Health inspection·March 5, 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 ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. Residents Affected - Few This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included rheumatic tricuspid insufficiency (a heart condition in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood pressure in the arteries and lungs). A review of Resident 1's order summary report indicated the physician ' s order, [All] Care plan read and approved by MD [physician] .[ordered on] 6/27/23 . A review of Resident 1's progress note dated 6/28/23 at 3:54 p.m. indicated, admission Braden Scale [a tool used to predict pressure injury risk] of 11 [a score of 10-12 is high risk of developing a pressure injury]. A review of Resident 1's care plan for, Bowel/bladder incontinence [unable to control bowel/bladder] related to cognitive loss [the thought process], decreased awareness of urge was initiated on 6/28/23. Staff were to provide, .perineal care [area between the anus and the vulva] care AM [in the morning], PM [in the afternoon/evening], and after each incontinence .[to assist Resident 1 to meet the goal of] .free of skin breakdown x 90 days [by] 10/1/23 . A review of Resident 1's care plan for, Potential for skin breakdown related to history of skin breakdown, [history] of bruises or skin tears due to fragile skin, incontinence, others was initiated 6/28/23. Staff were to provide, .incontinence care as needed .monitor for discoloration, bruises, swelling, skin tears or redness and report promptly .pressure relieving mattress as needed .treatment as ordered .turn and reposition frequently as needed .[to assist Resident 1 to meet the goal of] Have less skin tears or bruises x90 days .will be healed .no bruises or skin tears x90 days by [10/1/23] . Page 1 of 3 555421 555421 03/05/2024 Stonebrook Post Acute 4367 Concord Boulevard Concord, CA 94521

F 0686 A review of Resident 1's order summary report indicated the following physician ' s orders: Level of Harm - Minimal harm or potential for actual harm Skin protection for incontinence associated dermatitis [skin inflammation] on sacrococcygeal region, Residents Affected - Few gluteal cleft [the groove between the buttocks], opposing medial buttock region: Apply [moisture barrier ointment] every shift [starting on 6/28/23] .[and] as needed [starting on 6/28/23] . Turn and reposition as needed off load from pressure areas. Observe decubitus [lying down] areas every shift and notify MD for skin discoloration .every shift [starting on] 6/28/23 . A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/3/23 indicated, Resident has pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] No .Does this resident have one or more unhealed pressure .injuries? .[facility chose] No . A review of social service progress notes dated 7/3/23, 7/10/23, and 8/7/23 indicated Resident 1 was cooperative, communicative, and motivated. A review of progress notes dated 7/7/23 at 11:15 a.m., 7/13/23 at 11:15 a.m., 7/21/23 at 12:46 p.m., and 7/28/23 at 1:03 p.m. indicated a Braden Scale (a tool to predict pressure injury risk) score of 12 which indicated Resident 1 was at high risk for developing a pressure injury. A review of Resident 1's progress note dated 8/6/23 at 1:07 a.m. indicated, .MASD on coccyx sacral [sacrococcygeal] area . A review of Resident 1's order summary report indicated the following physician order, Eroded skin lesion/Open wound on sacrococcygeal region combined with [MASD] Treatment Order: Apply .hydrophilic wound dressing paste [a paste used to keep a wound protected from moisture] .3x [three times] per day and as needed for episodes of incontinence. Paste should be applied after every stool and does not need to be scrub [sic] off completely. After stooling, remove soiled part of cream with wet cloth or wet gauze, avoid scrubbing. Notify MD for progression. (Only apply on areas with eroded/ open lesions) every shift .[starting on 9/11/23 .[and] as needed .starting on 9/11/23 . A review of Resident 1's progress note dated 9/23/23 at 6:09 a.m. indicated, .eroded skin lesion to sacrococcygeal region combined with MASD . A review of Resident 1's progress note dated 10/1/23 at 4:13 p.m. indicated, Sacral with open area, with scant red drainage, pink in color . A review of a progress note initiated on 10/13/23 indicated Resident 1 needed extensive assistance from staff for bed mobility, toilet use, and transfers from surface to surface. A review of Resident 1's progress note dated 10/30/23 at 11:19 a.m. indicated, .Open Wound on sacrococcygeal region, measurement 1.5x2x0.1cm [centimeter, a unit of measure] combined with [MASD] .Continue same treatment as ordered . A review of Resident 1's order summary report indicated, Stage 3 coccyx [injury] Treatment Order: Cleanse with NSS [normal saline, a cleaning solution] Pat dry, Apply [Brand Name] barrier film on peri-wound [the area surrounding the wound] areas, calcium alginate [a substance used to assist in 555421 Page 2 of 3 555421 03/05/2024 Stonebrook Post Acute 4367 Concord Boulevard Concord, CA 94521

F 0686 Level of Harm - Minimal harm or potential for actual harm wound healing] impregnated with [leptospermum honey which helps with wound healing] on wound bed then secure with [foam dressing] every day .in the morning .and [as needed] soiling .[starting on] 11/16/23 . A review of Resident 1's Discharge summary dated [DATE] at 3:25 p.m. indicated, .Resident was admitted to [facility] for skilled services. During her stay there .developed an open area on her coccyx while in house. Residents Affected - Few A review of Resident 1's progress note dated 11/18/23 at 11:30 a.m. indicated, Coccygeal eroded skin reclassified by [physician] to Stage 3 pressure injury 2x3 cm in size/ progressing . A review of Resident 1's MDS dated [DATE] indicated, Resident has a pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] Yes .Does this resident have one or more unhealed pressure .injuries? .[facility chose] Yes .Number of Stage 3 pressure [injuries] .1 . In an interview and record review of Resident 1's medical chart on 3/5/24 at 4:15 p.m., the WN confirmed Resident 1 did not have a pressure injury upon admission to the facility. The WN also confirmed Resident 1 did not have a low air-loss (LAL) mattress (a type of pressure relieving mattress). The WN stated Resident 1's MASD was, profuse eroded skin on the sacral area. There was no measurable depth .the wound was a Stage 2 [a partial-thickness skin loss involving the outer most layer of the skin and/ or the dermis layer which contains nerve endings, sweat glands and oil glands, hair follicles, and blood vessels]. The WN further stated the physician assessed Resident 1's wound and determined it had progressed to a Stage 3. In a telephone interview and concurrent record review on 4/30/24 at 3:30 p.m., the DON confirmed there was no care plan for Resident 1's Stage 3 sacrococcygeal wound in her medical chart. The DON stated a care plan should have been initiated for each skin concern. A review of the facility's undated policy and procedure titled Prevention of Pressure [Injuries] indicated, Protect against adverse effects of external mechanical forces: friction, shear and pressure .Systematically reposition and turn frequently while in bed .Pressure reduction devices (i.e. mattresses) should be considered for bed-bound/ chair-bound residents. Apply pressure-reducing mattress or air mattress to bed upon admission . A review of the facility's undated policy and procedure titled Treatment of Pressure [Injuries] indicated, Residents with pressure [injuries] can expect to maintain and/or improve skin integrity .Care planning must be provided by licensed nursing personnel .Implementation may include other caregivers under the direction of the Nursing Supervisor and MDS Coordinator .At the time any stage II, III, IV [injury] is first identified .Initiate a plan of care including reassessment interval . Monitor response to treatment [with every] dressing change or according to plan of care and document changes in wound status .At least every 7 days, evaluate ulcer as in plan of care as indicated .Implement measures for minimize of pressure [injuries] .Position resident off pressure ulcers .It is the policy of the [facility] to complete a .reassessment using the Braden Scale will be done quarterly. 555421 Page 3 of 3