Other·February 9, 2024

California Code of Regulations, Title 22, section 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 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. (2) Encouraging, assisting, and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (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. On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. As a result of the investigation, California Department of Public Health determined that the facility failed to: 1. Conduct a skin evaluation for Patient 1 on admission on October 2, 2023, in accordance with the policy and procedure titled, " Skin Management Guidelines," dated March 2022. 2. Developed interventions to address Patient 1's risk for pressure injury (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body) on admission. The patient was assessed to be at risk for developing pressure injury. 3. Initiate treatments for Patient 1's pressure injury on the right and left heel; sacrococcygeal (pertains to both the sacrum and the tailbone); and right buttocks identified on October 12, 2023, until October 17, 2023 (5 days after the pressure injuries were identified). These failures resulted in Patient 1 developing a Stage 2 pressure injury (partial thickness skin loss with exposed dermis) on the right and left heel, a Stage 2 pressure injury on the right buttock, and an unstageable pressure injury (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow/white material in the wound bed] or eschar [slough or piece of dead tissue that is cast off from the surface of the skin]) on the sacrococcyx area on October 12, 2023. In addition, the failure to promptly initiate treatments on October 12, 2023, resulted in Patient 1's pressure injuries worsening on the sacrococcyx, and right buttocks, 15 days after Patient 1's admission to the facility. A review of Patient 1's general acute care hospital (GACH)wound documents titled, "Wound Ostomy Continence Nurse Consult Note," indicated the following: a. On September 29, 2023, skin tear (separation of skin) to left elbow; and b. On September 30, 2023, skin tear to left arm. Further review of the GACH record titled, " Discharge Summary," dated October 2, 2023, at 5:05 p.m., indicated the patient had an incision site on the right hip. The discharge summary did not indicate Patient 1 had pressure injuries prior to being transferred to the skilled nursing facility (SNF) on October 2, 2023. A review of Patient 1's Admission Record Report at the SNF dated November 30, 2023, indicated Patient 1 was admitted to the facility on October 2, 2023, with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes) and thrombocytopenia (deficiency of platelets which causes bleeding in tissues, bruising and slow blood clotting after injury). A review of Patient 1's medical record did not indicate a skin evaluation on admission was completed on October 2, 2023. A review of Patient 1's Braden Scale for Predicting Pressure Score Risk assessment dated October 2, 2023, indicated a Braden Score (consists of six subscales and the total scores range from 6-23. A lower Braden scores indicates higher level of risk for pressure ulcer development) of 15, indicating Patient 1 was at risk for developing pressure ulcer. The risk assessment indicated the patient was occasionally moist, chairfast, has very limited mobility, adequate nutrition, and has a potential problem for friction/shear (force applied to the body tissues or parts that caused these tissues to move in opposite directions). A review of Patient 1's care plan titled, "At risk for alteration in skin integrity related to impaired mobility," initiated on October 2, 2023, did not indicate interventions addressing the risk for alteration in skin integrity. A review of Patient 1's medical record untitled which contained body assessment diagram for October 7, 2023 (5 days after admission), indicated a surgery site on the right hip, generalized discoloration on the right lower extremity, and discoloration on the waist area. The body assessment did not indicate pressure injuries on the sacrococcyx area, left and right heel, and right buttock. A review of Patient 1's Skin worksheet, dated October 12, 2023, indicated, an open skin to the sacrococcyx area. A review of Patient 1's Progress Notes dated October 12, 2023, (ten days after admission) by Registered Nursing Supervisor (RNS) indicated, " Certified Nursing Assistant [CNA] reported patient was displaying skin breakdown at the coccygeal region as well as bilateral heels. RN Supervisor examined lesions and established that coccygeal [ related to the short section of small bones at the base of the spine] lesion is unstageable decubitus [bed sore] with eschar with no bone or tendon visible. No undermining or tunneling [opening underneath the surface of the wounds] visualized. Patient reports no pain felt at site. Sacral [relates to the triangular-shaped bone at the base of the spine] dressing applied. Heel lesions are stage 2 with island dressings [gauze dressing for wounds] applied, heels elevated on pillow. Patient reports no pain at either heel." A review of the Order Summary report dated November 30, 2023, did not reflect treatment orders for the coccygeal region and bilateral heels skin breakdown observed by the RNS on October 12, 2023. A review of Patient 1's Shower Sheets dated October 13, 2023, 11 days after admission, indicated on the posterior (back) side of the body map a cross mark on the coccyx (small triangular bone at the base of the spine) and right and left heels. The worksheet did not indicate a description of the marked areas. A review of Patient 1's Progress Notes dated October 13, 2023, indicated the RNS and the wound nurse visited Patient 1 "to assess and treat decubiti." A review of the Physician Orders dated October 16, 2023, (4 days after the pressure injuries were documented as identified on October 12, 2023) indicated treatments for the following: 1. "Right heel pressure injury open wound, clean with NS or wound cleanser, pat dry, apply Medihoney (used to clean and debride acute and chronic wounds), cover with silicone foam dressing. Every day shift every 2 day(s) for 21 Days until finished, and as needed for when saturated/soiled/dislodged." 2. "Right buttocks pressure injury partial thickness open wound, clean with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. Every day shift every 2 day(s) for 21 Days until finished." 3. "Left heel pressure injury open wound, clean with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. Every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged." 4. "Sacrococcygeal pressure injury unstageable eschar, clean with NS or wound cleanser, pat dry, apply medhoney, cover with silicone foam dressing. Every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged." A review of Patient 1's Care Plan titled, "Pressure Ulcers," developed on October 16, 2023, indicated the following: Focus: "Resident has pressure ulcers at sacrococcygeal region and bilateral heels related to limited mobility." Goal: "Debridement of necrotic tissue [dead tissues]; Free from odor; Free from signs and symptoms of infection (such as increased drainage/pain/peri wound erythema [abnormal redness of the skin])" Interventions: "Administer treatment per physician orders; Daily body audit; Dietary consult; Friction reducing transfer surface." Further review of Patient 1's Progress notes dated October 17, 2023, (15 days after admission) by Registered Nurse (RN) 1 indicated, " Patient was admitted with unstageable pressure ulcer on sacrococcygeal and Pressure injury open wound on right and left heel stage 2...Wound # 1 Sacrococcygeal unstageable, wound bed 100 % covered with dark non-viable necrotic tissue, soft to touch, patient denies any sensitivity at time of inspection. Measures 8 x 4.5 cm., no depth...Wound # 2 Rt. buttocks stage 2, partial thickness open wound, shallow, pink wound bed, small amount of serosanguinous drainage [normal drainage of fluid from a wound]...wound size 3 x 2 cm shallow, peri wound slightly pink 1 cm. blanchable[skin color pales or changes]...Wound # 3 stage 2, rt. heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm. Wound # 4 left heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm..." A review of Patient 1's medical record which included: the physician's progress notes on October 4, 2023; the skin worksheet dated October 7, 12, and 13, 2023; and the care plan developed on October 2, 2023; did not reflect Patient 1 had the pressure injuries on admission as documented in RN 1's progress notes dated October 17, 2023. The order summary report dated November 30, 2023, did not include physician orders for treatment on Patient 1's pressure injury on sacrococcyx area, right and left heel, and right buttocks, contrary to what was indicated in the progress notes dated October 17, 2023. During a concurrent interview and record on November 30, 2023, at 1:59 p.m., RNS stated a skin assessment should be done as soon as a patient was admitted, and the assessment should be documented in the progress notes. RNS stated skin assessment for a newly admitted patient should be conducted weekly for four weeks. The RNS stated if a change in skin condition was noted, the floor nurse should document in the progress notes, notify the physician and the wound care team right away. The RNS stated Patient 1 did not come to the facility with pressure injuries. RNS acknowledged Patient 1's skin assessment was not done on admission. During a concurrent interview and record review on November 30, 2023, at 2:41 p.m., RN 1 stated once a pressure injury was identified, a low air loss mattress (a mattress designed to prevent and treat pressure wounds) should be ordered by the nurse after obtaining orders from the physician. RN 1 further stated the physician, the wound care team, the Director of Nursing (DON), and the Registered Dietician (RD) should be informed right away, along with the patient's family and rest of the team that a pressure injury was identified. RN 1 stated Patient 1 was not admitted with pressure injury on admission contrary to what was documented on the progress notes dated October 17, 2023. During an interview on November 30, 2023, at 3:20 p.m., the DON stated the policy and procedure in managing pressure injuries indicated if a patient was admitted with a pressure injury or developed a facility acquired pressure injury; a daily body audit, a care plan, wound treatment should be provided to the patients. She added, the physician and the patient's family should be notified of the status of the pressure injury. The DON stated the interventions for pressure injury included the following: to provide a low air loss mattress, scheduled turning /repositioning, float heels to relieve pressure and conducting daily rounds by the wound care team. The DON stated Patient 1's skin assessment should have been done within 24 hours of admission. The DON further stated a change in skin condition should be noted and reported to the physician, the wound nurse, the DON, and the patient's responsible party. During an interview on January 4, 2024, at 9:30 a.m., the Minimum Data Set nurse (MDS nurse) stated if a wound was present on admission, it should be reflected under Section M (Skin Conditions) of the MDS and from the documentation by the wound nurse. During an interview on January 4, 2024, at 3:40 p.m., Licensed Vocational Nurse (LVN) 2 stated Body Audits (skin worksheet) was checked and signed by the nurses after every shower. LVN 2 stated the result of the body audit would be documented in the computer under the patient's medical record. LVN 2 stated if there was a change in the patient's skin condition, it would be the responsibility of the charge nurse to notify the physician, the treatment nurse, the DON, the RNS and the patient's family and should be documented under the progress notes and skin assessment. LVN 2 stated Patient 1 did not have pressure injury on admission. She stated the skin assessment should be done within two hours of admission. LVN 2 stated if the patient needed dietary consult, it would be the responsibility of the charge nurse to call the physician to obtain an order for the consult. A review of Patient 1's medical record did not indicate a dietary consult was completed as indicated in the care plan developed on October 16, 2023. A review of Patient 1's progress notes titled," Change of Condition," dated October 18, 2023, indicated," ...Pt. (patient) had a hypotensive [characterized by low blood pressure] episode this morning. Attending physician present and evaluated pt. Physician orde