Other·July 10, 2025

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. It was determined that the facility failed to: a. Assess the blister on Patient 3’s right elbow when initially identified on April 13, 2025; b. Notify the physician of the right elbow blister identified on April 13, 2025; c. Provide treatment for Patient 3’s right elbow blister when initially identified on April 13, 2025. These failures resulted in the worsening of Patient 3’s right elbow blister to a stage 4 PI (pressure injury-full thickness skin loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). On April 23, 2025, at 9:34 a.m., during an interview with Patient 3 in her room, Patient 3 stated she had wounds on her right elbow and left heel which she acquired in the facility. On April 23, 2025, at 10:38 a.m., during a concurrent wound care observation for Patient 3 and interview with Treatment Nurse (TN) 1 and Licensed Vocational Nurse (LVN) 3, TN 1 stated Patient 3 had a stage 4 PIs on her right elbow and left heel. Patient 3's right arm was offloaded on a rolled bed sheet. Patient 3 had an open wound on her right elbow, circular in shape, which measured approximately three centimeters (cm-a unit of measurement) in length and three cm in width, the wound bed was pink, and the bone was exposed. On April 23, 2025, at 12:55 p.m., during an interview, TN 1 stated he received a report from a Certified Nurse Assistant (CNA) on April 15, 2025, that Patient 3's right elbow was wrapped with a bandage. TN 1 stated he assessed Patient 3's right elbow after he removed the bandage and noted that Patient 3 had a stage 4 PI on her right elbow. TN 1 stated if Patient 3's right elbow was wrapped when she was re-admitted to the facility on April 13, 2025, the staff should have assessed the skin underneath the bandage. A review of the General Acute Care Hospital (GACH) Notes indicated the following: a. Wound Nurse Record, dated April 10, 2025, the patient has a history of chronic wounds, and had PIs on the right buttock, left buttock, coccyx, right first toe, left heel, and purple bruising on BUE (bilateral upper extremity) with no open skin. b. PA (Physician Assistant)/NP (Nurse Practitioner) Progress notes, dated April 13, 2025, discharged. Further review did not indicate an open area in the right elbow. A review of Patient 3's Skilled Nursing Facility (SNF) "Nursing Admission Assessment," dated April 13, 2025, indicated Patient 3 had a pressure injury on the following sites: coccyx, right heel, and left heel. The admission assessment also indicated that the patient had bruising on the left hand and right hand. The document did not indicate skin issue(s) on the patient's right elbow area. Further review of the admission assessment included the Braden Skin Risk Scale & Skin Assessment which indicated the following: a. Sensory Perception: Ability to respond meaningfully to pressure-related discomfort- 4. No impairment (responds to verbal commands). b. Moisture: Degree to which skin is exposed to moisture. - 1. Constantly Moist (skin is kept moist almost constantly by perspiration, urine). c. Activity: Degree of physical activity- 2. Chairfast (ability to walk is severely limited or nonexistent). d. Mobility: Ability to change and control body position- 1. Completely immobile (does not make even slight changes in body or extremity position without assistance). e. Nutrition: Usual food intake pattern- 3. Adequate (Eats over half of most meals). f. Friction and Shear - 1. Problem (Requires moderate to maximum assistance in moving). A review of the Braden Skin Risk Assessment Scale dated April 13, 2025, has a total score of 12, which meant the patient is at high risk of developing pressure injury. On April 24, 2025, at 3:22 p.m., during a concurrent interview with Registered Nurse (RN) 4 and record review of Patient 3's medical record, RN 4 stated she was familiar with Patient 3. RN 4 stated Patient 3 was re-admitted to the facility on April 13, 2025, and she stated the Patient's right elbow was wrapped with kerlix and an ACE bandage (compression bandage). RN 4 stated Patient 3's right elbow had a blister on it, the size of a ping-pong ball. RN 4 stated she did not document it because the blister was intact. RN 4 stated she should have documented the presence of the blister, notified the doctor and she should have obtained a treatment order for the right elbow blister. A review of the “Order Summary Report,” active orders as of April 23, 2025, did not indicate any treatment orders for the blister on the right elbow, observed during re-admission on April 13, 2025. On April 25, 2025, at 12:20 p.m., during an interview, RN 3 stated the licensed nurses are expected to assess patients from head to toe, upon admission or re-admission, and document skin issues. RN 3 stated if the assessment was not documented then it was not done. RN 3 stated RN 4 should have unwrapped Patient 3's bandage on the right arm, conducted an assessment, measured the pressure injury, notified the doctor, obtained a treatment order and documented in Patient 3's medical records. RN 3 stated wound care should have been provided to prevent the wound from worsening. On May 12, 2025, at 10:50 a.m., during a telephone interview, LVN 5 stated she was familiar with Patient 3. LVN 5 stated she was the TN after Patient 3 returned from the hospital. LVN 5 stated Patient 3's right arm was wrapped and had a sling, but Patient 3 did not want her to check her right elbow. On May 12, 2025, at 12:18 p.m., during an interview, TN 2 stated every licensed nurse should be able to document and describe any skin problems they identified, notify the doctor and obtain a treatment order. TN 2 stated it was important to document skin assessments to keep track of the progress of any wounds. On May 12, 2025, at 1 p.m., during an interview, the Director of Nursing (DON) stated if Patient 3 had a blister on her right elbow when she was re-admitted, there should be an assessment, a treatment order, and a care plan. The DON stated a blister is treated by cleaning with normal saline, patted dry and a dressing placed over it to protect it from popping. A review of Patient 3's “Order Summary Report,” active orders as of April 23, 2025, indicated, "Right Elbow stage 4 pressure injury: Cleanse with Normal Saline, pat dry with gauze, apply MEDIHONEY (medical grade honey) AND CALCIUM ALGINATE (highly absorbent wound dressing), pad with ABD and wrap with kerlix for 21 days and PRN (as needed) for soiled or dislodged dressing...Start date 4/15/2025 (2 days after admission)..." A review of the facility's policy and procedure titled, "Initial Nursing Assessment and Re-Assessment," dated August 2019 indicated, "...It is the policy to assess residents upon admission and re-admission to the facility...upon admission, the licensed nurse will conduct a head to toe assessment of resident...Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition...All data collected shall be recorded in the nursing assessment record and shall be available to all disciplines involved in the care of the patient..." A review of the facility's policy and procedure titled, "Skin Breakdown, Prevention and Management," dated December 2017 indicated, "...Upon admission or when a resident is identified to have a non-pressure skin discoloration or skin breakdown, the licensed nurse will contact the attending independent licensed practitioner...for any sites or area that requires any form of treatment...The licensed nurse assigned to the resident will assess, evaluate and initiated a change of condition nursing documentation...Initial wound assessment will be documented on the nursing admission assessment..." As a result of the investigation, it was determined that the facility failed to: a. Assess the blister on Patient 3’s right elbow when initially identified on April 13, 2025; b. Notify the physician of the right elbow blister identified on April 13, 2025; c. Provide treatment for Patient 3’s right elbow blister when initially identified on April 13, 2025. These failures resulted in the worsening of Patient 3’s right elbow blister to a stage 4 PI. 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.