Health inspection·May 2, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow facility's policies and patient's care plan to prevent further damage to Patient 1's wounds at bilateral buttocks. Residents Affected - Few This deficient practice had the potential to result in Patient 1's bilateral buttocks wounds progressing to unstageable wound. Findings: On May 2, 2023, at 8:05 AM, during initial tour of the facility with Wound Care Nurse (WCN), Patient 1 was observed lying in bed with ventilator (breathing machine) connected to tracheostomy (a hole in the windpipe make to relieve obstruction to breathing) in patient's neck. Patient 1 was observed with a wound to his right ear. Concurrently, WNC stated Patient 1's bilateral buttocks wounds were identified since March 7, 2023, as moisture-related-skin damage and progressed to unstageable with the treatment changed from barrier ointment to calcium alginate with honey. On May 2, 2023, at 8:21 AM, during concurrent interview with Quality Assurance Nurse (QA) and record review of Patient 1's face sheet, dated August 19, 2022, Patiewnt 1's Facesheet indicated patient was admitted to the facility with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own) and pneumonia (lung infection). A review of Patient 1's history and physical (H&P), dated August 19, 2022, the H&P indicated patient was transferred from another facility with a history of COVID-19 infection. The H&P further indicated Patient 1 was dependent on a breathing machine and had a tracheostomy placed for breathing and a gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition directly into the stomach) for feedings. A review of Patient 1's initial assessment, dated August 19, 2022, indicated the following: 1. Activities of daily living - patient required extensive assistance for all cares. 2. Level of consciousness - patient was awake, but cannot understand others, is unable to make self-understood, and was severely impaired for decision-making, and was non-verbal. 3. Gastrointestinal - patient had a g-tube on abdomen, for tube feedings. 4. Genitourinary - patient was incontinent. Page 1 of 3 555255 555255 05/02/2023 East Los Angeles Doctors Hosp 4060 E. Whittier Blvd. Los Angeles, CA 90023

F 0686 5. Musculoskeletal - patient was non-ambulatory. Level of Harm - Minimal harm or potential for actual harm 6. Integumentary - Braden score was 12 and was a risk for skin injury. Residents Affected - Few On May 2, 2023, at 9:14 AM, during concurrent interview with WCN and review of Patient 1's Care Plan for patient's bilateral buttocks, dated March 7, 2023, interventions included to turn and reposition every 2 hours for comfort and circulation. On May 2, 2023, at 8:50 AM, during concurrent interview with WCN and record review of Patient 1's turning documentation, dated April 8, 2023, WCN stated patient was not repositioned every 2 hours, per facility policy and per patient's care plan, from 4 PM to 8 PM, because patient was on right side for four hours. Concurrently, during record review of Patient 1's turning documentation, dated April 15, 2023, WCN stated patient was not repositioned every 2 hours, per facility policy and per patient's care plan, from 2 PM to 6 PM, because patient was on left side from 2 PM to 6 PM. A review of Patient 1's Treatments, dated April 19, 2023 and April 20, 2023, indicated there was no documentation of daily skin treatment done for patient's sacral area to cleanse with normal saline, pat dry, apply Thera-honey with calcium alginate, and cover with dry dressing. A review of Patient 1's Surgical Consult, dated April 11, 2022, indicated the following: 1. Reason for visit - to manage patient's wounds at the bilateral buttocks. 2. Etiology - moisture-associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, and characterized by inflammation of the skin without erosion). 3. Lesion description - redness with areas of denuded skin and dead tissue is very concerning for a Kennedy terminal ulcer. 4. Treatment - continue protective barrier cream twice daily and after each incontinence, turn per facility protocol, and offloading. A review of Patient 1's Surgical Consult, dated April 18, 2023, indicated the following: 1. Reason for visit - to manage patient's wounds at the sacro-coccyx area extending to the right buttocks. 2. Etiology - pressure injury, unstageable. 3. Lesion description - serous exudate, wound edge with redness and dead tissue. 4. Treatment - dry dressing with calcium alginate with honey and protective skin barrier to peri-wound daily and after each incontinence, off-loading, and turn per facility protocol. A review of facility's Pressure Injury Assessment, Management, Preventions and Treatment Protocol, dated April 2023, indicated the following: 555255 Page 2 of 3 555255 05/02/2023 East Los Angeles Doctors Hosp 4060 E. Whittier Blvd. Los Angeles, CA 90023

F 0686 1. All patients will have skin integrity assessed during admission, tranfer from another department or unit, and every shift. Level of Harm - Minimal harm or potential for actual harm 2. A risk assessment will be done using the Braden Scale for patients greater than eight years old. Residents Affected - Few 3. Braden protocols included frequent turning - every two hours, and maximal remobilization. 4. Upon discovery of a pressure injury, the nurse will notify provider, wound care nurse, immediate supervisor, patient and/or family, initiate incident event report, and complete the EHR/photographic wound documentation. 5. Initiate a care plan specific to patient. 6. Implement Braden protocol and repositioning every two hours. 555255 Page 3 of 3