Health inspection·March 7, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of quality for 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknown length of time. Residents Affected - Few This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and death, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe), and gastrostomy (a surgically placed device used to give direct access to stomach for feeding, hydration, or medicine) dependence. Patient 2's H&P indicated under the physical examination, Neruo: Encephalopathic (disturbance of brain function) without purposeful movement, hypertonic and spastic. The H&P indicated the plan for respiratory care, Tracheostomy dependent . During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 1:18 p.m., the DIR stated patient 2 sustained a burn injury at the right middle lateral back and right posterior forearm on 1/2/24. The DIR stated Patient was found lying on a ventilator humidifier tube and the WCN noted that Patient 2 was found with blister on the back and right forearm. During an interview with the Wound Care Nurse (WCN) on 3/7/2024 at 2:45 p.m., stated that she was asked to initial a wound consult for Patient 2; found serous exudate intact blisters at Patient 2's right posterior foreman and rupture blister with partial thicken at right lateral back, no one witness what had happened, but facility investigated that the cause from the blister could be from lying on the ventilation heated tubing with unknown time. A review of Patient 2's medical record titled Wound Care Specialist Evaluation notes, dated 1/2/24, the WCN validated that she was consulted on Patient 2 for evaluation of lesions on the right arm Page 1 of 4 555589 555589 03/07/2024 Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605

F 0658 Level of Harm - Actual harm Residents Affected - Few and right back. A serous filled bulla (fluid under a thin layer of your skin) presents on the right forearm measuring 1.3 cm (centimeters - unit of measurement) x (by) 5 cm x 0.1 cm. Erythema (redness of the skin caused by injury) with a small serous (clear to yellow fluid that leaks out of a wound) blister noted on the right upper back. A rupture bulla noted on the mid right lateral back 1.5 cm x 1.5cm x 0.1 cm and Erythema with intact ruptured blisters present on the mid right lateral posterior back measuring 2.5 cm x 15 cm x 0.1 cm with small amount of serous exudate (fluid that leaks out of blood vessels into nearby tissues). During interview with Licensed Vocational nurse (LVN1) on 3/7/2024 at 2:33 p.m , stated that they found Patient 2 had redness and blisters at his right forearm and right upper back during the charge nurse round in the morning on 1/1/24. Staffs are supposed to do hourly round to check patient to make sure patient is not lying on any tubing or anything that can cause pressure on the skin. During interview with certified nurse assistant (CNA1) on 3/8/2024 at 12:30 p.m., stated that CNA are supposed to do the hourly round with their assigned patients. During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 3:18 p.m., the DIR stated the hourly rounding is a practice that all staff adhere in the pediatric sub-acute unit. This practice was existing for a long time before the incident happened. They do not document on the hourly round before the incident. The hourly round is not assigned to a specific person. Charge nurse, license nurse, CNA, and respiratory therapist are supposed to performing the hourly check. A review of Patient 2's nursing notes dated 1/1/24, indicated, Upon morning assessment, Patient 2) was found lying on the heated ventilator tubing for an unidentified amount of time. Patient was found with visible redness and elevated skin under the back, on the right side and up the middle upper back. During a review of the facility's policy and procedure (P&P) titled, Skin care, prevention of skin breakdown reviewed in 04/2021, the P&P indicated that Our goal is to maintain skin integrity and to prevent tissue breakdown and the development of pressure ulcers .the licenses nurse will document the overall condition of the resident's skin every shift in the resident record, utilizing the shift physical. During a review of the facility's policy and procedure (P&P) titled, Safety measures for pediatric residents, reviewed in 04/2021, the P&P indicated that All caregivers are to observe the safety measures for Pediatric residents in order to provide a safe and secure environment for pediatric residents. During a review of the facility's policy and procedure (P&P) titled, Mechanical Ventilation, with last reviewed date 12/2022, the P&P indicated, In order to ensure that patient-ventilator monitoring are being performed according to these guidelines an indicator should be created to monitor this activity as part of the department's quality assurance program. 555589 Page 2 of 4 555589 03/07/2024 Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 4 sampled (Patient 2), a pediatric patient who was unable to verbalize needs and unable to move extremities, did not suffer from burns of being laid on top of a heated humidifier tubing for unknow length of time. This deficient practice resulted in patient 2 suffering burn injury on his right arm and right back. Finding: A review of Patient 2's admission record indicated the patient was originally admitted to the facility on [DATE] with admit diagnosis chronic respiratory failure (condition when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). A review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem) dated 6/29/2023, the H&P indicated Patient 2's past medical history included Anisocoria eye's pupils are not the same size. Acute Hemorrhagic encephalomyelitis (a rare disorder that cause rapid neurologic deterioration and death, tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe), and gastrostomy (a surgically placed device used to give direct access to stomach for feeding, hydration, or medicine) dependence. Patient 2's H&P indicated under the physical examination, Neruo: Encephalopathic (disturbance of brain function) without purposeful movement, hypertonic and spastic. The H&P indicated the plan for respiratory care, Tracheostomy dependent . During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 1:18 p.m., the DIR stated Patient 2 sustained a burn injury at the right middle lateral back and right posterior forearm on 1/2/24. The DIR stated Patient was found lying on a ventilator humidifier tube and the WCN noted Patient 2 was found with blister on the back and right forearm. During an interview with the Wound Care Nurse (WCN) on 3/7/2024 at 2:45 p.m., stated that she was asked to initial a wound consult for patient 2; found serous exudate intact blisters at patient 2's right posterior foreman and rupture blister with partial thicken at right lateral back, no one witness what had happened but facility investigated that the cause from the blister could be from lying on the ventilation heated tubing with unknown time. A review of Patient 2's medical record titled Wound Care Specialist Evaluation notes, dated 1/2/24, the WCN validated that she was consulted on Patient 2 for evaluation of lesions on the right arm and right back. A serous filled bulla (fluid under a thin layer of your skin) presents on the right forearm measuring 1.3 cm (centimeters - unit of measurement) x (by) 5 cm x 0.1 cm. Erythema (redness of the skin caused by injury) with a small serous (clear to yellow fluid that leaks out of a wound) blister noted on the right upper back. A rupture bulla noted on the mid right lateral back 1.5 cm x 1.5cm x 0.1 cm and Erythema with intact ruptured blisters present on the mid right lateral posterior back measuring 2.5 cm x 15 cm x 0.1 cm with small amount of serous exudate (fluid that leaks out of blood vessels into nearby tissues). During interview with Licensed Vocational nurse (LVN1) on 3/7/2024 at 2:33 p.m , stated that they 555589 Page 3 of 4 555589 03/07/2024 Whittier Hospital Medical Ctr D/P Snf 9080 Colima Road Whittier, CA 90605

F 0689 Level of Harm - Actual harm Residents Affected - Few found patient 2 had redness and blisters at his right forearm and right upper back during the charge nurse round in the morning on 1/1/24. Staffs are supposed to do hourly round to check patient to make sure patient is not lying on any tubing or anything that can cause pressure on the skin. During interview with certified nurse assistant (CNA1) on 3/8/2024 at 12:30 p.m., stated that CNA are supposed to do the hourly round with their assigned patients. During an interview with the Director of Pediatric Subacute Unit (DIR) on 3/7/2024 at 3:18 p.m., the DIR stated the hourly rounding is a practice that all staffs adhere in the pediatric sub-acute unit. This practice was existing for a long time before the incident happened. They do not document on the hourly round before the incident. The hourly round is not assigned to a specific person. Charge nurse, license nurse, CNA, and respiratory therapist are supposed to performing the hourly check. A review of Patient 2's nursing notes dated 1/1/24, indicated, Upon morning assessment, patient 2 was found lying on the heated ventilator tubing for an unidentified amount of time. Patient was found with visible redness and elevated skin under the back, on the right side and up the middle upper back. During a review of the facility's policy and procedure (P&P) titled, Skin care, prevention of skin breakdown reviewed in 04/2021, the P&P indicated that Our goal is to maintain skin integrity and to prevent tissue breakdown and the development of pressure ulcers .the licenses nurse will document the overall condition of the resident's skin every shift in the resident record, utilizing the shift physical. During a review of the facility's policy and procedure (P&P) titled, Safety measures for pediatric residents, reviewed in 04/2021, the P&P indicated that All caregivers are to observe the safety measures for Pediatric residents in order to provide a safe and secure environment for pediatric residents. During a review of the facility's policy and procedure (P&P) titled, Mechanical Ventilation, with last reviewed date 12/2022, the P&P indicated, In order to ensure that patient-ventilator monitoring are being performed according to these guideline and indicator should be created to monitor this activity as part of the department's quality assurance program. 555589 Page 4 of 4