Collagen (helps with wound healing), cover with foam dressing every day shift for Wound Healing for 30 days..." A review of Patient 1’s progress notes and TAR for September 2024 indicated Patient 1 did not receive treatment to the wound until September 15, 2024. A review of Patient 1's "(name of wound specialist) Progress Notes," dated September 26, 2024, indicated the sacrococcyx PI was reclassified to stage 4 (full thickness skin and tissue loss that exposes muscle, and bone). During an interview with TXN 2 on November 4, 2024, at 11:55 a.m., TXN 2 stated when patients were identified with a wound, she would contact the doctor, contact the family, and would write a treatment order following the facility wound treatment protocol, the day the wound was identified. TXN 2 verified Patient 1's wound treatment was ordered on September 14, 2024 (one day after the PI was discovered), and the TAR indicated Patient 1 received treatment to the wound on September 15, 2024 (two days after the PI was discovered). On November 4, 2024, at 1:44 p.m., during an interview with Registered Nurse (RN) 1, who was the Minimum Data Set (MDS - an assessment tool) Coordinator, RN 1 stated the interventions for patients identified as at risk for developing a PI include repositioning, encourage the patient to get out of bed as tolerated, provide moisture barrier cream, peri care, and a pressure reducing mattress. RN 1 stated all patients in the facility are provided with a pressure reducing mattress. RN 1 stated interventions for patients who are moderate and high risk for developing a PI would be the same for those who are at risk because once a patient is identified as at risk for developing a PI, the facility implements all interventions right away to prevent the development of a wound. RN 1 stated CNAs are trained to reposition patients every two hours and it was part of their daily routine. However, RN 1 stated the CNAs do not document turning and repositioning of the patients. On November 12, 2024, at 10 a.m., during a telephone interview with the Director of Staff Development (DSD), the DSD stated when licensed nurses signed the "Skin Inspection" sheet, they acknowledged the wound or any skin issues reported by the CNA, and the licensed nurses should notify the physician and get a treatment order. A review of the facility’s policy and procedure titled, "Skin Assessment," dated December 19, 2022, indicated, "...It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management...A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter...Documentation of skin assessment...Include date and time of the assessment,.. name, and position title...Document observations...type of wound...describe wound...document if resident refused assessment and why...other information as indicated or appropriate..." A review of the facility's policy and procedure, titled, "Pressure Injury Prevention and Management," dated December 19, 2022, indicated, "...the facility shall establish and utilize a systematic approach for pressure injury and prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate...licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale for Predicting pressure Ulcer Risk, on all residents(patients) upon admission/re-admission, weekly time 3 (sic) more weeks, then quarterly or whenever the resident's condition changes significantly...licensed nurses will conduct a full body skin assessment at least weekly after admission/re-admission. Findings will be documented in the medical record...Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task...after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions...basic routine care interventions could include, but are not limited to: redistribute pressure...minimize exposure to moisture and keep skin clean...provide appropriate pressure-redistributing, support surfaces...provide non-irritating surfaces; and... maintain or improve nutrition and hydration status, where feasible..." As a result of the investigation, it was determined that the facility failed to ensure facility policy and procedures were implemented to prevent and identify the development of a pressure injury for Patient 1, when an open area of the skin on Patient 1’s sacrum on August 30, 2024, was not assessed and was not provided treatment. As a result of these failures Patient 1 developed a stage 3 PI (full -thickness tissue loss, exposing fat tissue) on the sacrum which was identified on September 13, 2024. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.