Health inspection·March 17, 2023

42 CFR § 483.25(b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that— (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 22 CCR § 72311 Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 22 CCR § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 1/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to provide the necessary treatment and services to prevent the formation and progression of a pressure injury (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to the sacrococcyx (pertaining to the large, curved, triangular-shaped bone at the base of the spine and tailbone) for Resident 93 as per the facility’s policy, by failing to: a. Ensure wound weekly monitoring assessments were completed to determine the healing status of Resident 93’s sacrococcyx pressure injury. b. Notify the physician on 12/27/2022 when Resident 93’s wound treatment order came to an end which resulted in Resident 93 not receiving wound treatment since 12/27/2022 until a new treatment was ordered on 1/2/2023. c. Notify the Registered Dietitian (RD) to provide nutritional recommendations to promote healing of the pressure injury when Resident 93’s sacrococcyx wound worsened from a stage three (3) pressure injury (full-thickness loss of skin, in which subcutaneous [beneath the skin] fat may be visible in the injury) to a stage four (4) pressure injury (a deep wound reaching the muscles, ligaments, or bones). d. Ensure Resident 93’s skin checks were conducted by the Certified Nursing Assistants (CNAs) during shower days (12/23/2022, 12/26/2023, 12/30/2023, and 1/6/2023). As a result, Resident 93 developed a facility-acquired (developed after admission to the facility) stage 3 sacrococcyx pressure injury that progressed to a stage 4 pressure injury while in the facility. A review of Resident 93’s Admission Record indicated the facility admitted the 70-year-old female resident on 5/27/2021 with diagnoses including diffuse traumatic brain injury (a sudden, violent blow or jolt to the head that causes damage to the brain) with loss of consciousness of unspecified duration, generalized muscle weakness, and diabetes mellitus type two (a chronic disease characterized by high levels of sugar in the blood due to impairment in the way the body regulates and uses sugar for fuel). A review of Resident 93’s Wound Weekly Monitoring Assessment - Pressure, dated 5/28/2021, indicated Resident 93 did not have a sacrococcyx wound upon admission. A review of Resident 93’s Wound Weekly Monitoring Assessment, dated 9/24/2022, indicated a stage 3 sacrococcyx wound measuring 1 centimeter (cm – unit of measure) in length by 1 cm in width by 0.2 cm in depth with no undermining (erosion under the wound edges resulting in a large wound with a small opening) or tunneling (wound that has progressed to form passageways underneath the surface of the skin). A review of Resident 93’s Braden Scale for Predicting Pressure Sore Risk form (Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries), dated 11/30/2022, indicated the resident was a high risk for developing pressure injuries. A review of Resident 93’s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/30/2022, indicated Resident 93’s cognitive skills (the act or process of knowing and perceiving) for daily decision making were severely impaired and Resident 93 was totally dependent on staff with two people assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from bed, chair, wheelchair, standing position), dressing, and toilet use. A review of Resident 93’s Wound Consultation Notes by Wound, Ostomy (an artificial opening in an organ of the body created during an operation) and Continence Nurse 1 (WOCN 1), dated 12/16/2022, indicated a stage 3 pressure injury described as crater-like injury extending through dermis to subcutaneous tissue but not through fascia. A review of Resident 93’s Wound Weekly Monitoring Assessment, dated 1/13/2023, indicated an unstageable (full thickness tissue loss in which the base of the injury is covered by slough [yellow, tan, gray, green, or brown colored dead tissue separating from living tissue] and/or eschar [collection of dry, dead tissue within a wound that appears tan, brown, or black] in the wound bed) sacrococcyx wound measuring 6 cm in length by 6 cm in width with 80% slough, 10% granulation (pink lumpy tissue that forms during wound healing), and 10% epithelialization (formation of new tissue covering the wound surface). A review of Resident 93’s COC, dated 1/16/2023, indicated the resident’s pressure injury had deteriorated as evidenced by an increase in size and depth and that the Medical Doctor (MD) had reclassified the sacrococcyx wound from stage three pressure injury to stage four pressure injury. The COC did not specify the name of the MD being referenced to. A review of Resident 93’s Wound Weekly Monitoring Assessment - Pressure, dated 1/16/2023, indicated a stage 4 sacrococcyx wound measuring 8.5 cm in length by 8.5 cm in width by 4 cm in depth with undermining of 4 cm noted at 9 to 4 o’clock (a method using the face of the clock to guide measurement). The assessment further indicated muscle and tendon were exposed with 30% slough, 60% granulation, and 10% epithelialization. A review of Resident 93’s Care Plan, dated 1/16/2023, indicated the resident was at risk for further deterioration of the stage 4 sacrococcyx pressure wound and indicated interventions that included monitoring and reassessing pressure injury for healing weekly, providing treatment as ordered and changing treatment when signs of healing are not noted, RD evaluation as ordered, and notifying MD for changes. The Care Plan did not specify the name of the MD being referenced to. A review of Resident 93’s Wound Consultation Notes by WOCN 1, dated 1/17/2023, indicated the sacrococcyx wound deteriorated to stage 4 with visible muscle and bone and malodor (a very unpleasant smell) noted. The wound consultation note indicated Resident 93 was noted with slight fever of 100.4 degrees Fahrenheit (unit of measure) and signs and symptoms of infection were noted that included increased pain, increased drainage, and increased wound size. Medical Doctor 1 (MD 1) was notified of the changes. During a concurrent interview and record review, on 2/1/2023 at 10:45 a.m., Treatment Nurse 1 (TN 1) stated Resident 93 developed a stage 3 pressure injury on the sacrococcyx that had reopened on 9/23/2022 at the facility. TN 1 reviewed Resident 93’s Wound Weekly Monitoring Assessment, dated 9/24/2022 to 1/27/2023, and stated that weekly assessments of Resident 93’s sacrococcyx pressure injury were not done on 12/30/2022 and 1/6/2023. TN 1 stated she was not aware the weekly assessments were not completed until 1/13/2023 when the next weekly wound assessment was due since she was not working from 12/24/2022 to 1/2/2023 and TN 1 was not assigned to Resident 93 on 1/6/2023. TN 1 stated the treatment nurse assigned to Resident 93 on 12/30/2022 and 1/6/2023 should have assessed the wound and documented on the Wound Weekly Monitoring Assessment form. TN 1 further reviewed Resident 93’s physician’s order and stated the following order: Cleanse with half-strength Dakin’s (solution is used to prevent and treat skin and tissue infections), pat dry, apply gentamycin (antibiotic) ointment on wound bed first, then apply thin layer of triad paste (topical wound dressing), apply skin prep to periwound (tissue surrounding a wound), and cover with foam dressing every day shift every other day for wound management for 14 days, ordered on 12/17/2022. TN 1 reviewed Resident 93’s Treatment Administration Record (TAR) for December 2022 and January 2023 and stated a wound treatment was missed on 12/29/2022 which should have been the last treatment date for the specified order. TN 1 stated that no wound treatments were provided for Resident 93’s sacrococcyx pressure injury since 12/27/2022 until a new treatment order was obtained from the physician on 1/2/2023, with instructions to cleanse with normal saline, pat dry, apply Medihoney (is a brand name of a wound and burn gel made from 100% Leptospermum [Manuka] honey), followed by calcium alginate (dressing used for moderate to heavily draining wounds), apply skin prep to periwound, and cover with foam dressing every day shift. TN 1 stated there is potential outcome for the wound to deteriorate further if treatments are missed. TN 1 stated Resident 93’s sacrococcyx wound had deteriorated to a stage 4 pressure injury with exposed muscle and tendon when she reassessed the wound on 1/16/2023 and verified the wound had grown larger measuring 8.5 cm in length by 8.5 cm in width by 4 cm in depth with undermining of 4 cm noted. During an interview on 2/1/2023 at 2:08 p.m., the Assistant Director of Nursing (ADON) stated she worked on 12/30/2022 and was assigned to Resident 93. The ADON stated she typically does not provide wound treatments but would fill in as wound treatment nurse when needed. The ADON stated she was not aware Resident 93 had a sacrococcyx wound and stated she did not complete the weekly wound assessment for Resident 39 on 12/30/2022 since she was not aware Resident 93 was due for one. During a concurrent record review of Resident 93’s TAR, the ADON stated that the facility did not provide any wound treatment to Resident 93 on 12/30/2022. The ADON stated that she was unaware at that time (12/30/2022) that Resident 93’s wound treatment had been completed and that a new order had to be obtained to continue treatment for Resident 93’s sacrococcyx wound. The ADON stated that had she known at that time (12/30/2022) that Resident 93 had no further wound treatments ordered for her unhealed sacrococcyx pressure injury, she would have called the registered nurse (RN) to assess and evaluate the wound with her and contact the physician to determine if any changes would need to be made to continue or order a new treatment. The ADON stated there was a potential for Resident 93’s sacrococcyx wound to deteriorate further due to wound treatments not being continued and missed opportunities for assessments to monitor the progress of the wound. During a concurrent interview and record review, on 2/1/2023 at 2:28 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she worked on 1/6/2023 and was assigned to residents in station 2 including Resident 93. LVN 3 reviewed Resident 93’s TAR and stated the wound treatment was provided for Resident 93 on 1/6/2023. However, LVN 3 stated she did not get a chance to observe Resident 93’s sacrococcyx wound since the treatment was provided by another LVN who offered to assist her that day. LVN 3 stated that a wound assessment was not completed on 1/6/2023 and only the ordered wound treatment was done. LVN 3 stated the weekly wound assessment should have been completed to measure the wound and monitor for any changes and abnormalities that needed to be communicated to the physician promptly. LVN 3 stated there is potential for further skin issues and worsening of existing pressure injuries if skin is not assessed weekly. During a concurrent interview and record review, on 2/2/2023 at 8:50 a.m., the RD stated she was unaware Resident 93’s sacrococcyx wound had deteriorated to a stage 4 pressure injury and stated that she was not notified and that she would have documented that in the dietary/nutritional progress notes addressing the wound. The RD stated she did not receive a call from the treatment nurse and that she did not receive an autopopulated (to automatically fill a form) alert via email which should have been triggered if a resident develops a wound or has a wound that has worsened. The RD reviewed Resident 93’s dietary progress note, dated 1/29/2023, and stated she did not make any changes or provide new recommendations for wound management since Resident 93’s most recent weekly wound assessment, dated 1/27/2023, indicated the sacrococcyx wound had decreased in size. The RD further stated the treatment nurse should have notified her immediately for timely interventions and recommendations for wound management since wound healing can be inhibited if interventions are not implemented promptly. The RD stated that if she had been notified, she would have made recommendations to check laboratory results for complete blood count (CBC, blood test used to look at overall health and help diagnose a medical condition), basic metabolic panel (BMP, blood test that measures the body’s fluid and electrolyte balance), albumin (is a protein made by the liver), and prealbumin, and reevaluated the need for zinc (essential mineral) and arginaid (a supplement) to promote wound healing. During a concurrent interview and record review, on 2/2/2023 at 10:19 a.m., TN 2 stated she worked on 12/29/2022 and that she was the only treatment nurse available during the day shift. TN 2 reviewed Resident 93’s TAR for December 2022 and stated there was no documented evidence that wound treatment was provided for Resident 93’s sacrococcyx pressure injury on 12/29/2022. TN 2 stated she did not provide wound care for Resident 93 on that day. TN 2 further stated she did not call the doctor for a new wound treatment order and that she was unaware the wound treatment for 12/29/2022 was the last scheduled treatment. TN 2 stated WOCN 1 should have been notified to ensure Resident 93 continued to receive wound treatments for her sacrococcyx pressure injury. TN 2 further stated it is important that treatments are not missed to prevent Resident 93’s wound from deteriorating and prevent wound infections. During an interview, on 2/2/2023 at 10:28 a.m., LVN 8 stated she worked on 12/29/2022 and stated she did not remember providing a wound treatment for Resident 93. LVN 8 stated that Resident 93’s TAR for December 2022 indicated that a wound treatment was not provided on 12/29/2022. During an interview, on 2/2/2023 at 3:45 p.m., WOCN 1 stated Resident 93’s sacrococcyx pressure injury was a stage 3 and was stable and small in size when she had visited the resident on 12/16/2022. WOCN 1 stated she was on vacation starting 12/22/2022 and her next visit to see Resident 93 was on 1/17/2023 when she noticed Resident 93’s sacrococcyx wound had suddenly worsened and deteriorated very fast. WOCN 1 stated she also found Resident 93 to have a fever of 100.4 degrees Fahrenheit and there was foul odor coming from the sacrococcyx wound. WOCN 1 confirmed Resident 93’s sacrococcyx wound had increased in size with visible muscle and bone and that the wound had progressed to a stage 4 pressure injury. WOCN 1 stated she notified MD 1 and ordered a wound treatment on 1/17/2023. WOCN 1 stated since she was not available, the treatment nurse should have called MD 1 prior to when the last treatment was provided on 12/29/2022 so there would be no lapse in wound treatment. During an interview, on 2/2/2023 at 5:16 p.m.,