Health inspection·January 28, 2025

F686 Title 42 Code of Federal Regulations §483.25(b) Skin Integrity §483.25(b)(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. 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. §72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 12/27/2024, the California Department of Public Health (CDPH, the Department) conducted onsite investigation for an annual recertification survey. The facility failed to provide skin and pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedures for Resident 1, by failing to: a. Implement interventions to prevent Resident 1 from developing a stage 1 coccyx (tailbone) pressure injury. b. Create, implement, and update individualized interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent Resident 1's coccyx stage 1 pressure injury discovered on 12/2/2024 from progressing to a stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacrum (Large triangle bone above the tailbone) and coccyx on 12/18/2024. c. Develop individualized resident-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) interventions to address Resident 1's non-compliance with turning and activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. These deficient practices resulted in Resident 1 developing a stage 1 pressure injury which progressed to a stage 4 pressure injury in 16 days, requiring debridement (medical removal of dead, damaged, or infected tissue to improve healing, removal may be surgical, mechanical, or chemical therapy) of the pressure injury. A. A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/8/1998, with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), polyneuropathy (when multiple peripheral nerves become damaged) and overactive bladder (sudden urges to urinate that may be hard to control). A review of Resident 1's at risk for skin breakdown injury care plan, initiated 10/16/2024, indicated the resident was at risk for skin breakdown due to non-compliance with turning and repositioning, and ADL care. A further review of the care plan indicated the goal was for the resident's risk of skin breakdown to be minimized and the resident would cooperate. The care plan interventions indicated staff were to: - provide care and reposition with care rounds. - clean Resident 1's skin after each episode of incontinence. - encourage independent turning. - provide activities that allow for skin improvement. - provide education to resident, responsible party, and staff regarding special care. - provide pressure redistributing devices and assess for effectiveness. - provide skin care frequently. A further review of the care indicated there were no interventions to address what to do when the resident was non-compliant with turning and repositioning. A review of Resident 1's History and Physical (H&P), dated 11/11/2024, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 did not have any skin issues. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/19/2024, indicated the resident's cognition (ability to think, understand, and reason) was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, supports trunk or limbs, but provides less than half the effort) with bed mobility, oral hygiene, showering, dressing and personal hygiene. The MDS also indicated Resident 1 was always incontinent, at risk for developing pressure sores, and did not have any pressure ulcers present at the time of the assessment (11/19/2024). A review of Resident 1's Braden Scale (pressure sore risk predictor tool) dated 11/19/2024, indicated Resident 1 had a Braden score of 16 which indicated the resident in the at-risk category to develop a pressure injury. A review of Resident 1's Progress Note, dated 12/2/2024, indicated the resident was on monitoring for sacrum non-blanchable redness (blood flow does not return to skin when pushed down). The note also indicated the resident was encouraged to turn and reposition with assistance and the resident was kept clean and dry. A review of Resident 1's stage 1 sacrum pressure injury, initiated 12/2/2024, indicated the goal was for the wound to show signs of improvement. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning. - Encourage resident to frequently shift weight. - Evaluate skin for areas of blanching or redness. - Evaluate ulcer characteristics. - Keep skin clean and well lubricated. - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness. - Monitor nutritional status. - Monitor ulcer for signs of progression or declination. - Notify provider if no signs of improvement on current wound regimen. - Provide wound care per treatment order. - Refer to specialized practitioner for wound management. A review of Resident 1's Physician Assistant (a licensed health professional who works with physicians to provide patient care) Wound Care Note, dated 12/4/2024, was the initial evaluation of the wound (2 days after the identification of a stage 1 by facility staff). The Note indicated the wound was a stage 2 wound and measured 3.2 centimeters (cm) x 2.1 cm width x 0.8 cm (length x width x depth). The Note indicated Resident 1 received skin/tissue debridement (removal of dead skin tissue to help a wound heal) performed by sharp selective debridement using a curette (a surgical instrument designed for debriding biological tissue) and #15 blade (a surgical scalpel). A review of Resident 1's Physician's Order, dated 12/4/2024, for a treatment of the stage 2 pressure injury on the coccyx, "cleanse the area with normal saline (a saltwater solution), pat dry, apply Calmoseptine ointment (a topical medication used to protect and heal irritated or damaged skin) then cover with a bordered dressing every day until 1/4/2025." A review of Resident 1's stage 2 sacrum (coccyx) pressure injury care plan, initiated 12/4/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order A review of Resident 1's Wound- Weekly Observation Tool dated 12/5/2024, indicated Resident 1 had acquired while at the facility a Stage 1 pressure ulcer on the coccyx (tail bone) that measured 3.2 centimeters (cm) x 2.1 cm x 0.8 cm. The Wound - Weekly Observation Tool also indicated the skin around the wound was macerated (skin is soft, soggy, or wet to the touch which occurs when the skin is in contact with moisture for too long). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/11/2024, indicated Resident's coccyx stage 2 pressure injury worsened to a stage 3 (full-thickness loss of skin. Dead and black tissue may be visible). The SBAR indicated the resident was seen by wound physician assistant with new orders given. A review of Resident 1's Physician's Order, dated 12/11/2024, indicated an order for the treatment of the stage 3 coccyx pressure injury, "cleanse the area with sodium hypochlorite 0.25% (antiseptic, used prior to surgical procedures or for minor wound care to reduce risk of infection), pat dry, apply Mupirocin 2% ointment (a topical antibiotic used to treat skin infections caused by bacteria) and Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas), then cover with dry dressing every day until 1/11/2025." A review of Resident 1's Nurse's Note, dated 12/11/2024, indicated the resident was on monitoring for coccyx stage 3 pressure injury. The note indicated the resident was kept clean and dry, turned, and repositioned every 2 hours. A review of Resident 1's stage 3 sacrum pressure injury, initiated 12/11/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order - Refer to specialized practitioner for wound management A review of Resident 1's Wound- Weekly Observation Tool dated 12/12/2024 (one week later), indicated Resident 1's coccyx pressure ulcer was originally a stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) and was a stage 3 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the date of assessment (12/12/2024). The Wound Observation Tool indicated the wound was worsening. And the skin was devitalized (skin that is weak or no longer living, often due to injury or disease). The Wound Observation Tool indicated Resident 1's coccyx pressure injury measured 3.5 cm x 2.5 cm x 1 cm (an increase in size in length, width, and depth). A review of Resident 1's Nurse's Note, dated 12/13/2024, indicated the resident refused to be changed every hour. The Note further indicated the resident remained in the wheelchair does not want to be transferred into bed to get changed. The nurse explained the risks and benefits and the resident still refused. A review of Resident 1's Physician Assistant Wound Progress Note, dated 12/18/2024, indicated Resident 1 had a stage 4 pressure ulcer with necrosis of muscle and necrosis of bone. The Progress indicated the wound's healing status was declining. The note further indicated the wound underwent debridement and the type of tissue removed was necrotic subcutaneous tissue, devitalized subcutaneous tissue and necrotic muscle. A review of Resident 1's SBAR, dated 12/18/2024, indicated Resident 1's coccyx stage 3 pressure injury worsened to a stage 4. The SBAR indicated the resident was seen by a wound physician assistant with new orders given and carried out. The SBAR indicated the resident was medicated with Tylenol 650 mg 30 minutes prior to wound care. A review of Resident 1's Nurse's Note, dated 12/18/2024 timed at 6:29 PM, indicated the resident was on monitoring for a coccyx stage 4 pressure injury. The note indicated Resident 1 was turned and reposition every 2 hours. A review of Resident 1's stage 4 sacrum pressure injury care plan, initiated 12/18/2024, indicated the goal was for the wound to show signs of improvement. A review of the care plan indicated there were no updates to the care plan interventions. The care plan interventions included to: - Educate the resident/representative on causes of skin breakdown including transfer/positioning, good nutrition, and frequent repositioning - Encourage resident to frequently shift weight - Evaluate skin for areas of blanching or redness - Evaluate ulcer characteristics - Keep skin clean and well lubricated - Monitor bony prominences (areas where bones are close to the skin's surface, making them vulnerable to pressure) for redness - Monitor nutritional status - Monitor ulcer for signs of progression or declination - Notify provider if no signs of improvement on current wound regimen - Provide wound care per treatment order - Refer to specialized practitioner for wound management A review of Resident 1's Wound- Weekly Observation Tool dated 12/19/2024 (two weeks after the initial assessment), indicated Resident 1's coccyx pressure ulcer was a Stage 4. The Wound Observation Tool indicated the wound went from a stage 4 from a stage 3 and measured 4.1 cm x 3.5 cm x 1 cm (an increase in length and width. A review of Resident 1's Physician's Order, dated 12/19/2024, for the treatment of the stage 4 pressure injury on the coccyx, cleanse the area with Dakins 0.25% solution (an antiseptic first aid cleaning solution for wounds), pat dry, apply Mupirocin ointment and Santyl, then cover with dry dressing every day for 30 days. A review of Resident 1's Nurse's Note, dated 12/22/2024, indicated the resident refused to be turned and repositioned during the shift. The Nurse's Note further indicated the nurse explained the risks and benefits, but the resident stated they were comfortable in their position. During an observation in Resident 1's room with Licensed Vocational Nurse 3 (LVN 3), on 12/28/2024 at 2:25 PM, Resident 1's wound care was observed. During the observation Resident 1 was noted with a Sacro-coccyx (wound over the sacrum and coccyx) pressure sore that was open, deep, and the skin surrounding the wou