Health inspection·December 13, 2024

CFC§483.25(b) Skin Integrity CFC§483.25(b)(1) Pressure injuries. 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 injuries and does not develop pressure injuries unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. CCR§ 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 injurys. The facility shall notify the physician, when a decubitus injury first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). CCR§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 11/5/2024 the California Department of Public Health (CDPH) conducted an annual recertification survey onsite. During the recertification survey CDPH determined the facility failed to: 1. Implement Resident 40’s (untitled) care plan intervention to turn and reposition the resident every two hours to prevent the resident from developing a Stage III pressure injury (full thickness tissue loss – underlying fat tissue may be visible, but bone, tendon, or muscle is not exposed) to the sacro-coccyx (tailbone) area. 2. Implement the facility’s policy and procedure (P&P) titled, “Skin and Wound Monitoring and Management” revised 12/2023, that indicated to reposition the resident in order to prevent the development of skin breakdown/pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). These deficient practices resulted in Resident 40 developing a facility-acquired, preventable, Stage III pressure injury on the sacro-coccyx area measuring 9.0 centimeters (cm) in length by 9.0 cm in width and 0.1 cm in depth. The wound had a little serosanguinous (contains or relates to both blood and the liquid part of blood - serum) exudate (fluid that leaks out of blood vessels into nearby tissues) with 20 percent (%) slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) and 80 % epithelial (appears pink or pearly white, and wrinkles when touched, occurs in the final stage of healing) tissue. A review of Resident 40, an 80-year-old female’s , Admission Record indicated Resident 40 was admitted to the facility on 1/5/2023 with diagnoses including fracture (broken bone) of greater trochanter of right femur  (hard area on the outside of the hip), age related osteoporosis (a disease that causes bones to become weak and more likely to break) with pathological (caused by disease) fracture, type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), abnormal posture, need for assistance of personal care, difficulty of walking, and lack of coordination. A review of Resident 40’s Minimum Data Set ([MDS], a resident assessment tool), dated 7/12/2024, indicated Resident 40’s cognitive (ability to think and reason) skills for daily decision-making were moderately impaired. The MDS indicated Resident 40 required partial assistance (helper does less than half the effort helper lifts support or holds trunk or limbs but provides less than half the effort) with toileting hygiene and rolling to the left and to the right (ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 40 was at risk for developing pressure injuries. The MDS indicated Resident 40 did not have pressure injuries. The MDS indicated Resident 40’s skin was intact. A review of Resident 40’s Braden Scale (a scoring tool used to predict residents’ risk of developing a pressure injury, total scores range from 6 - 23. A lower score indicating a higher risk of developing a pressure injury) assessment, dated 7/11/2024, indicated Resident 40’s score was 14 indicating Resident 40 was at moderate risk for developing a pressure injury. The Braden Scale assessment indicated Resident 40’s skin was often moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility, was unable to make frequent or significant positional changes independently and required moderate to maximum assistance when moving. During an interview on 11/5/2024 at 10:16 a.m., Resident 40 stated he had a wound on his buttocks area because the facility staff left him sleeping on one side for too long. Resident 40 stated that facility staff did not reposition him to take the pressure off his buttocks area. During an interview and record review on 11/6/2024 at 3:13 p.m., with Registered Nurse (RN 1), Resident 40’s Licensed Nurses Skin Evaluation – PRN (as needed)/weekly, dated 9/29/2024 was reviewed. The Licensed Nurses Skin Evaluation indicated Resident 40’s skin had no redness, bleeding, or open skin areas noted upon assessment. RN 1 confirmed Resident 40’s skin was intact on 9/29/2024. During an interview and record review on 11/6/2024 at 3:18 p.m., with RN 1, Resident 40’s Licensed Nurse’s Skin Pressure injury Weekly documentation, dated 10/8/2024 was reviewed. The Licensed Nurse’s Skin Pressure injury Weekly documentation indicated Resident 40 had a suspected deep tissue injury ([SDTI ]- non blanching [skin that doesn't fade when pressure is applied to it indicating bleeding under the skin] purple or maroon skin discoloration) in the sacro-coccyx area which was not present on admission (1/5/2023), on the MDS dated 7/12/2024, and on the Licensed Nurses Skin Evaluation date 9/29/2024. During an interview and record review on 11/6/2024 at 3:25 p.m., with RN 1, Resident 40’s Licensed Nurse’s Skin Pressure Injury Weekly documentation dated 10/8/2024 was reviewed. The Licensed Nurse Skin Pressure Injury Weekly documentation indicated the STDI measured 9.5 cm by 9.5 cm with no depth, no exudate, and with attached wound edges. RN 1 stated Resident 40 had an STDI on 10/8/2024, nine days after Resident 40’s skin was assessed on 9/29/2024 and was intact. During an interview and record review on 11/6/2024 at 3:28 p.m., with RN 1, Resident 40’s Physician’s Order Summary report as of 11/7/2024, was reviewed and the Order Summary report indicated the following orders: a. A physician’s order dated 10/14/2024, for a nutritional supplement (Nutrition powder to promote wound healing) one time a day for supplement (wound healing) for 30 days one packet with six ounces of fluids. b. A physician’s order dated 10/9/2024, for a low air loss mattress (mattress designed to prevent and treat pressure wounds). c. A physician’s order dated 10/8/2024, Wound Consult until wound resolves. d. A physician’s order dated 10/8/2024, for Ascorbic acid (Vitamin C supplement) 500 milligrams by mouth one time a day. e. A physician’s order dated 10/12/2024, for Medi honey wound/burn dressing external gel (wound dressing to promote healing) apply to Sacro-coccyx topically as needed for stage III pressure injury. Clean with Normal saline (salt and water solution), pat dry, apply Medi honey, apply skin prep to peri wound then cover with dry dressing. f. A physician’s order dated 10/8/2024, for Pro-Stat Oral liquid (supplement liquid protein for wound healing) give 30 milliliters in the evening. During a continued interview and record review on 11/6/2024 at 3:28 p.m., with RN 1, Resident 40’s Physician’s Order Summary report as of 11/7/2024 was reviewed. RN 1 stated the physician’s orders indicated there were interventions initiated because of Resident 40’s newly developed and identified pressure injury. During an interview and record review on 11/6/2024 at 3:40 p.m., with RN 1, Resident 40’s untitled care plan initiated on 4/26/2023, and revised on 7/2/2024, was reviewed. This care plan indicated Resident 40 was at risk for impaired skin integrity. The care plan goal indicated Resident 40 would have intact skin, free of redness, blisters (a fluid-filled sac in the outer layer of skin that may be caused by rubbing, or pressure), or discoloration through review date on 10/8/2024. During an interview and record review on 11/6/2024 at 3:43 p.m., with RN 1, Resident 40’s untitled care plan initiated on 4/26/2023, and revised on 7/2/2024, was reviewed, the care plan interventions included Resident 40 would be encouraged to turn and reposition with assistance as necessary. RN 1 stated the care plan was not updated with new interventions on 10/8/2024 when Resident 40’s STDI was identified. RN 1 stated the care plan intervention did not indicate turning and repositioning routinely every 2 hours. RN 1 stated the care plan should be updated and implemented to prevent further pressure injury development. During an interview on 11/7/2024 at 12:14 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 40 developed a preventable, facility acquired pressure injury because Resident 40 had impaired mobility and was not probably repositioned every two hours. During an interview and record review on 11/7/2024 at 1:47 p.m., with LVN 1 Resident 40’s Documentation Survey Report for September and October 2024, the Turned and Repositioned Task documentation was reviewed. The Turned and Repositioned Task documentation indicated Resident 40 was not turned and repositioned on each shift. LVN 1 stated there was no documented evidence Resident 40 was turned and repositioned every two hours on every shift for the months of September and October. During an interview and record review on 11/8/2024 at 12:30 p.m., with the Director of Nursing (DON), Resident 40’s Surgical Consult Note, dated 10/10/2024, was reviewed. The Surgical Consult Note indicated Resident 40 had a wound (referencing to a pressure injury) located in the sacro-coccyx area measuring 9.0 cm in length and 9.0 cm in width and 0.1 cm in depth. The wound had scant serosanguinous exudate with 20 % slough and 80 % epithelial tissue, and the wound edge was macerated (skin looks soggy there may be a white ring around a wound that is too moist or has exposure to too much drainage). During an interview and record review on 11/8/2024 at 12:36 p.m., with the DON, Resident 40’s Surgical Consult Note, dated 10/10/2024, was reviewed. The DON stated repositioning the resident was important to prevent pressure injuries on residents’ (in general) skin. The DON stated a resident should not develop a Stage III pressure injury while in the facility, but it also depends on the resident’s comorbidities (medical diagnoses). The DON stated if the turning and repositioning every two hours was not documented then it was not done. The DON stated care plans should be updated. A review of, “Pressure Injury Prevention Points” Portable Document Format (PDF) published by the National Pressure Injury (referencing to pressure injury) Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention points: 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. 3. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 4. Continue to reposition an individual when placed on any support surface. 5. Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a review of the facility’s P&P titled, “Skin and Wound Monitoring and Management” revised 12/2023, the P&P indicated: 1. A resident having pressure injury received necessary treatment and services to promote healing, prevent infection, and prevent new avoidable pressure injuries from developing. 2. ln order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: a. Stabilize, reduce, or remove any existing any underlying risks. b. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition. c. Reposition the resident. The facility failed to: 1. Implement Resident 40’s (untitled) care plan intervention to turn and reposition the resident every two hours to prevent the resident from developing a Stage III pressure injury to the sacro-coccyx area. 2. Implement the facility’s P&P titled, “Skin and Wound Monitoring and Management” revised 12/2023, that indicated to reposition the resident in order to prevent the development of skin breakdown/pressure injury. These deficient practices resulted in Resident 40 developing a facility-acquired, preventable, Stage III pressure injury to the sacro-coccyx area measuring 9.0 cm in length by 9.0 cm in width and 0.1 cm in depth. The wound had scant serosanguinous exudate with 20 % slough and 80 % epithelial tissue. These violations had a direct or immediate relationship to the health, safety, or security of Resident 40.