Health inspection·August 14, 2024

(Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (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. § 72315. Nursing Service--Patient Car. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). §72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/26/2024, the California Department of Public Health (CDPH) received a complaint alleging Licensed Vocational Nurse (LVN 1) did not provide necessary treatments to the wound on a resident's (Resident 1) left foot, resulting in an infection and maggots to Resident 1's left foot, and Resident 1 being in pain, all day, from 9 a.m., until approximately 5 p.m. On 6/27/2024 at 1 p.m., CDPH conducted an unannounced visit to the facility to investigate the allegation. During the investigation, CDPH determined LVN 2 did not provide treatment to Resident 1's right medial leg wound, and maggots were present in Resident 1's wound. The facility failed to: 1. Provide a wound treatment to Resident 1's right medial leg wound, per Resident 1's physician's orders and Resident 1's care plan. 2. Follow the facility's Policy and Procedure (P/P), titled "Wound Care" and "Medication Orders" that indicated to ensure there was a physician's order for the procedure and when recording treatment orders, specify the treatment, frequency, and duration of the treatment. As a result of this deficient practice Resident 1's right medial leg wound was infested with maggots that were undetected by LVN 1 and LVN 2. Resident 1 was transferred to a GACH for evaluation and treatment. This deficient practice had the potential for worsening of Resident 1's right medial leg infection and increased infestation of maggots, potentially leading to physical and psychological harm. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was originally admitted to the facility on 1/24/2024 and readmitted on 6/6/2024 with a diagnosis of type 2 diabetes mellitus ([DM] a condition associated with abnormally high levels of sugar in the blood). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 4/19/2024, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was at risk for developing pressure ulcers (breakdown of skin)/injuries. A review of Resident 1's Care Plan dated 6/12/2024, indicated Resident 1 had a right medial leg venous ulcer. The Care Plan's goal indicated Resident 1 would have no skin complications throughout the review date of 10/17/2024. The Care Plan's interventions included administering treatment per the physician orders. A review of Resident 1's Physician's Orders dated 6/20/2024, indicated to apply Gentamicin Sulfate External Ointment 0.1% (a medicated ointment applied on wound, used to treat infection) to Resident 1's right medial leg topically (applied to body surface) every day shift for green tinged exudate (a fluid which leaks out of damaged tissues) for 14 days. A review of Resident 1's Care Plan dated 6/20/2024, indicated Resident 1's right medial leg wound would present with no infection. The Care Plan's interventions included cleansing Resident 1's right medial leg wound with normal saline ([N/S] a solution that is a mixture of Sodium Chloride [salt] and water that has a number of uses in medicine including cleaning wounds), pat dry, apply Gentamycin 0.1% ointment to the site, cover with calcium alginate and cover with a dry dressing. A review of Resident 1's Change of Condition (COC) Note dated 6/26/2024, indicated on 6/26/2024 at 10:25 a.m., Resident 1's right medial leg had a foul odor with green exudate and Resident 1 verbalized pain of 6 out of 10 (on an 11 eleven point scale where pain in rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). The COC indicated Resident 1's physician ordered Resident 1 to be transferred a GACH for further evaluation. During an interview on 6/27/2024, at 1:45 p.m., LVN 1 stated the last time she changed Resident 1's right medial leg wound dressing was on 6/24/2024, she did not change Resident 1's dressing on 6/25/2024 because she had a personal emergency and had to leave the facility. LVN 1 stated on 6/25/2024 she was at Resident 1's bedside with LVN 2 and before she left the facility at approximately 2 p.m., she asked LVN 2 to complete the treatment to Resident right medial leg wound. LVN 1 stated on 6/26/2024 at approximately 10:30 a.m., when she assessed Resident 1's right medial leg dressing she saw that the dressing looked moist, as though it had not been changed on 6/25/2024. LVN 1 stated when she (LVN 1) removed Resident 1's dressing, she observed maggots in Resident 1's wound. During an interview on 6/28/2024, at 10:30 a.m., LVN 2 stated on 6/25/2024 she was at Resident 1's bedside with LVN 1, when LVN 1 had to leave the facility and LVN 1 asked her (LVN 2) to complete the dressing change on Resident 1's right foot. LVN 2 stated she (LVN 2) saw a wound on top of Resident 1's right foot and assumed that was the wound that LVN 1 was talking about. LVN 2 stated she placed a dressing on top of the wound on Resident 1's right foot and did not see the other wound (on Resident 1's right medial leg). LVN 2 stated the endorsement from LVN 1 regarding Resident 1's right foot wound treatment was very confusing. During a concurrent interview and record review on 6/28/2024 at 12 p.m., with LVN 1, Resident 1's physician orders dated 6/28/2024 were reviewed. The physician's orders did not indicate to cleanse the right leg medial wound with N/S, pat dry, apply Gentamycin 0.1% ointment to the site, cover with calcium alginate and cover with a dry dressing. LVN 1 stated, she failed to add the complete wound care treatment order to Resident 1's treatment regimen per the physician's instructions, and because of that Resident 1's wound was not treated as ordered. During an interview on 6/28/2024 at 1:05 p.m., and after reviewing Resident 1's Physician's Orders for wound care, dated 6/28/2024, the Director of Nursing (DON) stated, the Physician's Orders only indicated to apply Gentamicin to the infected wound on Resident 1's right medial leg. The DON stated the nursing staff should have ensured the accuracy of Resident 1s' wound care treatment, per the physician's orders, and not doing so resulted in Resident 1's right leg wound not being treated on 6/25/2024. A review of the facility's policy and procedure (P&P) titled, "Wound Care" revised 10/2010, indicated "the purpose of this procedure is to provide guidelines for the care of wounds to promote healing." The P&P indicated to ensure there is a physician's order for the procedure. A review of the facility's P&P titled, "Medication Orders," revised 11/2014, indicated when recording treatment orders, specify the treatment, frequency, and duration of the treatment. The facility failed to: 1. Provide a wound treatment to Resident 1's right medial leg wound, per Resident 1's physician's orders and Resident 1's care plan. 2. Follow the facility's Policy and Procedure (P/P), titled "Wound Care" and "Medication Orders" that indicated to ensure there is a physician's order for the procedure and when recording treatment orders, specify the treatment, frequency, and duration of the treatment. As a result of this deficient practice Resident 1's right medial leg wound was infested with maggots that were undetected by LVN 1 and LVN 2. Resident 1 was transferred to a GACH for evaluation and treatment. This deficient practice had the potential for worsening of Resident 1's right medial leg infection and increased infestation of maggots, potentially leading to physical and psychological harm. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.