Other·May 25, 2021

483.25 QUALITY OF CARE Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices. Title 22, Division 5, Chapter 3, Article 3, Section 72313 Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (5) All medications and treatments shall be administered only by licensed medical or licensed nursing personnel… (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient’s individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. Title 22, Division 5, Chapter 3, Article 5, Section 72547 Content of Health Records (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses’ notes which shall be signed and dated. Nurses’ notes shall include: (A) Records made by nurse assistants, after proper instruction, which shall include: (1) Care and treatment of the patient (2) Narrative notes of observation of how the patient looks, feels, eats, drinks, reacts, interacts and the degree of dependency and motivation toward improved health. (3) Notification to the licensed nurse of changes in the patient’s condition. On February 27, 2020, at 9:07 a.m., an unannounced visit was made to the facility for the investigation of two complaints. It was determined that the facility failed to ensure that it provided care and services in accordance with professional standards of practice for Patient A. This failure occurred when a certified nursing assistant (CNA 1) administered an Epsom salt foot soak treatment for Patient A. This treatment resulted in a burn to the bottom of Patient A’s left foot from the water being too hot. The burn subsequently required wound treatment and the administration of an antibiotic to prevent infection. Patient A's facility medical record was reviewed and indicated the patient was admitted to the facility on December 27, 2019, with diagnoses that included aftercare following surgery on the digestive system, sequelae of cerebral infarction (effects of a stroke), protein-calorie malnutrition, essential hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and chronic kidney disease (kidneys do not function properly). A review of Patient A's "History and Physical," (H&P) dated December 27, 2019, indicated, "This patient has the capacity to understand and make decisions." A review of Patient A's, "Minimum Data Set," (MDS- standardized assessment for the management of care), dated January 3, 2020, indicated a "BIMS," (brief interview for mental status- screening tool to assess mental capability) score of 13 out of 15 (scores of 13-15 indicates cognitively intact). Review of a facility progress note for Patient A, dated February 11, 2020, at 3:15 p.m., indicated, "patient stating her husband brought her Epsom salt & (sic) if someone could soak her feet this evening, stated someone from the night shift has been soaking her feet in it & (sic) feels it is helping her swelling. Made (sic) her aware we would have to contact md (medical doctor) & (sic) get orders. Patient was very adamant on her being able to receive the soak. MD made aware. MD okay'd (sic) order for soak. n/o (new order) noted & (sic) carried out..." A review of a physician’s order for Patient A, dated February 11, 2020, indicated, "Epsom salt soak to bilateral (both) feet every 8 hours as need for comfort." A review of a facility progress note for Patient A, dated February 15, 2020, at 3:32 p.m., authored by a licensed vocational nurse (LVN 1), indicated, "pt (patient) has new coc (change of condition) for left plantar (sole of the foot) foot burn. New order for Silvadene (per the manufacturer- topical antimicrobial drug used for the prevention and treatment of wound sepsis (life-threatening condition caused by the body's response to an infection) in patients with second and third degree burns) abd (sic) pad then kerlix wrap (gauze bandage) to open area. Pt reported to am (morning) tx (treatment) nurse that PM (evening) CNA per pt request soaked (sic) her feet, water to (sic) hot." Review of a facility care plan for Patient A, dated February 15, 2020, indicated, "left foot plantar burn from hot water foot soak." Review of a physician's order, dated February 15, 2020, for Patient A indicated, "Silvadene Cream 1% Apply to left plantar foot topically one time a day for burn..." Review of a physician's order for Patient A, dated February 17, 2020, indicated, "Wound consult with (doctor's name) 02/19/2020. ind. (indication) plantar wound." Review of a care plan for Patient A, dated February 17, 2020, indicated, "2/17/2020 Patient requested for Epsom Salt soak to BLE (bilateral lower extremities) as ordered @ (at) around 1500 (3:00 p.m.), noted with left plantar foot burn, after the soak bath; tx (treatment) Nurse stated skin peeled from soak. Patient stated, "water was hot." Review of Patient A's facility record indicated that she had been sent to the acute care hospital on February 18, 2020, for an unrelated issue. Review of Patient A's hospital "History & Physical" (H&P), dated February 18, 2020, indicated, "...Patient states she requested foot bath, nursing aide provided water which was way too hot and this brought (sic)her feet...Patient is being admitted secondary to significant burn. Given ceftezole (antibiotic) in the ER (emergency room)." A review of Patient A's hospital H&P further indicated, "Left foot burn...Full thickness burn (third degree burn which destroys the outermost layer of the skin and the second layer of skin)...needs preventive measures, keep foot clean...daily woundcare (sic). Continue antibiotics.” On February 27, 2020, at 10:55 a.m., an interview and concurrent record review were conducted with LVN 1. LVN 1 stated that she had been asked to help another treatment nurse evaluate Patient A's left foot injury. LVN 1 stated that she had documented the situation in her progress note. A section of the progress note was read back to the LVN. At that time LVN 1 confirmed that the wound had occurred from the foot soak. LVN 1 also confirmed she had documented that the patient had told her that the water was too hot. On February 27, 2020, at 11:12 a.m., an interview was conducted with the facility's Director of Staff Development (DSD). The DSD was asked when she had been informed of Patient A's foot injury. The DSD stated that she had found out on Monday morning February 17, 2020, in the stand-up meeting (meeting held with department heads to review events in a facility). The DSD stated that CNA 1 had provided Patient A with an Epsom salt foot soak treatment with, "hot water." The DSD stated in her interview with CNA 1, he had told her that the water was too warm, so he took the patient's water pitcher and added cool water to the basin. The DSD stated that CNA 1 should have asked the Charge Nurse to administer the salt soak. The DSD continued that the Epsom salt soak was a treatment and it should have been done by the Charge Nurse. The DSD further said that a treatment is not within the scope of practice of a CNA. The DSD stated that treatments were only to be performed by a nurse. On February 27, 2020, at 11:18 a.m., an interview was conducted with the facility's Administrator, (AD), Acting Director of Nursing (ADN) and Assistant Director of Nursing (ADON), regarding the facility's investigation of the injury to Patient A's left foot. In review of the incident with the department heads, the AD stated that CNA 1 had not been working within the scope of his practice by providing the foot soak treatment for Patient A. On February 27, 2020, at 12:52 p.m., at the acute hospital an interview was conducted with Patient A. The patient was asked about her left foot injury. Patient A stated that she had asked her evening male CNA for an Epsom salt soak for her feet. She stated that CNA 1 brought her a basin of water and said he had "boiled the water." Patient A stated CNA 1 had told her that when he had been a football player this is what they would do. Patient A stated that she had trusted him and, "took his word for it." When asked the identity of the male CNA, the patient named CNA 1. Patient A stated that she could see the water "bubbling." Patient A was asked how the water was heated, and the patient stated that CNA 1 had put the water in the microwave. Patient A was asked if CNA 1 had tested the water prior to giving it to her. Patient A stated that, "he did not test the water," Patient A further stated that, "he just gave it to me." Patient A stated that she continued to, "see the bubbles." She stated that the skin is thin on her feet. Patient A stated that the water was "so hot and painful." Patient A stated that she put, "just the bottom of her left foot" in the water but barely touched the water to the bottom of her right foot. Patient A stated that she never submerged her feet in the water. Patient A was asked if CNA 1 had stayed to observe her put her feet into the water. Patient A stated, "No," and further stated that he had delivered the water and "left me." Patient A stated that CNA 1 "didn't stay there" in the room with her. Patient A stated that she had not "realized that her foot had been cooked." On February 27, 2020, at 2:19 p.m., a phone interview was conducted with CNA 1. CNA 1 confirmed that he had provided care for Patient A. CNA 1 was asked if he had gotten the water for Patient A's salt soak. CNA 1 stated, "Yes." CNA 1 stated that he had gotten the water for the basin in the sink at Nursing Station 4. When asked how he heated the water, CNA 1 stated that he, "just got it hotter from the microwave." CNA 1 was asked how long he left the water in the microwave. He stated he had left the water in the microwave for, "approximately a minute and a half." CNA 1 was asked if he had placed the plastic basin in the microwave. CNA 1 confirmed that he had put the plastic basin in the microwave. CNA 1 was then asked if he had checked the temperature of the water prior to giving it to Patient A. CNA 1 stated, "Yes, I stuck my finger in there." CNA 1 was asked if he had used a thermometer to check the water temperature. CNA 1 stated, "No" and stated he "just touched it myself." CNA 1 further stated it "wasn't too hot." CNA 1 was asked if Patient A had complained that the water was too hot. CNA 1 stated she had said that it, "was hot." CNA 1 stated that he had taken Patient A's water pitcher and added cool water to the basin. CNA 1 stated that after he had provided the foot soak to Patient A, he left the room for "half an hour and then came back." A review of a facility policy titled, "Applying a Warm Compress or Soak," revised April 2013, indicated, "Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the patient's care plan to assess for any special needs of the patient." The policy indicated "General Guidelines...2. Check the patient's skin often for redness or discoloration...5. Listen to the patient's complaints. Report them to the Staff/Charge Nurse." The policy further indicated, "The following equipment and supplies will be necessary when applying a warm soak: 1. Soak basin, 2. Pitcher of warm water (105 degrees Fahrenheit), 3. Bath thermometer...If applying a warm soak...5. Fill the water pitcher with warm water (105 degrees)...10. Unless otherwise instructed, check the skin of the limb being soaked every five (5) minutes. (Note: if the skin appears to be reddened or discolored, cease the treatment...12. Unless otherwise instructed, soak the limb for twenty (20) minutes..." Per Section 1337 of Health and Safety Code…(3)“Certified nurse assistant” means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients, and is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision of a registered nurse…” Therefore, it was determined that the facility failed to ensure that it provided care and services in accordance with professional standards of practice for Patient A. This failure occurred when a CNA administered an Epsom salt foot soak treatment for Patient A. This treatment resulted in a burn to the bottom of Patient A’s left foot from the water being too hot. The burn subsequently required wound treatment and the administration of an antibiotic to prevent infection. The violation of the above regulation had a direct relationship to the health, safety, or security of the patient.