Health inspection·October 10, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when license nurses did not accurately complete Resident 1's Skin Assessments. This failure had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data. Residents Affected - Few Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnoses including hypoxic ischemic encephalopathy (a type of brain damage that occurs when the brain has decreased oxygen or blood flow). Review of Resident 1's Nursing Notes, dated 8/15/24, indicated a license nurse checked on Resident 1's skin and noted dryness on left breast. Resident 1's weekly Skin Assessments, dated 8/16/24, were reviewed. There was a section asking if Resident 1 had impaired skin, and it was marked on No. Review of Resident 1's IDT: Special Issue, dated 8/19/24, indicated a licensed nurse checked on Resident 1's skin and noted swelling and discharge on the left nipple. Review of Resident 1's physician's order, dated 8/19/24, indicated to clean the affected site with NS (normal saline), put on Xeroform (topical medicated gauze used to cover wound), and cover it with Mepilex (topical foam dressing used to treat wound) every shift for 7 days on the left nipple. Review of Resident 1's physician's order dated 8/19/24 indicated, Amoxicillin-Pot Clavulanate (antibiotics, a medication to treat infections) Suspension reconstituted 400-57 milligram (mg, a type of unit measurement)/5 millimeter (ml, a type of unit measurement), give 3.1 ml two times a day for cellulitis for 7 days. Resident 1's weekly Skin Assessments, dated 8/22/24, were reviewed. There was a section asking if Resident 1 had impaired skin, and it was marked on No. During an interview and concurrent record review on 9/3/24 at 3 p.m. with the director of nursing (DON), she reviewed the above Skin Assessments and confirmed Resident 1's dryness on the left breast, and swelling and discharge on left nipple wound were not documented in the designated sections. The DON acknowledged Resident 1's Skin Assessments on 8/16/24 and 8/22/24 were not accurate. Page 1 of 2 555734 555734 10/10/2024 Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Skin Breakdown review date 11/30/2021, the P&P indicated, It is the policy of Sub-Acute/Skilled Nursing Facility to carefully assess and aggressively treat skin breakdown. It is the licensed nurse's responsibility to . document the lesions and skin assessment with appropriate interventions. During a review of the facility's policy and procedure (P&P) titled, Wound Care/Dressing Changes revised 11/22/2021, the P&P indicated, Perform wound assessment noting: location, size, depth, exudate, necrotic tissue, or granular tissue, appearance, surrounding skin condition, tunneling and infection. Also, note any redness, streaking, hot or swollen areas. 555734 Page 2 of 2