Health inspection·June 9, 2023

F687 §483.25(b)(2) Foot care To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

F697 §483.25(k) Pain Management The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences § 72523(a) 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 3/28/2023 the California Department of Public Health (CDPH) received a complaint from a resident alleging he was having extreme pain in both of his feet and staff refused to report his complaint of pain to the podiatrist (a person who treats the feet and their ailments) or his doctor. On 3/29/2023 at 10:45 a.m., an unannounced visit was conducted at the facility to investigate the allegations. The investigation indicated Resident 1 reported multiple times to multiple staff that he was experiencing pain in his feet and no assessment was conducted to determine the source of pain to Resident 1's feet, the resident's physician was not notified of the residents change in condition (COC) and there was no referral made to the podiatrist. The facility failed to ensure: 1. Resident 1's physician was notified, and a podiatrist referral was made after being made aware of Resident 1's complaint of pain in his feet. 2. An assessment of Resident 1 feet and pain was conducted after Resident 1 made the facility staff aware of the pain in his feet. 3. Resident 1 was provided pain management when he complained of both feet and leg pain. 4. The facility staff followed their Policy and Procedures (P/P), titled "Notification of Physician/other Prescriber," "Foot Care," and "Pain Management, Assessment and Reassessment," that stipulated, the licensed nurse was responsible to inform the physician or other prescriber responsible for the medical care of the person served of any changes in the person. A person served has the right to be free of pain while staff also promote pain relief. Pain evaluation is done when a person served complains of pain. Upon request of any resident the charge nurse shall obtain orders for podiatry (the treatment of the feet and their ailments) care. These failures resulted in a delay in treatment and pain relief to Resident 1's feet and the development of cellulitis (a deep infection of the skin caused by bacteria) going unnoticed causing unbearable pain, redness, swelling and dry/cracked skin on Resident 1's feet. These failures had the potential for Resident 1's pain to increase and worsening of his cellulitis. During a review of Resident 1's Admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on 4/30/2021 with a diagnosis of schizoaffective disorder (a mental disease characterized by abnormal thought processes and unstable mood). During a review of Resident 1's History and Physical (H&P), dated 4/19/2022, the H&P indicated, Resident 1 was alert and oriented to name, place, time. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 2/8/2023, the MDS indicated, Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated, Resident 1 had a functional limitation in range of motion ([ROM] task such as eating, bathing, dressing, grooming and toileting) to both of his lower extremities (legs). During a review of the facility's Medical Communication Book (MCB), dated 3/24/2023, with no time documented, the MCB indicated Resident 1 had "bilateral (both) foot pain/podiatry consult." During a review of Resident 1's Nursing Progress Notes (NPN) dated 3/25/2023 and timed at 12:04 a.m., the NPNs indicated, Resident 1 approached the nursing station complaining of pain on the ball of his feet and toes and requested to see a podiatrist. During a review of the facility's MCB, dated 3/28/2023 with no time documented, the MCB indicated Resident 1 complained of shoulder and leg pain and wanted to see a doctor. During an interview and concurrent observation on 3/29/2023 at 11:20 a.m., with Resident 1, Resident 1 stated he was having pain on the balls of his feet and in-between his toes. Resident 1 stated the pain was a 10 out of 10 (on a pain scale from 0-10, 0= no pain and 10= severe pain) and was unbearable. Resident 1 stated he told the nursing staff about the pain in his feet on Saturday (3/25/2023) and he also told the Ward Clerk (WC) (date unknown). Resident 1 stated he was offered Tylenol but refused it because he wanted something stronger for the pain. The skin on Resident 1's feet was noted to be dry, cracked with redness and swelling. During an interview on 3/29/2023 at 11:27 a.m., and a subsequent interview on 4/27/2023 at 3:36 p.m., with Licensed Vocational Nurse 1 (LVN) 1, LVN 1 stated, this was the first time (3/29/2023) she was made aware that Resident 1 had a complaint of pain. LVN 1 stated she approached Resident 1 (3/29/2023) to ask him why he had not told her he was in pain but stated she did not think at that time to assess Resident 1's feet to see if there was any injury to them. During an interview on 3/29/2023 at 11:41 a.m., and a subsequent interview on 4/27/2023 at 2:56 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated she spoke with Resident 1's FM on 3/29/2023 and was told by the FM that Resident 1 was experiencing pain in his lower legs and shoulder, and he (Resident 1) wanted to see a doctor. RNS 1 stated she was not aware at that time of Resident 1's complaint of pain from the nursing staff and after the phone call with Resident 1's FM she followed up with the physician's assistant (PA) and the podiatrist, but she did not assess Resident 1's feet. During an interview on 3/29/2023 at 11:59 a.m., and a subsequent interview on 4/27/2023 at 3:37 p.m., with the Ward Clerk (WC), the WC stated her primary responsibility at the facility was to schedule resident appointments. The WC stated, Resident 1 called her at the beginning of 3/2023 (not sure of the exact date) and complained that both of his legs and his feet were hurting and requested to see a doctor. The WC stated she told Resident 1 he had an upcoming appointment scheduled on 3/31/2023 with a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) and he (Resident 1) could address the problems with his legs and feet at that time. The WC stated she did not notify any nursing staff about Resident 1's complaints of pain because "sometimes things just slip through the cracks," and she thought the nursing staff were already aware of Resident 1's pain. The WC acknowledged having Resident 1 wait for almost a month to have his pain addressed by his "urologist" was too long. The WC stated she should have made a referral for Resident 1 to see a podiatrist but thought the appointment with the urologist was sufficient. During an interview on 3/29/2023 at 2:15 p.m., and a subsequent interview on 4/27/2023 at 2:16 p.m., with the Director of Nursing (DON), the DON stated the WC was negligent in not reporting Resident 1's complaint of pain to the nursing staff. The DON stated, the WC was not a nurse and her responsibilities at the facility consisted of assisting resident's with and accompanying them to appointments. The DON stated the WC should have reported Resident 1's complaint of pain to the nursing staff right away so they could have assessed him by looking at his feet, asking Resident 1 more detailed questions, documenting his response and what was observed and referred Resident 1 to a physician for orders and treatment. During a telephone interview on 4/28/2023 at 11:56 p.m. with LVN 3, LVN 3 stated Resident 1 came to her and reported he was having pain in his feet and lower legs (3/24/2023), she stated, she asked Resident 1 to let her see what was going on but Resident 1 stated no, he wanted to see a doctor. LVN 1 stated she documented that exchange with Resident 1 but did not document what she thought was his refusal to have his feet assessed nor did she notify Resident 1's physician. During a review of Resident 1's NPNs dated 3/29/2023 (five days after documentation indicating Resident 1 was in pain) and timed at 6:09 p.m., the NPNs indicated, Resident 1 was seen by a podiatrist with orders for Augmentin (a medication used to treat bacterial infections) and to apply Mupirocin 2% ointment (an ointment used to treat bacterial skin infections) directly on his feet twice a day. During a review of Resident 1's Post Event Assessment form (PEA) dated 3/29/2023 (five days after documentation indicating Resident 1 was in pain) and timed at 6:33 p.m., the PEA indicated Resident 1 was seen by a Podiatrist. The PEA indicated Resident 1 had cellulitis to the bilateral plantar aspect (the part of the foot contacting the ground) of his feet and the skin of his feet was cracked, red, swollen, and warm to touch. During a review of Resident 1's Order Summary Report ([OSR] Physician's Orders), dated 3/29/2023 (five days after documentation that Resident 1 complained of pain), the OSR indicated to start Resident 1 on the following medications: 1. Augmentin ([Amoxicillin and Potassium [Pot] Clavulanate] an antibiotic used to treat bacterial infections) 875-125 milligrams ([mg] a unit of measurement) (give one tablet every 12 hours for foot cellulitis (a deep infection of the skin caused by bacteria) for seven days. 2. Naproxen (a medication used to treat pain and inflammation) 250 mg every 12 hours as needed for foot and leg pain for one month. 3. Mupirocin External Ointment 2% apply to the plantar aspect of the right and left feet topically every day and evening shift for changes in skin texture for 21 days directly on the cracked skin, cover the feet with a dry dressing until healed then reassess. During a review of the facility's undated Policy and Procedure (P&P), titled, "Notification of physician/other Prescriber," the P&P indicated the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical or psychiatric care of the person served of any changes in the person served emotional, behavioral, physical condition, and/or involvement in adverse events. The medical provider/prescriber is called for medical problems. Notify the appropriate provider promptly of any sudden or marked adverse change in signs, symptoms of medical condition or behavior exhibited by an individual. During a review of the facility's undated policy and procedure titled, "Foot Care," the P&P indicated, feet shall be examined for pain, sores, bunions, ingrown toenails, pressure injuries, blisters, and skin tears. Upon request of any resident, a responsible family member and/or a legal representative, the charge nurse shall obtain orders for podiatry care from the resident's attending physician and shall contact a podiatrist. During a review of the facility's undated Policy and Procedure, titled, Pain Management, Assessment and Reassessment," the P&P indicated a person served has the right to be free of pain while staff also promote pain relief using a pain management plan during the stay. Pain evaluation is done when a person served complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Onset, location, frequency, duration, character of the pain, what makes it better or worse are also explored and documented. The facility failed to ensure: 1. Resident 1's physician was notified, and a podiatrist referral was made after being made aware of Resident 1's complaint of pain to his feet. 2. An assessment of Resident 1 feet and pain was conducted after Resident 1 made the facility staff aware of the pain to his feet. 3. Resident 1 was provided pain management when he complained of bilateral foot and leg pain. 4. The facility followed their Policy and Procedures (P/P), titled "Notification of Physician/other Prescriber," "Foot Care," and "Pain Management, Assessment and Reassessment," that stipulated, the licensed nurse is responsible to inform the physician or other prescriber responsible for the medical care of the person served of any changes in the person. A person served has the right to be free of pain while staff also promote pain relief. Pain evaluation is done when a person served complains of pain. Upon request of any resident the charge nurse shall obtain orders for podiatry (the treatment of the feet and their ailments) care. These failures resulted in a delay in treatment and pain relief to Resident 1's feet and the development of cellulitis (a deep infection of the skin caused by bacteria) going unnoticed causing unbearable pain, redness, swelling and dry/cracked skin on Resident 1's feet. These failures had the potential for Resident 1's pain to increase and worsening of his cellulitis. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.