Health inspection·November 1, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint. Complaint number CA00858162. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 43454 A Class "A" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: F684 Quality of Care § 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, including but not limited to the following: (b) Skin Integrity Title 22 California Code of Regulations: § 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 8/29/2023, the California Department of Public Health made an unannounced visit to the facility to investigate an allegation regarding resident neglect and care/services not received per physician order. The facility failed to provide care consistent with professional standards to maintain skin integrity for Resident 1 by failing to: 1. Implement the Comprehensive Care Plan for diabetic ulcer (a slow-healing wound that commonly appears on the feet) interventions on monitoring Resident 1's blood sugar to help with wound healing. 2. Ensure that a recommendation of a vascular consult (a doctor who specializes in the treatment of arteries and veins) by the Wound Care Specialist/Nurse Practitioner (WCS) was followed up with the physician to obtain an order after Resident 1' s left heel wound size increased from 8/8/2023, with a measurement of 4.2 centimeters (cm, unit of measurement) length by 4.7 cm width, to a size of 4.4 cm length by 5 cm width on 8/15/2023. 3. Conduct an Interdisciplinary (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) care conference when Resident 1's left heel wound increased from 8/8/2023 to 8/15/2023 and WCS recommended a vascular consult. 4. Implement the facility' s policy and procedures (P&P) titled, "Pressure Ulcer [injuries to skin and underlying tissue resulting from prolonged pressure on the skin] and Wound Management" to evaluate and document the status of Resident 1's skin condition weekly and ensure that an accurate assessment of the wound was provided for Resident 1. 5. Ensure Resident 1 did not receive "Fibersource" (formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements and has higher carbohydrate content) tube feeding (TF- a method of supplying nutrients directly into the stomach) via gastrostomy tube (GT- a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) in accordance with a physician' s order. The facility was aware Resident 1 had diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and administered "Diabetisource" TF (a unique carbohydrate blend which includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia [high blood sugar]) to Resident 1. These deficient practices resulted in Resident 1 being transferred to the general acute care hospital 1 (GACH 1) on 8/23/2023, in need of intravenous (IV - administering fluid medication through a needle or tube inserted into a vein) antibiotics (medication that fight bacterial infection) and a left below the knee amputation (BKA, removal of the limb). Additionally, GACH 1 reported maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1's left heel wound upon admission in the Emergency Department (ED). FINDINGS: A review of Resident 1's Admission Record indicated that Resident 1 was originally admitted to the facility on 9/26/2014 and re-admitted on 2/10/2022 with diagnoses including type II DM, sepsis (a life-threatening condition that arises when the body ' s response to infection causes injury to its own tissues and organs) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). During a review of Resident 1's Physician Order Summary Report (POSR), dated 2/23/2023, indicated, "wound consult and treatment as indicated with Skilled Nursing Facility (SNF) wound care". During a review of Resident 1's Care Plan for DM initiated on 5/27/2023, the goal stated was, "will have no complications related to diabetes", with interventions included, "finger stick (blood tests conducted on capillary blood [sample of blood is obtained by pricking the skin's surface to obtain a drop or several drops of blood for laboratory testing] obtained by fingerstick) blood sugar check every six hours ...", and "fasting serum blood sugar (measures blood sugar after not eating) as ordered". During a review of Resident 1's POSR, an active order which was discontinued as of 5/27/2023 indicated, there was no order for monitoring Resident 1's blood sugar level via fingerstick every six hours. During a review of Resident 1's Care Plan for diabetic ulcer of the left heel initiated on 6/14/2023, indicated a goal of, "resident will have no complications related to ulcer", with interventions to, "monitor blood sugar levels" ..."monitor/document wound size, depth, margins, periwound tissue surrounding a wound] [skin, document progress in wound healing on an ongoing basis, notify medical doctor as indicated" ... "monitor/document/report as needed changes in wound color, temperature, sensation, pain or presence of drainage and odor" ... During a review of Resident 1's Non-Pressure Ulcer Skin Report, completed by Treatment Nurse (TXN), indicated from 8/2/2023 to 8/21/2023, no weekly progress report was documented regarding Resident 1's non-pressure ulcer skin by the TXN. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 8/14/2023, indicated Resident 1 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required extensive assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, dressing, toileting, and personal hygiene). The same MDS also indicated that Resident 1 was at risk for developing pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Resident 1's SNF Wound Care Notes dated 8/15/2023, completed by WCS indicated, i. Wound: left heel, diabetic wound ... ix. Plan: cleanse with NS [normal saline]and apply Santyl (used to remove dead tissue from wound) daily, also recommended a vascular consult for this left foot. During a review of Resident 1's SNF Wound Care Notes dated 8/22/2023, completed by WCS indicated, i. Wound: left heel diabetic wound ... xi. Overall wound condition: declined. xii. Plan: cleanse with Dakin's solution (strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) and apply Santyl (medicine that removes dead tissue from wounds) to the wound bed and vascular consult is needed. During a review of Resident 1's POSR, an active order as of 8/23/2023 indicated there was no order for monitoring Resident 1's blood sugar level via fingerstick every six hours. During a review of Resident 1's Medical Records from GACH 1 indicated the following: a. Resident 1 presented in the ED on 8/23/2023 with diagnosis of osteomyelitis (infection in the bone), abscess (buildup of a pus), sepsis, bacteremia (bacteria present in the bloodstream). b. Necrotic ulceration [ the death of cells in living tissue caused by external factors such as infection] to the left heel with presence of maggots and malodor (unpleasant smell). c. Left foot x-ray (use of invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) on 8/23/2023 resulted in an extensive subcutaneous gas with osseous erosion (the loss of bone from disease processes) of the posterior (back side) and inferior (below) calcaneus (large bone forming the heel) consistent with osteomyelitis. d. Resident 1's infection was too severe and a BKA had to be performed per orthopedic surgeon (examines, diagnoses, and treats diseases and injuries to the musculoskeletal system) on 8/25/2023. e. On 8/23/2023, Resident 1's glucose level test result was 213 milligram/deciliter (mg/dL) (high - normal glucose test is between 70 mg/dL - 100 mg/dL). During an interview with the WCS on 8/29/2023, on 12:07 p.m., WCS stated, Resident 1 has a diabetic ulcer on her left foot which he assesses and monitors once a week. WCS stated Resident 1's left foot wound had "drastically changed and declined" on 8/15/2023. WCS stated, as a result, he recommended for a vascular consult and communicated it to the TXN. WCS further stated, a vascular consult would be able to further examine Resident 1's left heel wound as she (Resident 1) may have some blockage in the arteries or veins. WCS further stated, since Resident 1 has a DM, her (Resident 1) blood sugar level would also be a factor why the wound was not healing. WCS stated, there was no blood sugar level monitoring ordered for Resident 1. During an interview with the TXN on 8/29/2023 at 12:42 p.m., TXN stated they first noted Resident 1 developed redness on her left heel while doing rounds with the WCS on 6/13/2023, skin was intact, no drainage was noted, no signs/symptoms (s/sx) of infection and no odor was noted. TXN stated, Resident 1's left heel was not getting better and the WCS recommended a vascular consult on 8/15/2023, but he did not follow up on it as he had forgotten to obtain an order from MD 1. TXN further stated, he did not do any skin weekly assessment on Resident 1's left heel after 8/2/2023 until 8/22/2023. During an interview and a concurrent record review with Registered Nurse (RN) 1 on 8/30/2023, at 11:37 a.m., Resident 1's care plan regarding blood glucose was reviewed. RN 1 stated, Resident 1's care plans indicated that Resident 1's blood glucose was to be monitored via fingerstick every six hours to aid in wound healing. RN 1 stated and confirmed, Resident 1 did not have any blood glucose level monitoring via fingerstick every six hours since 5/27/2023 and was unable to provide documentation of calling the doctor for an order to monitor Resident 1's blood glucose levels. RN 1 stated, Resident 1's left heel wound was not getting better, was not healing, and was getting bigger. RN 1 further stated, if a wound was not getting better, they need to consult with the physician and have an IDT meeting for further recommendations. During a concurrent interview and record review of Resident 1's IDT Care Conference Record with RN 1 on 8/30/2023, at 11:37 a.m., RN 1 verified, as of 8/15/2023, there was no IDT care conference conducted when Resident 1's left heel wound increased from 8/8/2023 to 8/15/2023 in which WCS recommended for a vascular consult. RN 1 stated, she was aware of the GACH 1's report of finding maggots in Resident 1's wound. RN 1 stated, the maggots came from a fly but unable to answer how the maggots got into Resident 1's wound. RN 1 further stated, she had seen flies around the facility at times. RN 1 further stated she was unaware of the WCS recommendation for a vascular consult on 8/15/2023, but it should have been followed up. RN 1 stated licensed nurses are responsible for obtaining an order from the physician and calling for a vascular surgeon to make an appointment and arrange transportation for an appointment. RN 1 stated, if a vascular surgeon was consulted, it would have helped with Resident 1's wound healing. A review of Resident 1's POSR, dated 8/30/2023, indicated, "enteral feed - order every shift continuous feeding of Diabetisource via GT ..." During an observation of Resident 1 on 9/12/2023, at 10:25 a.m., Resident 1 was observed receiving enteral TF of "Fibersource" via GT. During a concurrent observation, interview, and record review with RN 1 on 9/12/2023, at 11:01 a.m., RN 1 observed Resident 1 was receiving "Fibersource" enteral TF with the surveyor. RN 1 stated, physician ordered "Diabetisource" for Resident 1 but was receiving the incorrect TF of "Fibersource". RN 1 stated Resident 1's was not receiving the correct nutrition and at risk of high blood sugar due to a higher carbohydrates content of "Fibersource." A review of the facility's P&P titled, "Pressure Ulcer and Wound Management (includes non-pressure ulcer wounds)", with review date of 9/12/2022 indicated, "it is the policy of this facility to ensure that resident's skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown ... skin assessment: the licensed nurse may assess resident's skin integrity at the minimum the following intervals: licensed nurse weekly progress review, upon completion of nursing weekly summary, the skin assessment is documented in the resident weekly summary ... evaluation: a licensed nurse on a weekly basis evaluates and documents the status of the pressure ulcers condition on the skin breakdown progress report and licensed nurse weekly progress notes and notifies the physician of pressure ulcer deterioration or lack of pressure ulcer progress." A review of the facility's P&P titled, "Foot Care", with reviewed date of 9/12/2022 indicated, "the purpose of foot care is to cleanse, prevent infection, control odor and stimulate peripheral circulation." A review of the facility's P&P titled, "Nursing Care of the Resident with Diabetes Mellitus", with review date of 9/12/2022, indicated, "glucose monitoring: the management of individuals with diabetes mellitus should follow relevant protocols and guidelines ... medication management: the nurse will closely monitor the diabetes management of cognitively impaired residents, assist the resident with his or her specific medication regimen, as ordered and as needed." A review of the facility's P&P titled, "Care Plans, Comprehensive Person-Centered," with review date of 9/12/2022 indicated, "a comprehensive, person-centered care plan must include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident," ... "each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: ... receive the services and/or items included in the plan of care," ... "the IDT must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met." A review of the facility's P&P titled, "Interdisciplinary Team Care Conference," with review date of 9/11/2023, indicated, "to provide an interdisciplinary discussion of residents' individualized status for integration into care plan approaches and goals ... The resident care coordinator is responsible for the timely and efficient facilitating of the IDT care conferences." A review of the facility's P&P titled, "Tube Feeding," with review date of 9/12/2022, indicated, "the purpose of a tube feeding is to administer specially prepared nutrients into the stomach ... the tube feeding procedure will be performed by the licensed nurse according to the physician's order." The facility failed to provide care consistent with professional standards to maintain skin integrity for Resident 1 by failing to: 1. Implement the Comprehensive Care Plan for diabetic ulcer interventions on monitoring Resident 1's blood sugar to help with wound