Health inspection·September 18, 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 observation, interview, and record review, the facility failed to ensure staff provide preventive care by consistently turning residents every 2 hours on two of two sampled residents (Resident 41 and Resident 42). Residents Affected - Few This failure had the potential to result in worsening of pressure injury (bed sore, injury to skin and underlying tissue resulting from prolonged pressure on skin) for Resident 41 and developing new pressure injury for Resident 42. Findings: During a review of Resident 41's History and Physical (H&P), dated 07/14/2023, the H&P indicated, Resident 41 was admitted to transitional care unit (where assists patients as they transition from a stay in the hospital to home or another level of care) for hypotension (low blood pressure). Patient had hemiparesis (weakness to move on side of body) affecting left side as late effect of cerebrovascular accident (damage to brain from interruption of its blood supply) and generalized weakness. During a review of Resident 41's care assessment dated 07/14/2023, the care assessment indicated, Resident 41 ' s Braden Scale (a tool to assess risk for developing pressure injury) Score was 12 (indicates high-risk for developing a pressure injury). During a review of Resident 42's History and Physical (H&P), dated 09/15/2023, the H&P indicated, Resident 42 was admitted to transitional care unit for rehabilitation. Patient had sepsis (a life-threatening complication of an infection), hypertension (high blood pressure), diabetes mellitus (high blood sugar), cellulitis (bacterial skin infection) and debility (physical weakness). During a review of Resident 42's PCS Open Chart dated 09/14/2023, the PCS Open Chart indicated, Resident 42's Braden Scale (a tool to assess risk for developing pressure injury) Score was 14 (indicates moderate-risk for developing a pressure injury). During an interview, on 09/19/2023 at 11:07 a.m., with Wound Care Ostomy Nurse (WCON) 1, WCON 1 stated with Braden Scale (a tool to assess risk for developing pressure injury) score of 18 or below, high risk turning protocol will be triggered to prompt nurses to document turning every 2 hours. During an interview, on 09/21/2023 at 11:16 a.m., with Resident 42, Resident 42 stated he could only turn a little and the staff turned him when changing him and when therapy comes once a day. During an interview on 09/21/2023 at 11:19 a.m., with director of TCU (DIR), DIR confirmed both Resident 41 and Resident 42 were on high risk turning protocol which required turning every 2 hours. Page 1 of 2 555610 555610 09/18/2023 Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723

F 0686 DIR stated turning patient every 2 hours was to prevent pressure over the bony prominence. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 09/21/2023 at 11:39 a.m., with DIR, Resident 42's Photographic Wound Documentation dated 09/20/2023 was reviewed. The Photographic Wound Documentation indicated, a picture of Resident 42 ' s right buttock has an open wound without measurement. DIR stated nurse discovered the open wound on 09/20/2023. Residents Affected - Few During a concurrent interview and record review on 09/21/2023 at 11:53 a.m., with DIR, Resident 42's care assessments was reviewed. The care assessments indicated, the last documented patient position was right side on 09/21/2023 at 4 a.m. DIR confirmed there was no documentation of turning since then. During a concurrent interview and record review on 09/21/2023 at 11:58 a.m. with Corporate Director of Nursing (CDN), Resident 42's care assessments from 09/14/2023 to 09/21/2023 was reviewed. The care assessments indicated, patient position was not documented every 2 hours on multiple dates. CDN stated the documentation did not reflect turning patient every 2 hours. During a review of Resident 41's care assessment from 08/19/2023 to 08/25/2023, the care assessment indicated there was no patient position documentation from 2 p.m. to 10 p.m. on 08/21/2023. During a review of Resident 41's Wound Consultation Note dated 08/22/2023, the Wound Consultation Note indicated Resident 41 ' s stage 2 (partial thickness of dermis loss) coccyx (tailbone) pressure injury became stage 3 (full thickness tissue loss). During a review of the facility's policy and procedure (P&P) titled, Skin Care Wound Care #S-200 dated 06/2021, the P&P indicated, Total Braden Score of 13 -14 is considered moderate risk. Intervention include: Frequent turning a minimum of every 2 hours .Total Braden Score of 10 - 12 is considered high risk .Intervention include: Frequent turning a minimum of every 2 hours. 555610 Page 2 of 2