Health inspection·April 3, 2023

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 assess skin and reposition every two hours for 1 (one) of 1 (one) Patient (Patient 1). This deficient practice had the potential to result in Patient 1 to developed pressure ulcer wound (an injury that breaks down the skin and underlying tissue caused when an area of skin is placed under pressure). Residents Affected - Few Findings: A review of Patient 1's H&P, dated 01/07/2023, indicated Patient 1 was admitted for medical management, physical therapy, occupational therapy, respiratory therapy, tube feeding and ventilator management. A review of Patient 1's Wound Assessment and Progress Record, dated 01/07/2023 at 1:34 PM, indicated Patient 1 was immobile, had no pressure injuries on admission, and skin was intact. A review of Patient 1's Skin Assessment Flowsheets, dated 01/05/2023 at 12:15 AM, indicated Patient 1's Braden Score (skin risk assessment tool to identify potential for skin breakdown and pressure injury development) was 11, the score indicated risk for skin breakdown. A review of Patient 1's Discharge summary, dated [DATE] at 5:14 PM, indicated Patient 1's skin was negative for rash with no documentation of full body skin assessment documented. A review of Patient 1's Care Plan, last documented on 03/14/2023 at 3:33 PM, indicated Patient 1 was at risk for pressure/ulcer or skin breakdown due to impaired physical mobility, was totally dependent, required repositioning every two hours, and monitoring for signs of imparted skin integrity. A review of Patient 1's Positioning Flowsheet documentation, dated 03/15/2023, indicated Patient 1 was in a side-lying position, on his left at 3:48 PM. No additional documentation on 03/15/2023 demonstrating Patient 1's turning was performed. A review of Patient 1's medical records, dated 03/15/2023, demonstrated no documentation of skin assessment performed by the primary nurse on 03/15/2023 during 7AM-7PM shift. A review of Patient 1's Discharge Documentation, indicated, Patient 1 was discharged on 03/15/2023 at 4:35 PM. During an interview and concurrent record review on 04/03/2023 at 1:38 PM, with Charge Nurse (CN), Patient 1's medical record was reviewed. CN stated, he did not make any documentation of head-to-toe Page 1 of 2 555848 555848 04/03/2023 Providence Little Comp of Mary Subacute Care Ctr 1322 West Sixth Street San Pedro, CA 90732

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin assessment on the day of discharge and throughout his shift because it was not required from nursing on a daily basis. Charge nurse also stated he did not do the full body skin assessment prior to Patient 1's discharge. During an interview, on 04/03/2023 at 2 PM, with Nurse 1, Nurse 1 stated she did not do Patient 1's skin assessment throughout her 12 hour shift on 03/15/2023. During an interview on 04/03/2023 at 2:30 PM, with Nurse Manger, Nurse Manager stated performing skin assessments is required by nursing to be done every shift. Nurse Manager stated, per facility's policy, the nurses are required to provide daily skin assessments; the Certified Nursing Assistants (CNAs') are required to document turning and repositioning of patients after providing the care; and the skin assessments are expected to be performed by nursing staff prior discharge. A review of the facility' Policy and Procedures (P&P), titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, the P&P indicated, B. A complete skin assessment will be performed and documented each shift to detect tissue integrity issues. C. Documentation is to be completed in the Electronic Health Records (EHR) by nursing and ancillary staff as appropriate for the intervention, including skin assessment and interventions/prevention strategies implemented. E. Pressure reduction measures for skin breakdown prevention for at risk patients include repositioning patient at least every 2 hours while in bed. A review of the facility's P&P titled, Documentation, last revised on 01/2023, the P&P, Section A. indicated The RN is responsible for overseeing and coordinating the resident's plan of care. 555848 Page 2 of 2