Other·February 15, 2023

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, section 483.25(b)(1) Treatment/Svcs to Prevent/Heal Pressure Ulcers (b) Skin Integrity. (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 that based on observation, interview, and record review, the facility failed to accurately assess and monitor Patient A's skin integrity underneath the right arm to prevent and/or treat pressure injury (the breakdown of skin integrity due to pressure), while using a sling immobilizer (a device used to support and keep still an injured part of the body). This failure resulted in the development of a Stage 4 pressure injury (a full thickness tissue loss with exposed bone, tendon, or muscle) on Patient A's right elbow area, while at the skilled nursing facility. In addition, Patient A was admitted to the facility on September 26, 2022, then discharged on October 25, 2022, without being identified of sustaining pressure injury on the right elbow area. According to the National Pressure Injury Advisory Panel (NPIAP - a nationally recognized organization) article titled, "NPIAP Pressure Injury Stages," a Stage 4 Pressure Injury is defined as, "Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury." (This is the worst staged pressure injury.) On November 9, 2022, at 9:20 a.m., an unannounced visit was conducted at the facility to investigate an allegation related to quality of care issue. On November 9, 2022, a review of Patient A's clinical record indicated the patient was admitted to the facility on September 26, 2022, with diagnoses that included fracture (broken bone) of the upper end of the right humerus (a long bone in the arm), fracture of the right femur (a long bone in the thigh) status-post nailing (a surgical procedure), and dementia (memory loss). Patient A was alert and oriented, with occasional forgetfulness, and able to make needs known. The history and physical indicated Patient A did not have the capacity to understand and make decisions. A review of the Progress Notes dated September 26 and 27, 2022, indicated a humeral (referring to the humerus bone) fracture brace (immobilizer) to the right arm. A review of the Weekly Skin Evaluation for October 11, 2022, and October 19, 2022, did not document an assessment was conducted on the right arm, including the elbow area. A review of the Treatment Administration Record (TAR) dated October 1 to 31, 2022, documented the monitoring of the honeycomb dressing to the right hip. However, the TAR did not provide documented evidence of skin integrity monitoring underneath the right humeral fracture immobilizer. A review of the Braden Scale for Predicting Pressure Score Risk (an assessment tool), dated October 25, 2022, indicated a score of 14 (moderate risk). The assessment tool further indicated that Patient A was assessed to have slightly limited sensory perception (ability to respond meaningfully to pressure-related discomfort), was occasionally moist (degree to which skin is exposed to moisture), was bedfast (confined to bed), and has very limited mobility (ability to change and control body position). A review of the Discharge Summary and Post-Discharge Plan of Care, dated October 25, 2022, did not document any skin problem on the body, nor indicated that skin underneath the right arm immobilizer was assessed prior to discharge. A review of Patient A's Minimum Data Set (MDS- a comprehensive assessment tool), dated October 25, 2022, indicated the patient was discharged with no pressure injury. On November 9, 2022, at 10:25 a.m., during an interview and record review with Licensed Vocational Nurse (LVN) 1, assigned to care for Patient A during the patient's admission at the facility, stated Patient A was admitted to the facility with a right arm sling immobilizer made of hard plastic. LVN 1 stated skin inspection during shower, and weekly skin check should have been conducted if there was a doctor's order to monitor the skin integrity on the patient's right arm. LVN 1 stated there should have been an assessment and routine monitoring of the skin integrity underneath the sling immobilizer. LVN 1 stated she was not aware of any skin integrity issue on the right elbow of Patient A. LVN 1 confirmed the discharge summary did not document that Patient A was discharged with skin breakdown. On November 9, 2022, at 10:41 a.m., during interview and record review, LVN/Treatment Nurse (LVN/TN) 2 stated if a patient is admitted to the facility with an arm sling immobilizer, the facility staff should have obtained a doctor's order to check the integrity of the skin underneath the sling immobilizer. LVN/TN 2 stated there was no documented evidence the skin integrity of Patient A's right arm had been assessed and monitored for skin injury while using the arm sling immobilizer. On November 9, 2022, at 11:31 a.m., during an interview, the Occupational Therapist (OT) stated he conducted evaluation on Patient A. He verified that the patient has a shoulder suspension device with a sling immobilizer on admission to the facility. The OT stated he had not worked with Patient A's shoulder, since there was no order from the physician to start mobilization on the right upper arm. He stated if there was no physician order from the acute care hospital, the therapist will not touch the immobilizer. On November 9, 2022, at 12:45 p.m., Patient A was visited at the board and care facility where he was transferred on October 25, 2022. Patient A was observed eating lunch, with the right arm sling immobilizer removed. A bandaged dressing was observed in the right elbow area. During a concurrent interview, the Board and Care Administrator (BCA) stated, Patient A was transferred at the Board and Care facility on October 25, 2022. The BCA stated that on October 26, 2022 (one day after discharge from the skilled nursing facility), the facility staff provided the patient a bed bath, and upon removal of the right arm immobilizer, they observed a foul-smelling pressure injury covered with gauze on the right elbow of Patient A. The BCA took a picture of the pressure injury, and informed the home health nurse about their finding. A review of the OASIS (Outcome and Assessment Information Set, a home health assessment tool) comprehensive assessment upon admission, dated October 28, 2022 (three days after discharge from the skilled nursing facility), indicated a Stage 4 pressure ulcer on the right elbow, measuring 3.20 cm (centimeter- a unit of measurement) in length X (by) 2.70 cm in width X 0.30 cm in depth. On December 12, 2022, at 11:43 a.m., a telephone interview was conducted with the Director of Nursing (DON). The DON stated she reviewed the record of Patient A and that there was no documented evidence the facility had assessed and monitored the skin integrity underneath the patient's right arm sling immobilizer. The DON stated there should have been a physician order, obtained by the nurse, to assess and monitor the skin integrity underneath the right arm sling immobilizer of Patient A. She stated if the integrity of Patient A's skin underneath the right arm immobilizer was assessed and monitored, they could have discovered skin issue early enough to initiate wound care. The DON stated the facility was unaware that a pressure injury had developed on the right elbow of Patient A. The facility policy and procedure titled, "Skin and Wound Monitoring and Management," dated January 2022, was reviewed. The policy indicated, "A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable...The facility provides care and services to promote interventions that prevent pressure injury development...Procedure: a. Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: a. Complete Initial Admission Record and Braden Scale to identify the risk and to identify any alterations in skin integrity noted at that time...c. Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure injury which include, but are not limited to: Impaired/decreased mobility and decreased functional ability...f. Skin and wound assessment on admission and readmission: *A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial Admission record...g. Ongoing Skin and Wound Assessments: * A licensed nurse will assess/evaluate a resident's skin at least weekly... Monitoring...c. Skin Inspection on Showering * On shower days, CNAs (Certified Nursing Assistant) to observe resident skin. * Identify any areas of skin breakdown, discoloration, tears or redness... d. Weekly skin conducted by a licensed nurse * All residents will have a head-to-toe skin check performed at least weekly by a licensed nurse...e. Weekly for those residents admitted with a dressing to a wound or cast/ splint to an extremity or who receive a dressing to a wound or cast/ splint to an extremity during the course of the facility admission. * When a resident is admitted...with, a dressed wound or a cast/splint that is being managed outside the facility, nursing staff shall assess and evaluate the dressed/casted/splinted area at least weekly to check the status of the skin. Factors to consider under these circumstances include...2. Whether there is a smell coming from the area underneath or around the dressing/cast/splint...4. Whether there is any abnormality or condition which requires attention in the area..." Based on observation, interview and record review, the facility failed to accurately assess and monitor Patient A's skin integrity underneath the right arm, while using a sling immobilizer (a device used to support and keep still an injured part of the body), of pressure injury (the breakdown of skin integrity due to pressure). This failure resulted in the development of a Stage 4 pressure injury (a full thickness tissue loss with exposed bone, tendon, or muscle) on Patient A's right elbow area, while at the skilled nursing facility. In addition, Patient A was admitted to the facility on September 26, 2022, then discharged on October 25, 2022, without being identified of sustaining pressure injury on the right elbow area. The violation of this regulation presented a direct relationship to the health, safety, or security of Patient A.