Health inspection·June 1, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain a complete skin assessment that is accurately documented. This failure had the potential to result in lack of coordination of care among healthcare practitioners and delayed management of skin issues. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (blood sugar levels are too high) and congestive heart failure (heart is unable to pump oxygen-rich blood to meet the body's needs). Resident 1 was discharged from the facility on 4/5/23. [Reference:https://medical-dictionary. com]. During review of Resident 1's Nursing -Admission/readmission Assessment, dated 2/27/23, the assessment indicated, under Body Assessment, Resident 1 had a left anterior foot sore that measured 7 centimeters (cm) x 5 cm. Resident 1 had other skin conditions that included, the front side of the right and left lower leg had scars and scattered sores and there was yellowish mild pus noted on the right anterior sore. During review of the IDT(Interdisciplinary Team, a group composed of individuals representing different departments of the facility) Conference Notes dated 2/28/23, the notes indicated, Resident 1 had a bilateral lower leg abrasion and wound care will be provided to the bilateral lower extremities abrasion. During review of Progress Notes dated 2/8/23, the notes indicated another skin assessment on 2/7/23, to clarify that it was Resident 1's right dorsal foot (top part of the foot) that had an abrasion instead of the left foot as indicated in the Nursing admission Assessment. The assessment further clarified there were no open areas on the left lower extremity as indicated in the IDT Conference Notes and Nursing-Admission/readmission Assessment. During an interview and concurrent review of the clinical record, on 4/12/23 at 10:39 a.m., with Assistant Director of Nursing (ADON), ADON stated, Resident 1 had scars and scattered sores on the right and left lower leg. The clinical record did not indicate a skin assessment during Resident 1's discharge on [DATE]. A review of Resident 1's discharge notes was requested. During review of Resident 1's clinical record, on 4/12/23 at 11: 20 a.m., while waiting for ADON to Page 1 of 2 555254 555254 06/01/2023 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few show documentation of Resident 1's skin status during discharge, a late entry was entered in Resident 1's Progress Notes electronic record. During an interview and concurrent review of Resident 1's clinical record with Treatment Nurse (TN), on 4/12/23 at 11:22 a.m., TN stated she had just entered a late entry dated 4/5/23 to indicate Resident 1's skin during discharge and stated the documentation was not previously in the progress notes. TN also stated she had to clarify the site of the open areas because the admitting nurse made a mistake. TN also stated skin sheets for open areas/abrasions were not in the medical record as skin assessments were only done if there were any changes noted and were not done routinely. Review of the Medical Practitioner Narrative Note dated 3/20/23 indicated a physical examination was done by the practitioner on Resident 1. Under Exam, lower extremities were observed for any swelling, under Skin, the notes indicated to see Skin Sheet. During an interview with ADON , on 4/12/23 at 11:57 a.m., ADON stated there were no skin sheets in Resident 1's medical record. ADON also stated, weekly wound rounds log (skin sheets) were completed only for pressure ulcers but not for abrasions like Resident 1 had. ADON also stated daily skilled charting by the charge nurses did not have skin assessments in them because it was the wound nurse (treatment nurse) that did skin assessments. During a telephone interview, on 5/11/23 at 1:55 p.m., with Registered Nurse (RN) 1, RN 1 stated, when Resident 1 was discharged on 4/5/23, RN 1 performed a quick assessment and noted there was a 4 x 4 dressing on Resident 1's foot. RN 1 stated she thought Resident 1 might have a wound or maybe a little skin tear on the foot . RN 1 further stated she did not remove the dressing to do a thorough assessment, and did not know what Resident 1 had on the lower extremities because the facility had a treatment nurse who was expected to do this task. Review of Resident 1's Discharge Summary written by RN 1 did not indicate an assessment of Resident 1's skin status during discharge. 555254 Page 2 of 2