Other·April 12, 2024

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) 42 C.F.R., § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: §72311(a)(3)(B) Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: . . . (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. §72523(a) (c)(2)(D)(3) 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: . . . (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. . . . (3) Infection control policies and procedures. 22 Cal. Code Reg., §72517(a)(1)(2) Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients; (2) Prevention and control of infections. On 2/21/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who suffered a broken ankle on 11/2023 after sustaining a fall that required surgery, developed an infection due to the facility's lack of care and neglect. On 2/29/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint. CDPH determined that following Resident 1's readmission to the facility (1/18/2024), Resident 1's right ankle surgical incision was not treated per the physician's orders and Resident 1's physician was not notified of Resident 1's change of condition (COC) when Treatment Nurse 1 (TN 1) identified for the first time (2/10/2024) Resident 1's surgical hardware was visible through the resident's right ankle surgical incision. The facility failed to: 1. Ensure TN 1 and TN 2 followed Resident 1's orthopedic surgeon's treatment orders to stop using an antibiotic ointment on Resident 1's right medial ankle wound at surgical incision site and to use Betadine-soaked gauze treatments to Resident 1's right ankle starting on 2/7/2024. TN 1 and TN 2 continued to apply antibiotic ointment to Resident 1's surgical wound from 2/7/2024 to 2/10/2024 (three days after the order to stop was made). 2. Ensure TN 1 and TN 2 implemented Resident 1's Care Plan to notify Resident 1's physician and/or Resident 1's orthopedic surgeon when Resident 1's surgical hardware was observed exposed through Resident 1's right ankle wound at the surgical incision site on 2/10/2024. 3. Ensure TN 1 documented Resident 1's COC on 2/10/2024 when Resident 1 was observed to have exposed surgical hardware at Resident 1's right ankle surgical incision site. 4. Ensure TN 1 notified Resident 1's physician and orthopedic surgeon when she identified Resident 1's surgical hardware was visibly exposed through the resident's surgical incision on the resident's right ankle on 2/10/2024. 5. Ensure TN 2 notified Resident 1's physician and orthopedic surgeon when TN 2 first noted Resident 1's surgical hardware was visibly exposed through the resident's surgical incision on the resident's right ankle on 2/20/2024. 6. Ensure the facility's policy and procedure (P/P), titled, "Notification of Changes," was implemented and followed, indicating the facility must consult with the resident's physician when there is a significant change in the resident's physical condition. 7. Ensure the facility's P/P, titled "Provision of Physician Ordered Services," was implemented and followed, indicating qualified nursing personnel will administer therapeutic treatments as ordered by the physician. 8. Ensure adequate training and supervision was provided to employees, which resulted in TN 1 and TN 2's failure to provide minimum standards of care and failure to implement established facility P/P. These deficient practices resulted in Resident 1's right ankle surgical incision becoming infected and Resident 1's transfer to a General Acute Care Hospital (GACH 1) where Resident 1 underwent a surgical procedure to remove infected hardware with irrigation and debridement ([I&D] washout and removal of dead, infected, or contaminated tissue) of the infected wound and placement of a wound vacuum (a device that promotes healing by gently pulling fluid from the wound over time, reducing swelling, cleaning the wound and removing bacteria). A review of Resident 1's facility Admission Record (Face Sheet) indicated Resident 1, a 75-year-old female, was initially admitted to the facility on 11/16/2023 and was readmitted on 1/18/2024 with the diagnoses including a history of falling and a displaced comminuted (type of broken bone where the bone snaps into two or more parts and moves so that the two ends are not lined up straight) fracture of the shaft of the right fibula and right tibia. A review of Resident 1's Change in Condition (COC) dated 12/08/2024 indicated Resident 1 used a shower chair to climb out of a bathroom window and was found sitting on the ground outside of the facility under the window holding her right ankle and grimacing from pain. The COC indicated Resident 1's physician was notified, and the physician ordered Resident 1 to be transferred to GACH 2 for further evaluation. A review of GACH 2's Face Sheet indicated Resident 1 was admitted to GACH 2 on 12/08/2024 with a diagnosis of a right tibia (the inner and typically larger of the two bones between the knee and the ankle) and fibula (the outer and usually smaller of the two bones between the knee and the ankle) fracture. A review of Resident 1's Discharge Summary from GACH 2 dated 1/18/2024 indicated on 12/9/2023 Resident 1 had an open reduction internal fixation ([ORIF] a surgical procedure that puts pieces of a broken bone into place using screws, plates, sutures, or rods) surgery of her right ankle. The Discharge Summary indicated Resident 1 was discharged from GACH 2 on 1/18/2024. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/22/2024 indicated Resident 1's cognitive (thinking and reasoning) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate to maximum assistance from staff to complete most activities of daily living ([ADLs] eating, drinking, toileting, and dressing). A review of Resident 1's Physician's Order dated 1/19/2024 indicated to cleanse Resident 1's right medial (toward the middle or center) ankle with normal saline ([NS] a non-toxic solution that does not damage healing tissues), pat dry, apply Betadine then cover with a dry island dressing daily and as needed. A review of Resident 1's Care Plan dated 1/19/2024 indicated Resident 1 had a potential/actual impairment of the skin integrity to the surgical site on her right medial ankle. The Care Plan indicated Resident 1 had sutures to her right medial ankle and was at continued risk for skin breakdown related to her fragile skin and infection. Under this Care Plan a goal was for Resident 1 was to have no complications through the next review date, 1/27/2024. The Care Plan's interventions included reporting declines in skin integrity to Resident 1's physician. A review of Resident 1's COC note dated 2/1/2024 indicated Resident 1's surgical wound on the right medial ankle had a moderate amount of pus, redness, swelling and warmth. The COC note indicated Resident 1's surgical wound was cleansed with NS, following application of Betadine and Mupirocin ointment. The COC note indicated Resident 1's primary physician was notified of the COC. A review of Resident 1's Care Plan dated 2/1/2024 indicated Resident 1 had drainage coming from the surgical wound on the right ankle surgical site. Under this Care Plan the goal for Resident 1 was to be free from any complications related to the surgical site on the right ankle. The Care Plan's interventions included to notify the physician regarding any Resident 1's COC. A review of Resident 1's Physician's Order dated 2/6/2024 indicated to apply Mupirocin to Resident 1's right medial ankle wound every day shift, cleanse the wound with NS, pat dry, apply Bactroban then cover with an abdominal pad dressing (ABD) and wrap with a Kerlix gauze roll. A review of Resident 1's orthopedic surgeon's Progress Note dated 2/7/2024 indicated the orthopedic surgeon ordered to apply a Betadine-soaked gauze to Resident 1's right ankle medial every two to three days, no ointment. A review of Resident 1's Nursing Progress Notes dated 2/10/2024 and timed at 9:17 a.m. indicated hardware was exposed and visible in Resident 1's right lower leg Continued review of the Nursing Progress Notes indicated there was no documentation that Resident 1's physician was notified of the exposed hardware. A review of Resident 1's Skin and Wound Evaluation dated 2/13/2024 indicated the hardware was visible in Resident 1's wound bed on the right ankle and the section that indicated if Resident 1's physician was notified was left blank. A review of the Wound Physician's Consult Note dated 2/13/2024 indicated Bactroban, and a dry dressing were applied to Resident 1's surgical wound on her right ankle. The Physician's Wound Consult Note indicated there was exposed hardware at the distal (a part of the body that is farther away from the center of the body than another part) end of Resident 1's surgical wound on the right ankle. A review of Resident 1's Treatment Record dated 2/2024 indicated the following: 1. From 2/7/2024 - 2/10/2024 Mupirocin and Bactroban was applied to Resident 1's right ankle medial wound daily (when the order from orthopedic surgeon on 2/7/2024 indicated no ointment to be used). 2. There was no documentation that Resident 1's right ankle medial wound was treated with a Betadine-soaked gauze every two to three days as ordered on 2/7/2024. A review of Resident 1's Physician Orders dated 2/7/2024, indicated Resident 1 had a follow up appointment with the orthopedic surgeon on 2/21/2024 at 9:45 a.m. A review of Resident 1's orthopedic surgeon's Progress Note, dated 2/21/2024 indicated there was no wet to dry (Betadine-soaked gauze) dressing done at the facility and Resident 1's surgical incision was noted with drainage and an exposed screw at the surgical incision site on her right ankle. The orthopedic surgeon's Progress Note indicated Resident 1 was referred to the emergency room for intravenous ([IV] in the vein) antibiotics and a Wound Care Consult for an exposed screw. A review of Resident 1's Nursing Progress Notes dated 2/21/2024 and timed at 1:22 p.m., indicated Resident 1 went to orthopedic surgeon appointment and returned with a new order to transfer Resident 1 to the emergency room (ER) due to an infected right tibia with exposed hardware. A review of Resident 1's Physician's Order, dated 2/21/2024 indicated to transfer Resident 1 to a GACH due to an infected right tibia with exposed hardware. A review of GACH 1's Face Sheet indicated Resident 1 was admitted to GACH 1 on 2/22/2024 with diagnoses including a right ankle surgical wound infection with exposed orthopedic hardware. A review of GACH 1's History and Physical (H&P) dated 2/22/2024 indicated during the physical's exam of Resident 1's right ankle, there was a wound measuring two centimeter (cm) in length with an exposed hardware screw on Resident 1's right medial malleolus (the inside of the ankle formed by the tibia). A review of Resident 1's Orthopedic Medicine Progress Note dated 2/24/2024 indicated Resident 1's right lower extremity hardware was removed, the wound underwent an I&D, and a closed wound vacuum was placed in the wound. A review of GACH 1's Discharge Order, dated 2/26/2024 indicated to leave the dressing on the right ankle in place until a follow up appointment with the orthopedic surgeon in one to two weeks. An observation of Resident 1 at the facility on 2/29/2024 at 12:15 p.m., indicated Resident 1 was in her room with a small wound vacuum machine attached to the resident's right ankle along with a cannister. During an interview on 2/29/2024 at 1:30 p.m., and a subsequent interview on the same day at 3:30 p.m., TN 2 stated Resident 1's right medial ankle surgical wound was treated with Mupirocin from 2/7/2024 until 2/10/2024. TN 2 stated when she (TN 2) was treating Resident 1's wound on 2/20/2024, she could see the top of a metal button that looked like the top of a screw, on Resident 1's right medial lower leg surgical wound (incision). TN 2 stated she was not sure if the metal hardware was supposed to be visible through the incision site, but the incision did not look normal because there was no skin covering the hardware. TN 2 stated she did not notify Resident 1's physician or the orthopedic surgeon that the hardware was visible, and stated she did not create a COC form and could offer no explanation why. TN 2 stated it was her understanding that if there was no skin covering Resident 1's wound to protect it, the wound could get infected. During an interview on 2/29/2024 at 2:35 p.m., and a subsequent interview on 3/1/2024 at 2:22 p.m., TN 1 stated on 2/10/2024 she noticed hardware was visible in Resident 1's right ankle surgical wound. TN 1 stated she reported to the wound doctor that the hardware in Resident 1's surgical incision was visible, and he (the wound doctor) did not provide any new orders for treatment of the visible hardware. TN 1 stated she did not notify the orthopedic surgeon on 2/10/2024 when she noticed the visible hardware because Resident 1 had a follow up appointment with the orthopedic surgeon in a few days on 2/21/2024, (11 days after the visible hardware was noticed in Resident 1's wound) and she thought the surgeon could evaluate it then. TN 1 stated she should have notified the orthopedic surgeon about the visible hardware in Resident 1's surgical wound incision on 2/10/2024 when she first noticed it and documented what she saw as a COC. TN 1 stated she overlooked treating Resident 1's wound with Betadine-soaked gauze and she should have stopped using the ointments (Mupirocin and Bactroban) on Resident 1's incision site, per the orthopedic surgeon's order on 2/7/2024. TN 1 stated the physician's orders should have been carried out as the orders were written and the resident's physician should have been called if clarification of the order was needed. During an interview on 3/1/2024 at 4:11 p.m., the Director of Nursing (DON) stated if there was a COC to resident's skin, the nurse should have notified Resident 1's physician and documented that change on a COC form. The DON stated visible hardware was a COC, but she was not sure if Resident 1's physician or the orthopedic surgeon were notified. The DON stated if hardware was visible through Resident 1's incision (wound), that meant the incision was open and there was a higher chance of infection to occur. The DON stated properly transcribing and implementing physician orders helps ensure residen