Other·November 8, 2023

§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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following – (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. § 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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: (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). § 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. The California Department of Public Health (CDPH) received a complaint on 10/6/2023 indicating the treatment nurse informed the complainant a resident (Resident 1) had a pressure ulcer on the coccyx (small triangular bone at the base of the spinal column) measuring 8 by (x) 6 centimeters (cm, unit of measurement). The complainant alleged a wound doctor had been treating Resident 1 with just ointment and began to use a blade to remove the dead tissue/skin. The complainant alleged Resident 1 was in pain and agony due to the neglect of the facility and failure to move the resident. On 10/7/2023, CDPH conducted an unannounced investigation at the facility. As a result of the investigation, CDPH determined that the facility failed to: 1. Conduct a pressure injury assessment on Resident 1 using the Braden scale for predicting pressure ulcer risk, on all residents upon admission in accordance with the facility’s policy and procedure titled, “Pressure injury prevention”, revised date 10/2022. 2. Develop a care plan addressing Resident 1’s risk for pressure ulcer (damaged skin caused by staying in one position for too long) development in accordance with the facility’s policy and procedure titled, “Pressure injury prevention”, revised date 10/2022. 3. Turn and reposition Resident 1 every 2 hours to prevent pressure ulcer development in accordance with the facility’s policy and procedure titled, “Turning and Repositioning,” revised date 9/12/2023 As a result, Resident 1 developed an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [yellow/white material consisting of dead cells that accumulate in the wound, contributing to delayed wound healing or eschar [collection of dry, dead tissue within a wound]) on the sacrococcygeal (tail bone) area. A review of Residents 1's Admission Records, indicated Resident 1, was a 97-year-old male, who was admitted to the facility on 9/11/2023. Resident 1’s diagnoses included difficulty in walking, anemia (lack of healthy red blood cells), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). A review of Resident 1’s Minimum Data Set (MDS, standardized care and screening tool), dated 9/18/2023, indicated Resident 1 was severely impaired with cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required an extensive assistance and one-person physical assist with bed mobility, transfer, personal hygiene, and a two-person physical assist with toilet use. Section M0100S of the MDS indicated Resident 1 was at risk for pressure ulcers and the resident had no skin conditions and/or pressure ulcers upon admission. A review of Resident 1’s Braden Scale for Predicting Pressure Ulcer Risk (tool commonly used in health care to assess and document a resident’s risk for developing pressure ulcers), dated 9/13/2023 at 3:28 p.m., indicated Resident 1 was bedbound and had very limited mobility, making position changes to the body or extremities (arms/legs) independently as factors for pressure ulcer development. The Braden Scale indicated Resident 1 had a score of 14, indicating the resident was at moderate risk for developing pressure ulcers. A review of Resident 1’s Braden Scale for Predicting Pressure Ulcer Risk, dated 9/19/2023 at 4:37 p.m., indicated Resident 1 had a score of 15, indicating moderate risk. During a concurrent interview and record review on 10/7/2023 at 12:52 p.m., with licensed vocational nurse (LVN) 1, Resident 1’s Medication Administration Record (MAR), for the month of September 2023, was reviewed. The MAR indicated Resident 1 was not repositioned every 2 hours from 9/11/2023 to 9/24/2023. LVN 1 stated Resident 1 was bed bound upon admission. LVN 1 stated from 9/11/2023 to 9/24/2023, there was no documentation indicating Resident 1 was being repositioned every 2 hours. LVN 1 further stated, “If it was not documented, it was not done.” During an interview with Family Member 1 (FM 1), on 10/7/2023 at 11:40 a.m., in Resident 1’s room, FM 1 stated Resident 1 was not being turned, repositioned every 2 hours upon admission. FM 1 stated the facility started repositioning Resident 1 after the resident acquired an unstageable pressure ulcer on 9/22/2023. During a concurrent observation and interview with Treatment Nurse 1 (TN 1), on 10/7/2023 at 12:40 p.m., in Resident 1's room, Resident 1’s unstageable pressure ulcer to the sacrococcygeal was observed. The unstageable pressure ulcer measured 9.0 cm, unit of) in length, 6.5 cm in width, and 0.4 cm in depth. The wound bed was observed with 100% slough. TN 1 stated residents that were high risk for pressure ulcer development were to be repositioned every 2 hours. During a concurrent interview and record review with TN 1, on 10/7/2023 at 1:26 p.m., Resident 1’s care plans were reviewed. TN 1 stated there was no care plan upon Resident 1’s admission addressing the resident’s skin integrity. TN 1 stated Resident 1’s care plan should have been initiated upon admission. TN 1 stated Resident 1 was unable to reposition herself upon admission and the resident’s skin was intact from 9/11/2023 to 9/21/2023. A review of Resident 1’s document titled “Skin Evaluation,” the document indicated the following: * 9/22/2023 - Resident 1 had an unstageable pressure ulcer to the sacrococcygeal area, measuring 8.0 cm in length, 6.1 cm in width, 80 percent (%) undetermined eschar, and 20 % yellow slough noted to the wound bed. * 9/25/2023 -Unstageable pressure ulcer to the sacrococcygeal area measuring 9.0 cm in length, 7.5 cm in width, and 100% necrotic tissue (premature death of cells or tissue from disease or injury) noted to the wound bed. * 10/02/2023 - Unstageable pressure ulcer to the sacrococcygeal area measuring 9.0 cm in length, 6.5 cm in width, 0.4 cm in depth, and 100% yellow slough noted to the wound bed. During a concurrent interview and record review with TN 1, on 10/7/2023 at 6:24 p.m., Resident 1’s medical record titled, “Physical Therapy Notes,” dated 9/12/2023, was reviewed. The notes indicated Resident 1’s bed mobility was maximum assist. TN 1 stated maximum assist meant Resident 1 was unable to move. TN 1 stated if Resident 1 was repositioned every 2 hours there was a possibility Resident 1 would not have developed an unstageable pressure ulcer. TN 1 stated the facility failed to prevent Resident 1’s pressure ulcer development. During a concurrent interview and record review with the Administrator, on 10/7/2023 at 7 p.m., Resident 1’s MAR for the month of September 2023, the MDS dated 9/18/2023, care plans, Braden Scale dated 9/13/2023 and 9/19/2023, and PT notes dated 9/12/2023 were reviewed. The Administrator verified the following: * The MAR indicated the resident was not turned and repositioned every (Q) 2hrs, from 9/11/2023 to 9/24/2023. * The MDS indicated Resident 1 was at risk for pressure ulcer development. * There was no initial care plan regarding Resident 1’s skin integrity and risk for skin breakdown initiated upon admission. * A Braden Scale was not initiated until 9/13/2023, and a second Braden Scale dated 9/19/2023, indicated a score of 15 indicating the resident was now at moderate risk for pressure ulcer development. * The PT notes indicated Resident 1’s baseline was maximum assist with bed mobility. The Administrator stated the facility failed to prevent the development of Resident 1’s unstageable pressure ulcer by not repositioning Resident 1 every 2 hours and by not initiating a care plan for skin integrity upon admission. A record review of the facility’s Policy and Procedure (P&P) titled, “Pressure injury prevention”, revised date 10/2022, indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries. The P/P indicated the following: a. Licensed nurse would conduct a pressure injury assessment using the Braden scale for predicting pressure ulcer risk, on all residents upon admission /re-admission, weekly times 3 more weeks, then quarterly or whenever the resident’s condition changes significantly. b. The tool would be used in conjunction with the other risk factor not captured by the risk assessment tool. Example of risk factors indicated impaired/ decreased mobility and decreased functional ability, cognitive impairment, and exposure of the skin to urine and fecal incontinence (inability to control). c. After completing a thorough assessment/ evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. A record review of the facility’s P&P titled, “Turning and Repositioning,” revised date 9/12/2023, indicated it was the facility’s policy to implement turning and repositioning as part of our systemic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. The P/P indicated the following: 1. Residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to medical condition. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of the nursing assistant. However, nursing staff are expected to assist with turning and repositioning. 3. The facility has an established routine for turning and repositioning schedules consisting of turning/repositioning every 2-4 hours, on the even hours. A maximum of thirty minutes before or after the scheduled time will be allotted for the compliance with the schedule. 4. The frequency of turning and repositioning will be determined by the resident’s: a. Tissue tolerance b. Level of activity and mobility c. Skin condition d. Overall medical condition e. Treatment goal f. Type of pressure distribution support in use (turning and repositioning is still required on specialty surface, but frequency may be reduced) g. Comfort levels The facility failed to: 1. Conduct a pressure injury assessment on Resident 1 using the Braden scale for predicting pressure ulcer risk, on all residents upon admission in accordance with the facility’s policy and procedure titled, “Pressure injury prevention”, revised date 10/2022. 2. Develop a care plan addressing Resident 1’s risk for pressure ulcer development in accordance with the facility’s policy and procedure titled, “Pressure injury prevention”, revised date 10/2022. 3. Turn and reposition Resident 1 every 2 hours to prevent pressure ulcer development in accordance with the facility’s policy and procedure titled, “Turning and Repositioning,” revised date 9/12/2023 As a result, Resident 1 developed an unstageable pressure ulcer on the sacrococcygeal area. These 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.