Health inspection·August 15, 2024

§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. § 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: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. 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. § 72315. Nursing Service--Patient Care. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing, and grooming of hair, oral hygiene, shaving or beard trimming, cleaning, and cutting of fingernails and toenails. The patient shall be free of offensive odors. . . . (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting, and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (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). On 7/1/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an allegation about quality of care. The facility failed to ensure Resident 1 received care consistent with professional standards of practice to prevent the development of a Stage 3 pressure ulcer by failing to: 1. Ensure Resident 1's right heel was elevated ([offloaded] minimizing or removing weight placed on the foot and heel to help prevent development and assisted in pressure ulcers healing) off the mattress and was not continuously laying directly on the mattress thus contributing to the development of Resident 1's right heel pressure ulcer. 2. Provide Resident 1 with a Low Air Loss Mattress ([LALM] a mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown. Air continually flows through tiny laser-made air holes in the top of the mattress surface so that a resident floats on a soft cushion of air) to prevent development of a Stage 3 pressure ulcer to the resident's right heel. 3. Ensure Resident 1 had an individualized plan of care (each resident’s conditions, abilities, needs, routines, and goals are unique, requiring a plan of care or road map for care that reflects who this individual is) with interventions to prevent development of a Stage 3 pressure ulcer to Resident 1’s right heel. 4. Ensure Resident 1’s Skin and Wound Assessment documentation was completed and accurate in accordance with facility’s policy and procedure (P&P) titled, "Charting and Documentation." 5. Ensure nursing staff inspected Resident 1’s skin when performed or assisted the resident with a personal care, or activities of daily living ([ADLs] a basic tasks that must be accomplished every day for an individual to thrive) in accordance with the facility’s policy titled, "Prevention of Pressure Injuries," and as indicated on the care plan titled, "Activities of Daily Living." As a result, Resident 1 developed a Stage 3 (full thickness loss of skin in which subcutaneous fat may be visible in the ulcer) PU on the right heel which required Resident 1 to undergo a bone tissue debridement (the surgical process of removing skin and bone close to and surrounding an infected wound associated with bone injuries or diseases). A review of Resident 1’s Admission Record indicated the facility admitted the 80-year-old female resident on 4/19/2024 with diagnoses including nondisplaced fracture (broken bones where the pieces were not moved enough during the break to be out of alignment) of the right femur (thigh bone), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage) affecting the right dominant side, and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Resident 1’s Skin Supplemental Assessment, dated 4/20/2024, indicated Resident 1 had a surgical incision (a cut made through the skin and soft tissue to facilitate an operation or procedure) on the right hip and multiple discoloration (a change to the original color of something that makes it look unpleasant or damaged) on both right and left upper extremity (the region of the body that included the arm, forearm, wrist, and hand). There was no documented evidence that Resident 1 had pressure ulcers on admission. A review of Resident 1’s Care Plan for ADLs initiated on 4/20/2024, indicated Resident 1 had mobility (ability to move) performance deficit related to activity intolerance (inability to endure), fatigue (an extreme sense of tiredness and lack of energy that can interfere with a person’s usual daily activities), hemiplegia, history of right femur fracture, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and left knee osteoarthritis (condition that causes the joints to become very painful and stiff). The Care Plan interventions indicated Resident 1 required skin inspection, including observation for redness, open skin areas, scratches, cuts, bruises, and report the changes to the nurse. Resident 1’s Care Plan interventions did not indicate the frequency of skin inspections. A review of Resident 1’s Care Plan for a Pressure Ulcer, dated 4/20/2024, indicated Resident 1 had the potential for pressure ulcer development. Resident 1’s Care Plan goal indicated the resident will have intact skin, free from redness, blisters (a small pocket of fluid in the upper skin layers and one of the body’s responses to injury or pressure) or discoloration. Resident 1’s Care Plan Interventions indicated to follow the facility’s policies and protocol for the prevention and treatment of skin breakdown. Resident 1’s Care Plan indicated there were no listed interventions implemented to prevent the development of right heel PU. A review of Resident 1’s History and Physical (H&P), dated 4/22/2024, indicated Resident 1 had a right sided weakness. The H&P indicated Resident 1 had a fall at home that led Resident 1 to undergo surgical intervention for an open reduction internal fixation [(ORIF] a surgical procedure for repairing fractured bones using either plates, screws, or an intramedullary rod to stabilize the bone) of the right femur. The H&P indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1’s Minimum Data Set ([MDS]a standardized assessment and care screening tool), dated 4/23/2024, indicated Resident 1’s cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were intact. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) from staff to roll left and right (the resident’s ability to roll from lying on back to left and right side and return to lying back on the bed) in bed. The Skin Condition section of the MDS indicated that Resident 1 was at risk of developing pressure ulcers or injury. The MDS indicated Resident 1 did not have any pressure ulcers or injury. A review of Resident 1’s Braden Scale for Predicting Pressure Sore (ulcer) Risk, dated 4/26/2024, indicated the resident’s score of 16. The score of 16 indicated Resident 1 was at risk for developing a pressure ulcer. A review of Resident 1’s Skin Observation Monitoring, dated 5/2024, indicated Resident 1’s skin condition was "not monitored" on 5/5/2024 on day shift (7 a.m. to 3 p.m.) and on 5/10/2024 on night shift (11 p.m. to 7 a.m.). Resident 1’s Skin Observation Monitoring indicated the resident’s skin condition monitoring was "not applicable" on the night shift on 5/25/2024, 5/27/2024, 5/28/2024, 5/30/2024, and 5/31/2024. A review of Resident 1’s Progress Notes, dated 4/19/2024 to 5/25/2024, indicated no documented evidence that Resident 1 was on a pressure relieving mattress (LALM) and that Resident 1’s right heel was offloaded from the mattress to prevent the development of a pressure ulcer. A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR) Communication Form, dated 5/23/2024, indicated Resident 1 had an open wound on the right heel. SBAR section ‘skin Changes ' indicated Resident 1’s right heel wound was described as a vascular wound (wounds on the skin that develop because of problems with blood circulation) with 15 percent (%) necrosis (the death of a body tissue), 25% slough (a necrotic tissue formed when dead cells and/or bacteria accumulate in the wound), 30% granulation (a development of new tissue and blood vessels in a wound during the healing process), 30% epithelization (the final stage of wound healing), and mild to moderate serosanguineous (contains or relates to both blood and the liquid part of blood [serum]) exudate (any fluid that had been forced out of the tissue because of inflammation or injury). On 5/23/2024 at 10:40 a.m., Resident 1’s Attending Physician (MD 1) and the resident representative 1 (FM 1) was notified about Resident 1’s right heel wound. A review of Resident 1’s Skin Ulcer (wound) Report-Initial, dated 5/23/2024, indicated Resident 1 had an acquired (developed while in the facility) right heel Unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because the wound bed is obscured by slough or eschar [a collection of dry, dead tissue within an wound]). The Skin Ulcer (wound) Report-Initial section 'Ulcer Dimensions' indicated Resident 1’s right heel PU was measured 3.5 centimeters ([cm]- unit of measurement) in length, 2.5 cm in width, with undetermined depth. The Skin Ulcer Report-Initial indicated Resident 1’s right heel PU had a 100% brown to black necrosis, was boggy (feels like it has fluid in it), had macerated (the process of skin softening and breaking down) per-wound (the surrounding area of the wound edge) with stable dry eschar (a collection of dry, dead tissue within a wound). A review of Resident 1’s Physician’s Orders, dated 5/23/2024, indicated an order for STAT (urgent or rush) arterial (blood vessels that distribute oxygen-rich blood to the body) /vascular ultrasound (a noninvasive test to determine how blood flows in arteries and veins in the arms, neck, and legs) of the right lower extremity. A review of Resident 1’s Radiology (the branch of medicine that use imaging technology to diagnose and treat disease) Report Interpretation, dated 5/23/2024, indicated Resident 1 had a right lower extremity arterial ultrasound. The Radiology Report 'Impression' section indicated that Resident 1 had no significant obstruction to arterial blood flow on the right lower extremity. A review of Resident 1’s Progress Notes, dated 5/26/2024, indicated the Licensed Vocational Nurse (LVN 3) clarified with MD 1 the change of Resident 1’s right heel peripheral vascular disease ([PVD] a reduced circulation of blood to a body part other than the brain or heart) wound to a Stage 3 pressure ulcer. Resident 1’s Progress Notes indicated there was no indication of PVD and arterial/venous occlusion. The Progress Notes indicated that FM 1 was notified. A review of Resident 1’s Surgical Consult Notes, dated 6/4/2024, indicated MD 2 was consulted for Resident 1’s right heel wound. The Surgical Consult Notes indicated Resident 1’s right heel wound was a pressure ulcer that was measured 2.0 cm in length, 2.8 cm in width, with undetermined depth, covering 5.6 square cm wound area. The Surgical Consult Notes section 'Tissue Type by Percentage' indicated Resident 1’s right heel wound had 100% necrotic tissue. Resident 1’s Surgical Consult Notes indicated Resident 1 had a bone tissue debridement. On 7/1/2024 at 9:30 a.m., during an interview, Resident 1 stated the right heel PU developed in the facility. Resident 1 stated that she required assistance with lifting her right leg. Resident 1 stated the facility staff did not elevate her right leg and her right heel was continuously laying directly on the mattress. Resident 1 stated facility staff placed the ankle-foot orthoses ([AFO] a supportive device intended to control the position and motion of the ankle, to compensate for weakness, or to correct deformities) while she was on the wheelchair. Resident 1 stated that FM 1 provided the air mattress after the facility staff discovered Resident 1 had right heel PU. On 7/1/2024 at 11:09 a.m., during a concurrent interview and record review, LVN 2 stated that on 5/23/2024, a Certified Nursing Assistant 2 (CNA 2) assisted Resident 1 with shower. LVN 2 stated CNA 2 observed Resident 1 had a wound on the right heel. LVN 2 stated that LVN 1 checked Resident 1 and found a PU on the right heel. Resident 1’s Admission Assessment, dated 4/20/2024, was reviewed with LVN 2 and indicated Resident 1 had no PU. LVN 2 stated Resident 1’s Braden Scale for Predicting Pressure Sore Risk, dated 4/26/2024, indicated Resident 1 was at risk for developing PU. LVN 2 stated on 5/26/2024 Resident 1’s physician ordered to offload the resident’s right heel, and use of LALM after the right heel PU was discovered. On 7/1/2024 at 12:02 p.m., during a concurrent interview and record review, Resident 1’s medical records were reviewed with LVN 1. LVN 1 stated Resident 1 was admitted in the facility on 4/19/2024 without PU. LVN 1 stated Resident 1 was at risk for developing PU because of Resi