Other·September 22, 2023

42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). 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: (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. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. 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 7/26/23 the California Department of Public Health (CDPH) received a complaint alleging the facility failed to treat severe infections under Resident 1’s breast and groin area. Resident 1 requested the facility be investigated for lack of treatment and care. The facility failed to: 1. Notify Resident 1’s Physician (MD) about Resident 1’s skin rash underneath the right and left breast and groin areas for evaluation and treatment. 2. Ensure the Licensed Nurses (LVNs) assessed and documented Resident 1’s skin rash located underneath the right and left breast and groin areas after Certified Nursing Assistants (CNAs) documented Resident 1’s skin rashes on 20 skin check sheets. 3. Develop and implement a care plan to address the rashes underneath Resident 1’s right and left breast and groin area. As a result, there was a two-month delay in treatment to Resident 1’s Moisture-Associated Skin Damage ([MASD] inflammation or skin erosion caused by prolonged exposure to various sources of moisture including urine, stool or sweat). Resident 1 endured constant skin irritation under her right and left breasts and groin area and was transferred to a general acute care hospital (GACH) on 7/25/2023. Resident 1 was found to have skin breakdown to both breasts with malodorous (unpleasant or offensive odor), grey, and thick discharge extending to the perineal area (located between the anus and vagina). Resident 1 also had skin breakdown to the lower abdominal wall in the groin area that was malodorous and wet. Resident 1 remained in the GACH until 8/4/2023. A review of Resident 1’s face sheet (admission record) indicated Resident 1 was an 87-year-old female initially admitted to the facility on 2/22/2022 and re-admitted on 3/10/2023, with diagnoses including diabetes (abnormal blood sugar), cardiomegaly (enlargement of the heart), and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). A review of Resident 1’s History and Physical (H/P) dated 11/14/2022, indicated Resident did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ((MDS) an assessment and care planning tool), dated 3/23/2023, indicated Resident 1 could sometimes understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for bed mobility, transfer, locomotion (moving from one area of the unit to another), dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 had MASD. A review of Resident 1’s Baseline Admission/Readmission Screen (BARS), dated 3/10/2023, indicated Resident 1 had right and left breast fold MASD with moist fragile skin, and abdominal fold MASD with moist tender fragile skin. A review of Resident 1’s Braden Scale ((BS) a standardized, evidence-based assessment tool commonly used in health care to assess and document a resident's risk for developing pressure injuries), dated 3/10/2023, indicated a score of 13, indicating Resident 1 was at moderate risk for developing a pressure ulcer (injury to the skin and underlying tissue) related to moist skin, very limited mobility, and the resident requiring moderate to maximum assistance moving. A review of Resident 1’s care plan (CP) titled, “The resident has potential/actual impairment to skin integrity of the Right Breast Fold Related to MASD,” dated 3/11/2023, indicated nursing staff would ensure Resident 1 maintained clean and intact skin through the review date. The CP nursing interventions indicated to: 1. Identify and document potential causative factors and eliminate/resolve where possible. 2. Keep Resident 1’s skin clean and dry. 3. Educate Resident 1 to avoid scratching her skin and to keep her hands or any body parts from excessive moisture. A review of Resident 1’s “Skin Check Sheet (SCS)”, dated 5/16/2023, indicated Resident 1 had a very bad rash with skin discoloration, redness, and rash under her breast and private (groin) area. The SCS was signed and dated by the CNA and the charge nurse. A review of Resident 1’s “Order Summary Report”, dated 5/31/2023, did not indicate a physician order for treatment of Resident 1’s MASD to the left and right breast and groin area. A review of Resident 1’s “Treatment Administration Record (TAR)”, dated May 2023, did not indicate treatment for Resident 1’s MASD to the right and left breast and groin area. A review of Resident 1’s SCS for the month of June 2023, indicated Resident 1 had a “rash” underneath her breast on the following dates: 6/4, 6/6, 6/8, 6/12/ 6/17, 6/28, 6/21, and 6/22/2023. A review of Resident 1’s SCS for the month of July 2023, indicated Resident 1 had a “rash” underneath her breast on the following dates: 7/2, 7/5-6, 7/9, 7/13, 7/17-18, and 7/20- 22/2023. A review of Resident 1’s “Interact Transfer Form V5 (ITV5)”, dated 7/25/2023, indicated Resident 1 was transferred to a general acute care hospital (GACH) for epigastric (upper abdomen) pain. The ITV5 form section for “skin/wound care area” was left blank and did not indicate Resident 1 had rashes, wounds, bruises, or any skin condition. A review of the GACH’s report titled, “Consult to Social Work”, dated 7/25/2023, indicated Resident 1 reported severe infections under her breast and groin area which the facility staff did not treat. The report indicated Resident 1 requested a proper wound care assessment and insisted the facility be evaluated for lack of care. A review of the GACH report titled, “Emergency Department, Physical Exam”, dated 7/25/2023, indicated Resident 1 had hygiene issues with skin breakdown. The report indicated Resident 1 had skin breakdown to both breasts with malodorous, grey, and thick discharge going down to the perineal area, and skin breakdown at the lower abdominal wall in the groin area that was malodorous and wet. During a concurrent interview and record review on 8/18/2023 at 12 p.m., with the Wound Treatment Nurse (LVN 1), Resident 1’s TARs for the months of May, June and July 2023 were reviewed. LVN 1 stated he (LVN 1) did not review Resident 1’s skin check sheet. LVN 1 stated not assessing Resident 1’s skin and reviewing the skin log may cause important skin changes go untreated and cause skin irritation to the resident. LVN 1 stated the facility needed a better system in place to communicate the residents’ skin changes. LVN 1 stated he did not perform any treatments to Resident 1’s breast and groin area in May, June, and July of 2023. LVN 1 stated he saw the CNAs documentations on the SCS but did not notify Resident 1’s physician. During a concurrent record review and interview on 8/18/2023 at 1:30 p.m., with the Director of Nursing (DON), Resident 1’s skin check log for May 16 through July 24, 2023, physician order summaries for March through July 31, 2023, the TAR for March through July 2023 and the skin care plan were reviewed. The DON stated Resident 1’s skin integrity care plan was not updated to reflect Resident 1’s skin impairment underneath the left and right breast and groin area. The DON stated there was no documentation to indicate there was observation, monitoring or assessments performed on Resident 1’s right and left breast and groin area. The DON stated there was no documentation to indicate the physician was notified from 3/10/2023 through 5/16/2023, regarding the rash underneath Resident 1’s left and right breast and groin area. The DON stated, the rash underneath Resident 1’s right and left breast and groin were not treated from May through July of 2023. The DON also stated Charge Nurses, Supervisors and Treatment Nurses were responsible for assessing skin changes, and communicating with the physicians, implementing physician orders, documenting the change of condition, and updating care plans. During a telephone interview on 8/21/2023, with Resident 1’s family member (FM) 1. FM 1 stated Resident 1 had MASD underneath her abdomen and buttocks, when she was admitted to the facility and to the GACH. FM 1 stated Resident 1 complained of staff rough handling her during diaper changes and felt staff was removing her skin each time staff cleaned her buttocks. FM 1 stated the facility neglected Resident 1. A review of the facility’s Treatment Nurse’s job description, dated 2003, indicated the primary purpose of the Treatment Nurse was to provide primary skin care to residents under the medical direction and supervision of the resident’s attending Physicians, the Director of Nursing Services, or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders. The job description indicated the Treatment Nurse’s duties and responsibilities included conferring with the Director of Nursing Services and/or other Licensed Nursing Personnel regarding dermatologic disorders (disease or abnormalities affecting the skin) of residents in the facility and examine the resident and his/her records and charts and discriminate between normal and abnormal findings, and to recognize when to refer the resident to a Physician for evaluation, supervision, or directions. A review of the facility’s policy and procedure (P/P) titled, “Change in a Resident’s Condition or Status,” dated 5/2017, indicated the facility shall promptly notify the resident, his or her Attending Physician, and his or her representative of changes in the resident’s medical/mental condition and/or status including changes in the level of care. The P/P indicated the nurse will notify the resident’s Attending Physician or physician on call when there was an incident involving the resident; significant change in the resident’s physical/emotional/mental condition; a need to alter the resident’s medical treatment, and or specific instruction to notify the Physician of changes in the resident’s condition. The P/P indicated a “significant change” of condition is a major decline or improvement in the resident’s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. B. Impacts more than one area of the resident’s health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident’s assessment. A review of the facility’s P/P titled, “Bath Shower /Tub,” dated February 2018, indicated its purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident’s skin. The P/P indicated the staff will dry residents from the head to the waist before assisting him or her from the tub or shower, observe skin residents for any rashes, reddened areas or skin discoloration and document all assessment data (any reddened areas, sores, etc., on the resident’s skin) obtained during the shower/tub bath. The P/P indicated to notify the physician of any skin areas that may need to be treated. Report other information in accordance with facility policy and professional standards of practice. The facility failed to: 1. Notify Resident 1’s Physician about Resident 1’s skin rash underneath the right and left breast and groin areas for evaluation and treatment. 2. Ensure the LVNs assessed and documented Resident 1’s skin rash located underneath the right and left breast and groin areas after the CNAs documented Resident 1’s skin rashes on 20 skin check sheets. 3. Develop and implement a care plan to address the rashes underneath Resident 1’s right and left breast and groin area. As a result, there was a two-month delay in treatment to Resident 1’s MASD. Resident 1 endured constant skin irritation under her right and left beast and groin area and was transferred to a general acute care hospital (GACH) on 7/25/2023. Resident 1 was found to have skin breakdown to both breast with malodorous (unpleasant or offensive odor), grey, and thick discharge extending to the perineal area (located between the anus and vagina). Resident 1 also had skin breakdown to the lower abdominal wall in the groin area that was malodorous and wet. Resident 1 remained in the GACH until 8/4/2023. These violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1.