Other·July 22, 2022

42 CFR §483.25(b) Skin Integrity (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. 22 CCR §72311(a)(2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 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 4/26/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1, who had a pressure ulcer (also called bedsores or pressure sores, are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time) and was at risk for developing pressure ulcers, received the necessary care and services to prevent new ulcers from developing. The facility failed to: 1. Implement the Wound Care Specialist’s (Physician 1) treatment ordered on 3/16/2022 to apply Medihoney (a brand name of a honey-based gel used to treat open wounds) to Resident 1’s Stage 2 pressure ulcer (the sore has broken through the top layer of the skin and part of the layer below presenting as a shallow, open wound with a red or pink wound bed; may also present as an intact or open/ruptured blister) to the sacral area (the portion of the spine between the lower back and tailbone). 2. Implement Physician’s 1 order on 3/16/2022, to provide Resident 1 with a low air loss mattress (LALM - an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and wicks away any moisture as well as to relieve pressure). 3. Implement Physician’s 1 order dated 3/23/2022 to apply zinc oxide (an ointment used in wound treatment and prevention) to the healed sacral pressure ulcer area. 4. Implement Resident 1’s Care Plan interventions for skin breakdown risk to do daily skin checks while assisting the resident with activities of daily living (ADLs, such as bathing, personal hygiene, and dressing) and report changes, to have the licensed nurses do weekly skin check, and to apply a pressure-redistribution surface (mattresses and overlays designed to prevent pressure ulcers by spreading the pressure more evenly across the surface of the mattress). As a result, on 4/18/2022, Resident 1 was identified with four pressure ulcers: 1. A Stage 2 pressure ulcer on the right trochanter area (right hip). 2. A Stage 3 pressure ulcer (full thickness skin loss involving damage or necrosis [dead tissue] of subcutaneous [under the skin] fat may be visible, but bone, tendon, or muscle are not exposed) on the right buttock. 3. A UTD pressure ulcer (unstageable or undetermined stage because the ulcer is covered with slough [type of dead tissue yellow, tan, green or brown in color and may be moist, loose, and stringy in appearance] or eschar [type of dead tissue that presents as dry, thick, leathery tissue that is often tan, brown or black]; the ulcer will reveal either a Stage 3 or 4 pressure ulcer [deep wound that may involve muscle, tendons, ligaments, and bone]) on the left buttock. 4. A Stage 2 pressure ulcer on the left gluteal fold (fold of the buttock). The resident also had an oxygen saturation (the amount of oxygen circulating in the blood) between 88 and 92% (normal above 97%) and an elevated body temperature of 102 degrees Fahrenheit (°F, normal range between 97 to 99 °F), and was transferred to a general acute care hospital (GACH) by the paramedics (Emergency Medical Services) for treatment. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 3/2/2022 with diagnoses including left hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) and morbid (severe) obesity (the body weight is more than 80 pounds above the recommended body weight for an individual based on various factors). A review of Resident 1’s Skin Assessment form, dated 3/3/2022, indicated Resident 1 had an inner sacral area Stage 2 pressure sore. A review of Resident 1’s Physician Order, dated 3/3/2022, indicated to cleanse the Stage 2 sacral pressure sore with normal saline (NS, a salt solution), pat dry, apply Silvadene cream (an antimicrobial [an agent that kills or stops the growth of bacteria] medication to prevent wound infection) and cover with dry dressing for 21 days every day. A review of Resident 1’s Care Plan for skin breakdown risk, initiated on 3/3/2022, indicated a goal for the resident’s sacral wound to heal. The interventions included observe skin daily for signs and symptoms of skin breakdown and report abnormalities, pressure-redistribution surface to bed, and do weekly skin checks by license nurses. A review of Resident 1’s Minimum Data Set (MDS – standardized assessment and care planning tool), dated 3/9/2022, indicated the resident had memory problems, needed extensive staff assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident 1 was at risk for developing pressure ulcers and had a Stage 2 pressure sore. A review of Resident 1’s Wound Care Evaluation & Treatment by Physician 1, dated 3/16/2022, indicated Resident 1 had a Stage 3 pressure ulcer with a post debridement (removal of dead tissue) size of 12.0 centimeters (cm) long by 5.0 centimeters wide by 0.1 centimeters deep. Physician 1’s treatment plan included to cleanse the wound with NS, apply Medihoney and cover with Mepilex Border (a self-adherent, multilayer foam dressings) daily, turn the resident every two hours, avoid direct pressure on the ulcer site, and to provide the resident with a LALM. A review of Resident 1’s Wound Care Evaluation & Treatment by Physician 1, dated 3/23/2022, indicated Resident 1’s sacral Stage 3 pressure ulcer had healed. Physician 1’s treatment plan included to continue turning the resident every two hours, avoid direct pressure to the healed ulcer site, LALM and apply zinc oxide to the healed ulcer and surrounding area daily. A review of Resident 1’s Physician Orders for the months of 3/2022 and 4/2022, did not include Physicians 1’s orders for wound treatment and LALM dated 3/16/2022 and 3/23/2022. A review of Resident 1’s licensed nurses’ weekly summary between 3/23/2022 and 4/18/2022, did not indicate the resident had pressure sores. A review of Resident 1’s History and Physical (H&P) dated 3/29/2022, indicated Resident 1 was incontinent (ability to control) of urine and stool. A review of Resident 1’s Change of Condition (COC) form Evaluation, dated 4/18/2022, indicated Resident 1 had an oxygen saturation between 88 and 92% and an elevated body temperature of 102 °F. The licensed nurse called the paramedics (Emergency Medical Services) to transfer the resident to a GACH. The COC Evaluation indicated Resident 1’s skin status as having: 1. A Stage 2 pressure sore to the right trochanter area (hip) measuring 11 cm in length by 2.5 cm in width 2. A Stage 3 pressure sore to the right buttock measuring 10.5 cm by 4 cm. 3. A left buttock UTD measuring 11 cm by 6 cm. 4. A Stage 2 pressure sore to left gluteal fold measuring 1.5 cm by 1.5 cm. On 5/26/2022 at 2:30 p.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent review of Resident 1’s documentation prior to hospitalization on 4/18/2022, the ADON confirmed she assessed Resident 1’s skin prior to transfer to the hospital and identified four pressure ulcers as documented in the COC form for Resident 1, dated 4/18/2022. On 5/26/2022 at 3:45 p.m., during interview with the Treatment Nurse and concurrent record review, she stated that she was not aware of Physician 1’s treatment plan on 3/16/2022 for Medihoney and LALM or the zinc oxide ordered on 3/23/2022. Treatment LVN 2 stated she did not do a daily or weekly skin check since the pressure sore to the sacral area healed. On 5/26/2022 at 4:11 p.m., during an interview, the ADON confirmed Resident 1’s clinical record did not have Physician 1’s orders for a LALM since the visits on 3/16/2022 and 3/23/2022. The ADON confirmed Physician 1’s recommendations/treatment plan were orders that should have been transcribed into Resident 1’s clinical record. Resident 1 did not have the order to apply zinc oxide to Resident 1's healed ulcer on 3/23/2022 because it was not carried out. On 5/26/2022 at 5:10 p.m., during an interview with the Director of Nursing (DON) and a concurrent review of Resident 1’s clinical record, the DON confirmed the Wound Care Evaluation & Treatment by Physician 1 dated 3/16/2022 and 3/23/2022 treatment plans were orders and were not followed. On 6/2/2022 at 9:30 a.m., during an interview, Resident 1’s Responsible Party (RP 1) stated she visited Resident 1 three times a week and did not observe Resident 1 on a LALM. A record review of Resident 1’s GACH record titled "Nursing Narrative Note," dated 4/18/2022 at 10:30 a.m., indicated "1030 (10:30 a.m.) pt (patient) received via EMS (Emergency Medical Service) from nursing home for complaints of fever, tachycardia (rapid heart rate), and AMS (altered mental status) … pt has large sacral wound, unstageable and raw… pt immobile and has open sacral wound." A review of the facility’s policy and procedures (P&P) titled, "Skin Integrity Management," dated 5/26/2021, indicated "nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care." The P&P also indicated the facility will "implement pressure ulcer prevention for identified risk factors" and "Implement special wound care treatment/techniques, as indicated and ordered." Furthermore, the P&P indicated the facility will "notify physician / APP (Advanced Practice Providers) to obtain orders" and "review care plan and revise as indicated." The facility failed to ensure Resident 1, who had a pressure ulcer and was at risk for developing pressure ulcers, received the necessary care and services to prevent new ulcers from developing. The facility failed to: 1. Implement the Physician 1’s treatment ordered on 3/16/2022 to apply Medihoney to Resident 1’s Stage 2 pressure ulcer to the sacral area. 2. Implement Physician’s 1 order on 3/16/2022, to provide Resident 1 with a LALM. 3. Implement Physician’s 1 order dated 3/23/2022 to apply zinc oxide to the healed sacral pressure ulcer area. 4. Implement Resident 1’s Care Plan interventions for skin breakdown risk to do daily skin checks while assisting the resident with ADLs and report changes, to have the licensed nurses do weekly skin check, and to apply a pressure-redistribution surface. As a result, on 4/18/2022, Resident 1 was identified with four pressure ulcers: 1. A Stage 2 pressure ulcer on the right trochanter area. 2. A Stage 3 pressure ulcer on the right buttock. 3. A UTD pressure ulcer on the left buttock. 4. A Stage 2 pressure ulcer on the left gluteal fold. The resident had an oxygen saturation between 88 and 92% and an elevated body temperature of 102 °F and was transferred to a GACH by the paramedics (Emergency Medical Services) for treatment. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result Resident 1.