Health inspection·July 16, 2021

The following reflects the findings of the California Department of Public Health during the investigation of Complaint Number 730408. Representing the Department: 34401, HFEN State Citation A was written. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. On 4/7/21, at 9:50 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding the quality of care for Resident 1 and wounds to his toes. Resident 1 was a 73-year-old male, admitted to the facility on 2/19/21 with diagnoses of chronic respiratory failure with hypoxia (low blood oxygen levels causing respiratory failure), dementia (impaired thinking ability and memory), and was dependent on supplemental oxygen. Based on interview and record review, the facility failed to assess, report, and document changes when skin issues were first identified on 3/17/21, for one of four sampled residents (Resident 1). This failure resulted in Resident 1's delayed treatment, development of gangrene (dead tissue caused by an infection or lack of blood flow), hospitalization, and amputation of Resident 1's left hallux (great toe) and left second toe. During an interview on 3/30/21, at 2:53 PM, with Resident 1's Family Member (FM) 1, FM 1 stated Resident 1 had been at the facility for approximately one month. FM 1 stated the facility did not make FM 1 aware of any concern or issues regarding Resident 1's left foot. FM 1 stated, on 3/22/21, FM 2 visited Resident 1 at the facility and had noted Resident 1's legs were "real dry, his left foot had scabs." FM 1 stated he notified the facility on 3/22/21, spoke to a charge nurse, and inquired about Resident 1's left foot but the charge nurse "didn't know anything about it [left foot]." FM 1 stated Resident 1 was transferred to the acute hospital on 3/24/21 and had undergone amputation to his left foot great toe and left second toe. FM 1 stated, "I just don't understand how they [the facility] didn't see that." During a review of Resident 1's shower sheet (facility document used for recording skin issues and dates of showers) dated 3/17/21, an outline of a human body had a line between the left great toe and second toe with the words hand-written "slight bigger." The shower sheet's signature line, for the Charge Nurse (Licensed Vocation Nurse [LVN] - nurse in charge) on the bottom of the sheet had no signature, it was left blank. During an interview on 4/7/21, at 12:09 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 3/17/21, he assisted Resident 1 during his shower and observed Resident 1's left foot great toe and left second toe to be "different, looked bigger." CNA 1 stated, he documented the observation on Resident 1's shower sheet and placed the shower sheet in a box located in the nurses' station for the assigned nurse to review. CNA 1 stated, he did not recall whether the assigned nurse had assessed Resident 1's left foot and stated, "The sheet would have been signed by the nurse if the assessment was done." During a concurrent interview and record review on 4/7/21, at 12:41 PM, with Director of Staff Development (DSD), Resident 1's shower sheet, dated 3/17/21 was reviewed. DSD stated, it was the facility practice for charge nurses to review residents' shower sheets before the end of the shift. DSD stated, the "Charge nurse looks at it [shower sheet], signs it acknowledging it was reviewed. If there is a skin issue noted on the shower sheet Charge Nurse must do a Change of Condition (COC), notify MD [medical doctor] and RP [responsible party], create a care plan, start a treatment, and must document on nurses note of the finding." DSD stated the charge nurse should have signed Resident 1's shower sheet and assessed Resident 1. DSD reviewed Resident 1's medical record. DSD was unable to find documented evidence the charge nurse had assessed Resident 1's left foot, was unable to find a COC note, care plan, treatment, or nurse's note. During a concurrent interview and record review on 4/7/21, at 12:46 PM, with Assistant Director of Nurses (ADON), Resident 1's medical record was reviewed. ADON was unable to find documented evidence of an assessment, COC note, or treatment of Resident 1's left foot on 3/17/21. ADON stated she had reviewed Resident 1's shower sheet, dated 3/17/21. ADON stated, "The assigned nurse should have reviewed Resident 1's shower sheet, signed it and assessed his [Resident 1] left foot." During a concurrent interview and record review on 4/7/21, at 1:15 PM, with Director of Nurses (DON), DON reviewed Resident 1's medical record. DON stated the charge nurse should have reviewed and signed Resident 1's shower sheet, dated 3/17/21, and assessed Resident 1. DON stated, "It looks like the shower sheets were being done but nobody seems to be looking at it." DON was unable to find documented evidence Resident 1's left foot was assessed on 3/17/21. During an interview on 4/12/21, at 1:49 PM, with LVN 1, LVN 1 stated, upon receipt of the residents' shower sheets from the CNAs, the charge nurse would sign off the shower sheets acknowledging the shower sheet was reviewed. LVN 1 stated, "If there is a new skin issue, we do a COC, notify family/MD [Medical Doctor], notify treatment nurse as well so she can take a look and make sure the treatment started is ok." LVN 1 stated she does not recall reviewing Resident 1's shower sheet dated 3/17/21 and stated, "If I did, I would have signed it." During a review of Resident 1's "Nurses Notes" (NN), dated 3/23/21, (6 days later) the NN indicated "discoloration to left foot ... dark/black/brown/dry tissue noted to top distal end of the great and second toe ... At top lateral side of left foot, excessive dryness and cracked skin is noted. Brown and red in color. Scant serosanguinous [yellowish fluid draining from wound] drainage." During a concurrent interview and record review on 4/21/21, at 1:19 PM, with Treatment Nurse (TN), the NN, dated 3/23/21, and Resident 1's shower sheet, dated 3/17/21, were reviewed. TN stated, on 3/23/21, at approximately 5 PM, she was made aware of the discoloration to Resident 1's left foot. TN stated, she assessed Resident 1's left foot and noted what was documented on the 3/23/21 NN. TN stated, she was not aware of Resident 1's skin issue noted on Resident 1's shower sheet, dated 3/17/21. TN stated the assigned charge nurse "should go and assess ... they [charge nurse] should have done a COC, notify MD, RP, put an order for monitoring ... there should be something documented." During a review of Resident 1's "Alteration in Respiratory" care plan, initiated on 2/19/21, interventions included "Observe feet and hands for edema, warmth, and color. If increased edema or significant discoloration noted, notify MD." During a concurrent interview and record review on 5/14/21, at 9:25 AM, with Nurse Practitioner (NP) 1, NP 1 stated, he visited Resident 1 at the facility on both 3/19/21, and 3/23/21. NP 1 stated face-to-face visits included reviewing residents' medical records, visiting and talking with residents, and assessing residents. NP 1 stated when the charge nurse made him aware of concerns for a resident, he would do a thorough head-to-toe assessment, otherwise he only performed a quick assessment wherever the resident was at the time of the visit including their room, hallway, etc. NP 1 stated, "If they [Residents] are in the hallway I will briefly look and talk to the patient." NP 1 reviewed Resident 1's physical exam note dated 3/19/21 and 3/23/21 and stated he had documented Resident 1 having "no rash or bruising." NP 1 stated the charge nurse did not make him aware of Resident 1 having any skin issues and he did not assess Resident 1's left foot on either 3/19/21 or 3/23/21. During a review of Resident 1's "Emergency Documentation," dated 3/24/21, the Emergency Documentation indicated, "Examination demonstrates left hallux and left second toe dry gangrene and minimally erythematous [skin redness] left foot with eschar [a dry dark scab] formation on the dorsum [bottom, sole] of the foot. . . Patient reports that symptoms began 3 weeks ago. . ." During a review of Resident 1's hospital Operative Report, dated 3/29/21, the Operative Report indicated, Resident 1 was diagnosed as having "gangrene to left foot and underwent left foot great toe and left second toe amputation." During a review of the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition or Status," dated 2017, the P&P indicated, "1.The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status." In violation of the above-cited standards, the facility failed to assess, report, and document changes when skin issues were first identified on 3/17/21 for Resident 1. This failure resulted in Resident 1's delayed treatment, development of gangrene, hospitalization, and amputation of Resident 1's left hallux and left second toe. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.