Health inspection·April 2, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions of turning and repositioning of dependent residents, for one of four residents (Resident 1), who had the potential for the development of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Residents Affected - Few This failure placed the resident at an increased risk for developing and/or worsening of pressure injuries. Findings: On April 2, 2024, at 10:17 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On April 2, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute and chronic respiratory failure (unable to breath without difficulty) post tracheostomy (an artificial opening in the trachea to allow oxygen to the lungs), quadriplegia (inability to move all four extremities), and intracranial hemorrhage (bleeding in the brain). The physician History and Physical indicated Resident 1 was nonverbal and noncommunicative. The records indicated Resident 1 was transferred to the general acute care hospital on January 21, 2024. Review of Resident 1's Care Plan dated February 23, 2023, indicated, .Focus .High risk for alteration in skin integrity .Resident's mother wants resident to be turned at 9pm, 12mn (midnight), 3am, and 6am .Interventions .During night shift turn resident at 9pm, 12mn, 3am, and 6am per family request .Turn and reposition at least every 2 hours and as needed for comfort and pressure relief . Review of the facility document untitled which included resident function and activity (turning and repositioning) for January 17-21, 2024, indicated: -January 17, at 2:17 p.m., .Assistance Needs .Total .Patient Position .Lying . -January 17, at 6:18 p.m., .Assistance Needs .Total .Patient Position .Supine . -January 18, at 1:06 p.m., .Assistance Needs .Total .Patient Position .Lying . There was no other documentation indicating Resident 1 was turned or repositioned. Page 1 of 2 555390 555390 04/02/2024 Corona Regional Medical Center D/P Snf 730 Magnolia Avenue Corona, CA 92879

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On April 2, 2024, at 10:44 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated residents needed to be turned and repositioned every two hours and documented in the resident's record. CNA 1 stated if it was not documented, it was not done. On April 2, 2024, at 1:09 p.m., an interview was conducted with CNA 2. CNA 2 stated residents needed to be turned and repositioned every two hours and documented in the resident's record. CNA 2 stated some families requested the residents to be turned more frequently or at specific times, but they should be repositioned at least every two hours to prevent pressure injuries. On April 2, 2024, at 1:20 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated residents needed to be turned or repositioned every two hours with documentation in the resident's record. The DON stated Resident 1's record did not have any documentation that Resident 1 was turned or repositioned every two hours between January 17-21, 2024. The DON stated there should be documentation to indicate Resident 1 was turned and repositioned, and there was not. The DON stated if it was not documented then it was not done. On April 2, 2024, at 1:55 p.m., an interview was conducted with the Treatment Nurses (TXN) 1 and 2. TXN 1 stated Resident 1 had a pressure injury to his buttocks, but the wound was improving. TXN 1 stated it was important for Resident 1 to be turned and repositioned to promote healing and prevent further pressure injuries from developing. TXN 2 stated turning and repositioning were important for skin integrity and wound healing. Review of the facility document titled Skin Care and Prevention of Pressure Injury revised May 2023, indicated, .Pressure injury are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue .For a person in bed .Change position at least every time ADL (activities of daily living- example would be brief change or peri-care) care is provided or more frequently if needed .in a chair .Change position regularly at least every 1-2 hours .Bed/Chair Fast .Change position as frequent as possible . 555390 Page 2 of 2