Health inspection·December 26, 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 ulcers. 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 11/14/2024 the California Department of Public Health (CDPH) received a complaint regarding Quality of Care. On 11/26/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the facility failed to: 1. Implement Resident 2’s care plan, titled “Alteration in Skin integrity” intervention to turn and reposition the resident at least every two hours and as needed from 1/2024 to 3/2024 to prevent Resident 2 from developing pressure injuries (damage to skin or underlying tissue due to unrelieved pressure) to the right and left lateral (to the side of, or away from, the middle of the body) malleolus (the bone on the outside of the ankle joint). 2. Ensure Resident 2 was assessed by the Registered Dietician (RD -food and nutrition expert) on 2/11/2024 when the deep tissue injury (DTI – persistent non-blanchable [something does not fade when pressure is applied, such as a rash or skin discoloration] deep red, maroon, or purple discoloration, related to damage from pressure and/or shear) to the left lateral malleolus was first identified, as indicated in the care plan titled, “Alteration in Skin integrity” and as the Wound Consultant recommended on 2/13/2024. 3. Ensure Resident 2’s Wound Consultants’ recommendation to cleanse the wound to the left lateral malleolus with Normal Saline (mixture of salt and water solution) prior to applying Betadine (a solution that kills germs promptly) was implemented starting on 2/11/2024. 4. Implement the facility’s policy and procedure (P&P) titled, “Pressure Injury also known as, Pressure Sore Management”, revised 10/2017, that indicated to prevent the development of skin breakdown/pressure injuries the staff need to implement the care plan to reposition the resident at least every two hours and follow the RD’s and physician’s recommendations. These failures resulted in Resident 2, who was assessed as a moderate risk for developing a skin injury and had intact skin upon admission on 1/9/2024 developing the following pressure injuries: 1a. A facility-acquired preventable Stage IV (full-thickness skin and tissue loss with exposed muscle or bone) pressure injury to the left lateral malleolus, measuring 2.2 centimeters (cm a unit of measure) long by 1.6 cm wide by 0.3 cm deep on 3/26/2024, 77 calendar days from admission. The wound bed was 30 percent (%) slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and be raised), and 10% epithelial (appears pink or pearly white, occurs in the final stage of healing) tissue. 1b. A Stage III (full-thickness loss of skin, dead and black tissue may be visible) pressure injury, to the right lateral malleolus, measuring 1.2 cm long by 1.2cm wide with an undetermined depth (UTD) and 100% slough. These failures placed Resident 2 at risk for poor healing and/or not healing of a Stage IV pressure injury to the left lateral malleolus and a Stage III to the right lateral malleolus, at risk for the pressure injuries infection with potential for osteomyelitis (bone infection) development, possible sepsis, and death. 1. A review of Resident 2’s Admission Record, indicated Resident 2, a male over 89 years of age, was admitted to the facility on 1/9/2024 with diagnoses including acute respiratory failure (when the lungs and blood are unable to exchange gases properly), generalized muscle weakness, hyperglycemia (a condition where there is too much glucose in the blood ), acute kidney failure (kidneys suddenly can't filter waste products from the blood), with gastrostomy ([GT] – a soft tube surgically placed into the stomach to provide nutrition, hydration and medication) in place. A review of Resident 2’s Minimum Data Set ([MDS], a resident assessment tool) dated 1/16/2024, indicated Resident 2’s cognitive (ability to think and reason) skills for daily decision-making were severely impaired. The MDS indicated Resident 2 was totally dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2’s skin was intact and did not have any ulcers, wounds, and skin problems. A review of Resident 2’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 1/9/2024, indicated Resident 2’s score was 14 indicating Resident 2 was at moderate risk for developing a pressure injury. The Braden Scale Assessment indicated Resident 2’s skin was occasionally moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility (ability to change and control body position), was unable to make frequent or significant positional changes independently and required moderate to maximum assistance (helper does more than half the effort) when moving. During a phone interview on 11/26/2024 at 9:04 a.m., family member (FM 1) stated Resident 2 had pressure sores (in reference to a pressure injuries) because the facility did not turn Resident 2 frequently. FM 1 stated she remembered one incident when the resident’s indwelling urinary catheter (a soft flexible tube inserted into the urinary bladder to drain urine into a collection bag outside the body) had been accidentally removed and no one discovered it until later. FM 1 sated if they were turning the resident every two hours, they would have seen it and identified the problem with skin sooner. During a concurrent interview and record review on 11/26/2024 at 12:36 p.m., with the Assistant Director of Nursing (ADON) Resident 2’s MDS, dated 1/16/2024, Resident 2’s Initial Nursing History and Assessment, dated 1/9/2024, and Resident 2’s Braden Scale Risk Assessment, dated 1/9/2024, were reviewed. The ADON stated Resident 2’s Initial Nursing History and Assessment, and Resident 2’s Braden Scale Risk Assessment indicated Resident 2’s skin was intact upon admission and Resident 2 was at a moderate risk for developing pressure injuries. The ADON stated Resident 2 was dependent on staff for all ADL’s including turning and repositioning in bed. The ADON stated Resident 2 was totally dependent on staff to implement interventions for preventing the development of pressure injuries, since Resident 2 could not independently reposition himself. During a concurrent interview and record review on 11/26/2024 at 12:40 p.m., with the ADON, Resident 2’s Situation Background Assessment Recommendation (SBAR) Communication Form, dated 2/11/2024, was reviewed. The ADON confirmed the SBAR indicated that 32 days after the resident’s admission Resident 2 developed a purplish discoloration on the left lateral malleolus measuring 2.5 cm by 2.5 cm., which was a sign and symptom of pressure injury development. During a concurrent interview and record review on 11/26/2024 at 12:44 p.m., with the ADON, Resident 2’s Wound Consultant Progress Notes, dated 2/13/2024, were reviewed. The ADON confirmed the Wound Consultant classified the purplish discoloration on the left lateral malleolus as a DTI. The ADON stated the Wound Consultant recommended turning and repositioning the resident every two hours, keeping the skin clean and dry, and to avoid massaging bony prominences (areas where bones are close to the surface). The ADON stated the Wound Consultant also recommended the RD to assess Resident 2 to ensure adequate intake of protein and calories, to maintain the current level of activity, mobility, and range of motion, and to use positioning devices to prevent prolonged pressure on bony prominences. The ADON stated the treatment plan was to cleanse the left lateral malleolus DTI with sterile (free of infection causing organisms) Normal Saline, pat dry, apply Betadine directly to the wound bed of the left lateral malleolus DTI and cover with dry sterile dressing. The ADON stated the treatment plan was also to change dressing daily and as needed for loss of integrity and soiling. During a concurrent interview and record review on 11/26/2024 at 12:47 p.m., with the ADON, Resident 2’s care plan titled, “Alteration in skin Integrity,” started on 2/11/2024, was reviewed. The ADON confirmed the care plan goal indicated Resident 2’s left lateral malleolus DTI would heal without complications. The ADON stated two of the care plan interventions included the RD’s evaluation of Resident 2’s nutritional needs for pressure injury healing to left lateral malleolus DTI, and to turn and reposition Resident 2 at least every two hours. During a concurrent interview and record review on 11/26/2024 at 12:49 p.m., with the ADON, Resident 2’s Wound Consultant Progress Notes, dated 2/27/2024, were reviewed. The ADON stated the Wound Consultant Progress Notes indicated Resident 2’s DTI to the left lateral malleolus opened up and it was reclassified as an unstageable pressure injury (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) measuring 2.9 cm long by 2.5 cm wide with UTD depth and 100% necrotic (dead tissue in the wound itself). The Wound Consultant Progress Notes indicated a recommendation to turn the resident every two hours and to follow the registered dietitian’s recommendations. The ADON stated the facility should have recommended the use of a low air loss mattress (a mattrass designed to prevent and treat pressure injuries) before Resident 2’s left lateral DTI worsened to an unstageable pressure injury. During a concurrent interview and record review on 11/26/2024 at 12:50 p.m., with the ADON, Resident 2’s Nutrition Care Progress Notes from 1/10/2024 to 3/29/2024 were reviewed and the Nutrition Care Progress Notes indicated the RD did not make any recommendations for Resident 2’s pressure injury healing until 3/5/2024, which was 23 days after the Wound Consultant’s and care plan recommendations for the RD to assess Resident 2. The ADON confirmed the RD did not assess Resident 2 and make recommendations for Resident 2’s wound healing interventions until 3/5/2024. The ADON stated Resident 2 should have been seen by the RD sooner so the RD’s recommendations could be implemented quicker to promote Resident 2’s pressure injury to start healing. A review of Resident 2’s Nutrition Care Progress Notes, dated 3/5/2024, indicated the RD made recommendations to promote wound healing as follows: a. Discontinue current GT feeding of Fibersource High Nitrogen (formula for nutrition) 1.2 at 65 milliliters ([ml] a liquid weight measurement)/hour over 20 hours and change formula with Jevity 1.5 Cal (high protein formula) 237 ml 5 times a day via bolus (a single dose administered all at once) at 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m., to provide a1185 ml equivalent to 1778 kilocalories (unit of energy), 76 grams of protein, and 901 ml of water. b. Discontinue Fluid restriction to 1500 ml. c. Discontinue folic acid (supplement). d. Discontinue free water flush (water used to clear the g-tube before and after administering medications). e. Start free water flush of 25 ml before and after each bolus feeding. f. Zinc (supplement) 50 milligrams ([mg] weight measurement) daily for 5 days. g. Discontinue Pro- Stat (liquid protein supplement). During a concurrent interview and record review on 11/26/2024 at 12:58 p.m., with the ADON, Resident 2’s Documentation Survey Reports for January, February, and March 2024 were reviewed. The Documentation Survey Reports indicated the column titled, Turn and Reposition Every Two Hours and As Needed indicated Resident 2 was not turned and repositioned every two hours and as needed on each shift in January, February, and March 2024. The ADON stated The Documentation Survey Reports indicated there were six eight-hour shifts in January, five shifts in February, and eight shifts in March 2024 that were left blank which meant there was no documented evidence Resident 2 was turned and repositioned every two hours on each shift in January, February, and March 2024. The ADON stated if it was not documented it was not done. During a review of Resident 2’s Wound Consultant Progress notes, the Wound Consultant Progress notes indicated the following: a. On 3/12/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as a Stage III (Full-thickness loss of skin, dead and black tissue may be visible) pressure injury measuring 2.8 cm long by 1.5 cm wide, with an undetermined depth. b. On 3/19/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as Stage IV pressure injury measuring 1.5 cm long by 1.8 cm wide by 0.4 cm deep. The notes indicated a new DTI was noted on the right lateral malleolus measuring 2.0 cm long by 2.0 cm wide with an undetermined depth. c. On 3/26/2024, the notes indicated the Stage IV pressure injury to the left lateral malleolus measured 2.2 cm long by 1.6 cm wide and 0.3 cm deep. The wound bed was 30% slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and raised), and 10% epithelial (appears pink or pearly white occurs in the final stage of healing) tissue. The right lateral malleolus DTI had gotten worse and was reclassified as a Stage III pressure injury measuring 1.2 cm long by 1.2 cm wide with an undetermined depth and 100% slough. Excisional debridement (surgical removal or cutting away of dead tissue, necrosis, or slough) was performed on both right and left lateral malleolus pressure injuries. During an interview and record review on 12/2/2024 at 10:12 a.m., with the DON, Resident 2’s Wound Consultant Notes dated 2/13/2024 and Physician’s Orders dated 2/2024 were reviewed. The Wound Consultant Notes indicated the treatment plan for the left lateral malleolus was to cleanse the wound with sterile Normal Saline, pat dry, apply Betadine directly to the wound bed and cover with dry sterile dressing. Change dressing daily and as needed for loss of integrity/soiling. Resident 2’s Physician Orders dated 2/11/2024, 2/16/2024, and 2/27/2024 indicated the order for the left lateral malleolus was to paint with Betadine, allow to dry and then cover with Silicone Foam (a type of wound dressing that seals the wound and absorbs any fluids) dressing each day shift.