Other·March 27, 2024

22, § 72315 - Nursing Service - Patient Care (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). 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. §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. Section 72311 - Nursing Service-General 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. On 02/06/24, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to: 1. Ensure Resident 163 did not develop a Stage III pressure ulcer ([PU] Full thickness tissue loss) to the right buttocks after the resident’s admission to the facility. 2. Ensure the nursing staff monitored Resident 163’s skin condition to identify the development of a PU to the right buttock at the earlier stage to prevent the development of a Stage III PU. 3. Ensure the nursing staff implemented Resident 163’s care plan titled “Skin Integrity” which indicated staff will assess residents’ skin daily and as needed, to prevent skin breakdown. 4. Ensure nursing staff turned and repositioned Resident 40 every two hours to prevent a deep tissue pressure injury ([DTPI]) a purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) from reopening. As a result, Resident 163 acquired a Stage III PU, and Resident 40's DTPI reopened. 1. A review of Resident 163's Face Sheet (Admission Record), indicated, Resident 163 was a 34-year-old-male admitted to the facility on 12/23/2023. Resident 163's diagnoses included chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help a person breathe), multiple fractures (partial or complete break of a bone), and a gunshot wound. A review of Resident 163's Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment, dated 1/4/2024, indicated, Resident 163 had severely impaired cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 163 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated, Resident 163 was at risk for developing a pressure ulcer and had one unhealed Stage III PU to a sacral (tailbone) area. The MDS indicated Resident 163 was incontinent (inability to control bowel and bladder function) of bowel and had a condom catheter (a device placed around the penis to drain urine from the bladder) for a sacral ulcer management. A review of Resident 163's Admission Assessment, dated 12/23/2023, indicated Resident 163 was admitted to the facility with a Stage III pressure ulcer to a sacral area. A review of Resident 163's Occupational Therapy Evaluation form, dated 12/23/2023, indicated Resident 163 was totally dependent for bed mobility. A review of Resident 163's Braden Scale (tool used to assess and document a resident's risk for developing pressure ulcers) form, dated 12/24/2023, 12/30/2023, 1/7/2024, and 1/14/2024, indicated Resident 163 had very limited sensory perception (ability to respond to pressure-related discomfort), was constantly moist, bedfast (confined in bed), completely immobile, was receiving nutrition via a gastrostomy tube ([GT] a soft tube surgically inserted into the stomach through the abdomen for food and medication administration) and had a problem with friction and shear. The Braden Scale indicated, Resident 163 had a score of nine (total score of 12 or less indicates high risk for developing a pressure ulcer). A review of Resident 163's Daily Assessment Inquiry under Certified Nursing Assistant (CNA) Documentation from 12/23/2023 to 2/7/2024, did not indicate Resident 163 had a pressure ulcer on the right buttock. A review of Resident 163's Progress Notes Inquiry from 12/23/2023 to 2/6/2024, did not indicate Resident 163 had a pressure ulcer to the right buttock. A review of Resident 163's Sub-Acute Nursing Weekly Summary dated 12/25/2023, 1/1/2024, 1/8/2024, 1/22/2024, 1/29/2024, and 2/5/2024, did not indicate Resident 163 had a pressure ulcer on the right buttock. A review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, indicated Resident 163 had a Stage III pressure ulcer to the right buttock, which was not present on admission. The note indicated Resident 163’s Stage III pressure ulcer to the right buttock measured 2.5 centimeters ([cm] unit of measurement) in length, 3.0 cm in width, and 0.1 cm in depth. The note indicated Resident 163’s PU had a scant (minimal) amount of serosanguineous (fluid containing both blood and blood serum [clear liquid part of the blood after blood cells have been removed]) fluid with no odor. On 2/9/2024 at 9:21 a.m., during a concurrent observation and interview with Treatment Nurse 1 (TN 1), TN 1 was observed performing a wound care treatment to Resident 163's right buttock PU. The wound bed had an adherent yellow slough (dead tissue, usually cream or yellow in color) dark gray skin and pink tissue, with an indistinct (not sharply outlined or separable) wound margins (edge). The Peri wound (tissue surrounding the wound) had a deep purple skin discoloration. TN 1 stated Resident 163's right buttock PU was acquired at the facility. TN 1 stated on 2/7/2024, she identified Resident 163 right buttock PU TN 1 stated she did not document it and did not notify Resident 163’s physician (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and she did not document about newly identified PU on Resident 163’s pressure ulcer and did not called MD 1. TN 1 stated she did not follow the standard of practice by not reporting Resident 163’s right buttock Stage III pressure ulcer, to MD 1 timely. TN 1 stated she had seen Resident 163's on several occasions soiled (dirty) with urine because his condom catheter was dislodged. TN 1 stated Resident 163 had only one Stage III pressure ulcer to the sacral area upon admission. TN 1 stated she did not observe Resident 163's developing redness, blister, or any skin damage to his right buttock until 2/7/2023 when it was already a Stage III pressure ulcer. TN 1 stated Resident 163 had no skin maintenance treatment ordered till after the right buttock Stage III PU developed. On 2/9/2024 at 10:23 a.m., during an interview with CNA 2, CNA 2 stated she gave Resident 163 a bed bath (bathing a patient who is confined to bed and cannot have the physical and mental capability of self-bathing) every time she was assigned to the resident. CNA 2 stated, she did not observe Resident 163 with a new pressure ulcer. CNA 2 stated if a resident was observed with a skin issue including bed sore, redness, and skin tear she would document on the resident’s flowsheet. On 2/9/2024 at 10:33 a.m., during an interview with Registered Nurse (RN) 2, RN 2 stated protecting and monitoring the condition of Resident 163's skin was important for preventing the development of a pressure ulcer and identifying a pressure ulcer earlier so it could be treated at the early stage and not to let it to get worse. RN 2 stated she was not aware Resident 163 developed a Stage III pressure ulcer to his right buttock. RN 2 stated the licensed nurses were supposed to check each resident’s skin before completing the Nursing Weekly Summary, and report identified concerns to the supervisor. On 2/9/2024 at 2:25 p.m., during a concurrent interview and record review with the Infection Preventionist Nurse (IP) 1, Resident 163's Subacute Pressure Injury Weekly Report dated 12/24/2023 and 1/28/2024 were reviewed. IP 1 stated Resident 163 had only one pressure ulcer Stage III to the sacral area. IP 1 stated it was important to identify the presence of a pressure ulcer and its stages early so nurses implement the interventions to treat and prevent it from getting worse. On 2/9/2024 at 3:00 p.m., during a concurrent interview and record review with Director of Nursing 1 (DON 1), Resident 163’s care plan titled "Skin Integrity" dated 12/27/2023, was reviewed. DON 1 stated the care plan interventions included to assess the resident’s skin daily, and as needed, report impaired integrity to the physician, apply protective skin barrier and treatment as ordered. The DON stated the care plan’s goals indicated: 1. To maintain Resident 163’s skin integrity as evidenced by intact skin daily for next three months. 2. Resident 163 will be free from skin breakdown daily for next three months. 3. There will be no further sacral pressure ulcer deterioration daily for the next three months. On 2/9/24 at 3:10 p.m., during an interview with the DON, the DON stated the facility failed to prevent Resident 163's right buttock PU from developing and did not identify from progression to a Stage III. The DON stated a Stage III pressure ulcer can develop fast but not right away. The DON stated with proper care treatment and interventions and early detection of a pressure ulcer Resident 163's right buttock PU could have been avoided. A review of facility's policy and procedure (P&P) titled, "Dignity, Patient/Resident," dated 9/2023, indicated, the facility will provide, every resident with the care and quality of life sufficient for them to attain and maintain their highest practicable physical, emotional, and social well-being, in accordance with Federal law requirements. b. A review of Resident 40's Admission Record indicated Resident 40 was a year-57 old- male admitted to the facility on 8/18/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). A review of Resident 40's Minimum Data set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated, Resident 40's cognitive (ability to learn reason, remember, understand, and make decisions) skills for daily decision making were severely impaired. The MDS indicated Resident 40 was dependent on staff for activities of daily living (ADL) including toileting, hygiene, and showering. A review of Resident 40’s Admission Assessment dated 8/18/2023, the Admission Assessment indicated the resident had the following: 1. Left heel undetermined (UTD) skin injury. 2. Sacral pressure ulcer Stage III. 3. Right lateral malleolus UTD skin injury. 4. Right buttock UTD skin injury. A review of Resident 40 ‘s care plan for Impaired Skin Integrity dated 8/18/2023, the care plan indicated a goal for the resident was to maintain intact skin daily for the next three months (until next care plan evaluation). One of the care plan interventions was to reposition the resident every two hours. A review of Progress Note Inquiry dated 9/21/2023 completed by a Wound Consultant, the Progress Note Inquiry indicated Resident 40’s left heel was assessed as unstageable pressure ulcer and measured 1.0 cm by 0.8 cm. The Wound Consultant documented recommendation for intervention to promote pressure ulcer healing included heel off loading, heel protector, and turning and repositioning the resident. A review of Resident 40's Physician's Orders, dated 2/1/2024, Physician's Orders indicated the order to cleanse left heel DTPI with Normal Saline solution, pat dry. Apply Betadine and cover with dry dressing daily. A review of Wound Photographic Documentation/Nursing dated 2/1/2024, the Wound Photographic Documentation indicated Resident 40 had DTPI to left heel measured 1.0 cm in length by 1.5 cm in width. During an observation on 2/6/2024 from 11:09 a.m. until 4:00 p.m. (a total of five hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/7/2024 from 9:17 a.m. until 4:15 p.m. (a total of seven hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/8/2024 from 8:15 a.m. until 12:15 p.m. (four hours) Resident 40 was observed lying on the left side facing the window. On 2/8/2024 at 12:15 p.m., during a concurrent observation and interview with Restorative Nurse Assistant (RNA 1), she stated Resident 40 was observed in bed lying on a left side facing the window. Resident 40 was observed to have a heel protector (a soft cushion covering the heel) on the left heel. Resident 40’s left heel had a sock on inside the heel protector. RNA 1 confirmed Resident 40 was facing the window and lying on the left side of his body. RNA 1 stated Resident 40 should be facing the door at 12:00 p.m. RNA 1 stated Resident 40 should be repositioned from side to side every two hours to prevent a pressure ulcer from developing, to help with blood circulation (the flow of blood through the heart and blood vessels), and to prevent DTPI to have a recurrent pressure ulcer. A review of Resident 40's Repositioning Schedule, date unknown, the Repositioning Scheduled indicated Resident 40 should be turned (repositioned) every two hours. On 2/8/2024 at 12:30 p.m., during a concurrent observation and interview with Infection Preventionist (IP 1), IP 1 stated 40 was lying on the left side facing the window. IP 1 stated Resident 40 had a sock on and a heel protector. IP stated if the resident is not turned every two hours, even though there is a heel protector on the heel, the resident can develop a pressure ulcer to the skin. IP 1 stated it was 30 minutes passed the time for Resident 40 to be repositioned on the right side and facing the door. IP 1 stated we should be following the reposition schedule every two hours. IP 1 stated it was important to reposition Resident 40 as scheduled