Other·July 26, 2024

California Code of Regulations, Title 22, section 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: (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 Regulations, Title 22, section 72523 Patient Care Policies and Procedures. (a)Written patient care and 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 (b) (1) 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; and (ii)A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. It was determined based on interview and record review, the facility failed to conduct a consistent weekly skin assessment to evaluate the changes in Patient 2’s redness to the coccyx (tailbone) identified on admission to the facility. In addition, the facility failed to initiate and provide treatment for Patient 2's redness to the coccyx upon admission. These failures resulted in Patient 2's redness to the coccyx to worsen into a Stage 3 pressure injury (full thickness tissue loss). According to the National Pressure Injury Advisory Panel article titled, “NPIAP Pressure Injury Stages (NPIAP- an independent professional organization dedicated to the prevention and management of pressure injuries) “…Stage 1 pressure injury: Non-blanchable erythema of intact skin…Stage 2 pressure injury: Partial thickness skin loss with exposed dermis…The wound bed is viable, pink or red, moist, and may present as an intact or ruptured blister…Stage 3 pressure injury: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead cells that accumulate in the wound exudate) and/or eschar (dead tissue that sheds or falls off from the skin) may be visible…Deep Tissue Injury (DTI): Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood blister…” On May 20, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. A review of Patient 2’s medical record titled, "Admission Record,” indicated the patient was an 86-year-old female, admitted to the facility on April 26, 2024, with diagnoses which included fractured (break in continuity of bone) left patella (kneecap), and was discharged from the facility on May 20, 2024, for a left hip replacement surgery. A review of Patient 2’s admission skin assessment, conducted by the admission nurse, dated, April 26, 2024, indicated the patient had redness to the coccyx on admission to the facility. A review of Patient 2’s Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), Section M-Skin Condition, dated May 2, 2024, did not reflect any skin impairment for Patient 2. The MDS assessment did not reflect the redness in the coccyx area of Patient 2 which was observed during admission to the facility on April 26, 2024. A review of Patient 2’s admitting physician orders in April 2024, did not indicate any treatment for redness on the patient’s coccyx. A review of Patient 2’s Treatment Administration Record (TAR) for April 2024, indicated Patient 2 was not receiving wound care treatment for redness on Patient 2's coccyx area. On May 20, 2024, at 3 p.m., an interview was conducted with Treatment (Tx: wound care) Nurse 1. Tx Nurse 1 stated a referral would be made for patients and would be evaluated by the Wound Care Specialist (WCS) Nurse Practitioner, if a patient was found to have skin impairments. In addition, she (Tx nurse) was expected to complete skin assessments weekly on each patient with pressure injury. On May 21, 2024, at 1:22 p.m. a concurrent interview and record review was conducted with Tx Nurse 1. Tx Nurse 1 verified there was no weekly skin assessment completed for Patient 2. On May 21, 2024, at 1:40 p.m., a concurrent interview and record review was conducted with the DON, and she stated the following: a. During admission, the admission nurse would complete skin assessment, followed by another skin assessment to be completed by the Tx Nurse, which would include the measurement and staging of the pressure injury; b. The Tx Nurse would notify the physician if there were skin impairment and would be responsible in transcribing the treatment orders and initiating the treatment for the patient; c. The Tx Nurse did not conduct Patient 2’s skin assessment on admission and there was no treatment provided to Patient 2’s reddened coccyx (in addition to the skin assessment completed by the admission nurse); and d. The DON’s expectations were for nursing staff to report the skin assessment findings to the physician, obtain treatment orders, document, and carry out the physician orders. A review of Patient 2’s weekly assessment did not indicate a weekly skin assessment was completed for Patient 2's pressure injury on the coccyx area, after admission on April 26, 2024, to reflect the reddened coccyx and its status. A review of Patient 2’s medical record titled, “Changes of Condition (COC) progress note," dated, May 9, 2024, at 1:35 p.m., indicated, “…(Patient 2) has a wound on her bottom, (Registered Nurse- RN) measured 3 X 1 cm. DTI to the coccyx area…” The COC progress notes further indicated, “…(Physician) responded with the following…(order)…cleanse with normal saline, pat dry, apply collagen (skin protectant) to wound and cover with dry dressing…” A review of Patient 2’s physician orders for the month of May 2024, indicated no treatment orders for Patient 2's DTI on the coccyx. There was no documentation reflecting the treatment plan for the DTI, as indicated in the COC progress notes dated May 9, 2024. A review of Patient 2’s TAR for May 2024, did not reflect wound treatment was provided for the patient's DTI to the coccyx identified on May 9, 2024. Further review of records did not indicate weekly skin assessment to reflect the progress of the DTI on Patient 2’s coccyx, since it was identified on May 9, 2024. A review of Patient 2’s WCS skin assessment, dated May 16, 2024, indicated, “…(Left) Ischium (anatomical term for the V-shaped bone at the bottom of the pelvis that contacts a surface when a person is sitting down) (Stage) 3 (measuring) 0.6 X 0.8 X 0.2 cm w/ (with) odor, signs & symptoms (S/S) of infection, c/o pain…Tx order recommendations: cleanse with normal saline, honey (skin protectant), cover with Alginate, daily." A review of Patient 2’s physician orders, dated May 16, 2024, indicated, “…Cleanse left ischium with Normal saline, pat dry, apply honey and alginate, cover with dry dressing. Every day shift…” A review of Patient 2’s TAR, for May 2024, indicated, the patient began receiving treatment for the Stage 3 on the left ischium on May 17, 2024, until discharge on May 20, 2024. On June 5, 2024, at 9:20 a.m., a concurrent interview and record review of Patient 2's medical records was conducted. The DON reviewed the admission skin assessment, the change of condition progress notes dated May 9, 2024, and the WCS skin assessment dated May 16, 2024. The DON verified the patient’s ischium wound noted by WCS which was a Stage 3 would be referring to the coccyx identified with redness on admission (April 26, 2024) which later became a DTI on May 9, 2024. On June 5, 2024, at 12:12 p.m., during an interview, Tx Nurse 2 stated if there was a change of condition related to skin, the Tx nurse would assess the skin impairment, notify the physician of the findings, obtain treatment (Tx) orders (if any), then transcribe the Tx orders into the patient’s medical record. Tx Nurse 2 verified she assessed and identified the DTI on Patient 2’s coccyx area and completed a change of condition progress notes on May 9, 2024, and she received treatment orders from the physician. Tx Nurse 2 stated she did not transcribe the Tx orders into Patient 2’s medical records, which delayed the provision of treatment to the patient’s DTI on the coccyx. (subsequently would be the direct proximate cause of the worsening of the pressure injury). On June 5, 2024, at 3:50 p.m., a concurrent interview and record review was conducted with the MDS Nurse. The MDS Nurse verified she did not identify Patient 2's skin impairments during the admission assessment. The MDS nurse stated redness was not considered a wound. The MDS nurse further stated she did not verify with the admission nurse if the redness on Patient 2’s coccyx area was blanchable (redness that disappears on with applied pressure – indicating healthy skin) or non-blanchable (redness that does not disappear with applied pressure – indication Stage 1 PI). A review of the facility Policy & Procedure (P & P), titled, “Wound Care,” revised, October 2010, indicated, “…Wound Care…Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing…Preparation: 1. Verify that there is a physician’s order for this procedure 2. Review the resident’s care plan to assess for any special needs of the resident…Documentation: The following information should be recorded in the resident’s medical records: 6. All assessment data (i.e., wound bed, color, size, drainage, etc.) obtained when inspecting the wound…Reporting: 2. Report other information in accordance with facility policy and professional standards of practice…” A review of facility P & P, titled, “Resident Examination and Assessment,” revised, February 2014, indicated, “…Purpose…is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan…review the resident’s admission assessment and/or preliminary care plan to assess for any special situations regarding the resident’s care…8. Skin…e. presence of pressure sores, redness…Documentation…3. All assessment data obtained during the procedure…Reporting…Notify the physician of any abnormalities such as, but not limited to…e. Wounds or rashes on the resident’s skin…3. Report information in accordance with facility policy and professional standards of practice…” A review of the facility P & P, titled, “Comprehensive Assessments and the Care Delivery Process,” revised December 2016, indicated, “…Comprehensive assessments will be conducted to assist in developing person-centered care plans…Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions…Monitoring results and adjusting interventions includes: a. Periodically reviewing progress and adjusting treatments…Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals…Completed assessments…are maintained in the resident’s active record...These assessments are used to develop, review, and revise the resident’s comprehensive care plan…” A review of the facility P & P, titled, “Medication and Treatment Orders,” revised, July 2016, indicated, “…7. Verbal orders must be recorded immediately in the resident’s chart by the person receiving the order and must include…the date and time of the order…9. Orders…must include b. Number of doses, start, and stop date, and/or specific duration of therapy…” The facility failed to conduct a consistent weekly skin assessment to evaluate the changes in Patient 2’s redness to the coccyx identified on admission to the facility. In addition, the facility failed to initiate and provide treatment for Patient 2's redness to the coccyx upon admission. These failures resulted in Patient 2's coccyx redness to worsen into a Stage 3 pressure injury. These violations presented, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result.