Other·April 19, 2024

§483.25(b) Skin Integrity §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. § 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 (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 2/2/2024, the California Department of Public Health (CDPH) received a compliant regarding substandard quality of care regarding a resident (Resident 1). On 3/6/2024 at 9:45 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. The facility failed to: 1. Provide care to prevent the development of an avoidable pressure injury consistent with Resident 1’s a 62-year-old-male’s care plan for skin integrity and the facility’s policies and procedures (P/P) titled, “Skin assessment, best practice”, “Pressure Wounds/Skin breakdown clinical protocol”, “Comprehensive person-centered care plans”, and “Charting and Documentation.” 2. Ensure the licensed nurses conducted a weekly assessment and monitoring of Resident 1’s right below the knee (BKA) surgical wound (incision due to surgical removal of part of the leg, up to the knee) and documented its condition from 11/11/2023 through 2/9/2024. These deficient practices resulted in: 1. Resident 1 developed a PI to the right BKA and transferred to a general acute care hospital (GACH) on 2/14/2024 to undergo a debridement (removal of a damaged tissue) of right BKA wound eschar (dead tissue). 2. Resident 1 feeling worried about possible further amputations of his right BKA due to the newly developed PI. 3. The potential to cause further infections and decline in Resident 1’s physical and psychosocial well-being. A review of Resident 1's Admission Record, indicated Resident 1 was originally admitted to the facility on 11/11/2023 and readmitted on 2/1/2024 with diagnoses including type 2 diabetes mellitus (condition when body cannot control the amount of blood sugar in the body) with diabetic polyneuropathy (caused by diabetes, affects many nerves which can cause numbness, in legs and hands), peripheral vascular disease ([PVD] reduced circulation of blood to the body), dependence on hemodialysis (treatment used to filter toxins from blood), and BKA of the right and left leg. A review of Resident 1's Nursing Admission Evaluation Assessment, dated 11/11/2023, indicated Resident 1 had a right BKA. The assessment did not indicate Resident 1 had any wounds or PIs. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 11/21/2023, indicated Resident 1’s cognitive skills for daily decision-making were intact. The MDS indicated Resident 1’s skin was intact and Resident 1 did not have any PI upon admission. The MDS indicated Resident 1 was at risk for developing a PI. A review of Resident 1's Comprehensive Skin Evaluation Assessment, dated 11/27/2023, did not indicate any assessments of Resident 1’s right BKA. A review of Resident 1's a physician’s orders dated 11/12/2023 through 1/15/2024, indicated a physician’s order for right BKA with 26 staples (metal device used to close surgical cuts/wound), paint with Betadine (anti-infection medication) solution and cover with abdominal wound dressing ([ABD] a type of bandage to cover large wounds), wrap with rolled gauze (thin, loose weave fabric used to cover wounds) and secure with a tape in place, daily. A review of Resident 1's untitled care plan, dated 11/12/2023, indicated Resident 1 had 26 staples on the right BKA stump. The care plan indicated the goal was that Resident 1’s BKA would not get infected until the next review date of 2/10/2024. The care plan interventions included to paint the BKA surgical wound with Betadine solution, cover with ABD pad, wrap with rolled gauze and secure in place with tape, to keep area clean and dry, monitor for pain, and notify physician and responsible party (RP) for any changes. A review of Resident 1's untitled care plan, dated 11/14/2023, indicated Resident 1 was identified to be at risk for a skin breakdown related to activity intolerance, cardiovascular (heart and blood circulation) disease, diabetes, other existing skin problems, impaired activity of daily living, impaired circulation, impaired mobility (moving from one space to another) neuropathy, PVD, sepsis (infection spread to bloodstream), BKA surgical wound/incision. The care plan goal was that Resident 1 would be compliant with treatments and intervention measures to decrease the risk and prevent a skin breakdown. The care plan interventions included to administer medication and treatment as ordered, nursing staff to assess Resident 1’s skin daily and notify physician of abnormal findings. A review of Resident 1's untitled care plan, dated 11/14/2023, the care plan indicated Resident 1 was identified to have a self-care deficit for activities of daily living related to activity intolerance, amputation of the right leg BKA, disease process, impaired balance, limited mobility, musculoskeletal (bones and muscles) impairment. The care plan interventions included for nursing staff to inspect skin weekly and as needed, observe skin for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of Resident 1's untitled care plan, dated 11/14/2023, indicated Resident 1 was identified to be at risk for impaired blood circulation related to PVD. The care plan goal for Resident 1 was to be free from signs and symptoms of PVD, remain free from complications related to PVD, lower extremities will be free from PVD signs and symptoms such as pain, pallor (pale), rubor (redness of skin, swelling), coldness (a symptom of poor blood circulation), edema (swelling of body) and skin lesions (damaged skin) through review date on 2/10/2024. The care plan interventions included to check blood circulation in left and right BKAs, check motor (ability to move) ability and sensation (ability to feel) to right and left lower extremities every shift, educate resident to use caution with heating pads, hot water bottles, monitor the extremities for signs and symptoms of injury, infections, development of wound, monitor, document, and report any changes to both legs to the physician including coldness, pallor, rubor, cyanosis (bluish discoloration of skin due to lack of blood flow) and pain. Monitor, document, report as needed any signs and symptoms of skin problems related to PVD, redness, edema, blistering, (area of skin covered by a raised, fluid-filled bubble) itching, burning, bruises, cuts, and other skin lesions. A review of Resident 1's untitled care plan, dated 11/14/2023, indicated Resident 1 had a below knee amputation of the right and left leg related to diabetes and history of infection of the right Transmetarsal ([TMA] surgically removes a part of the foot that includes the metatarsals [are five bones located between the ankle and toes in each foot] which is used to treat a severely infected foot or a foot with lack of oxygen supply. TMA involves surgical removal of a part of the foot that includes the metatarsals) site on 10/28/2023. The care plan goal for Resident 1 was to have the surgical wound heal without complications through the review date on 2/10/2024. The care plan interventions included for licensed nurses to check and document about the BKA surgical wound daily for signs and symptoms of infection, drainage, bleeding, any skin breakdown and impaired circulation, to check for edema and pain, monitor dressing for possible bleeding, document bloody drainage if any observed during the dressing change every shift and as needed, change dressing and record observations of the surgical wound site, rewrap stump as ordered and as needed. During a concurrent observation and interview on 3/6/2024, at 11:20 a.m., with Treatment Nurse (TN 2), in Resident 1’s room, Resident 1 had BKAs to the right and left legs. Resident 1’s right BKA had dry, blackish tissue on the front of the stump knee extending to both sides and the back. Resident 1 did not have any bandages covering the right BKA stump. TN 2 stated Resident 1 had necrotic (dead) tissue on the right stump because the wound dressing that was wrapped around the right stump wound, was causing pressure leading to a PI. During an interview on 3/6/2024, at 11:35 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had not been fitted for or used prosthetic (artificial body part) devices during his stay at the facility. The DOR stated she remembered bandages being present on Resident 1’s right stump during therapy sessions. During an interview on 3/6/2024, at 12:40 p.m., the Minimum Data Set Nurse ([MDSN] a Licensed Nurse responsible for conducting MDS assessments for facility residents) stated Resident 1’s care plans indicated Resident 1 had diabetes, a history of wound infections and a BKA of both legs. The MDSN stated Resident 1’s care plans indicated monitoring and documenting wound status every shift and as needed. The MDS nurse stated nursing staff was required to document residents’ skin conditions weekly on a document titled, “Nursing Comprehensive Skin Evaluation Assessment.” During an interview on 3/6/2024, at 12:45 p.m., the MDSN stated Resident 1 required daily right stump wound and skin assessments and documentation as per Resident 1’s care plans. During a concurrent interview and record review on 3/6/2024 at 12:50 p.m., with the MDSN, Resident 1’s medication administration records (MAR) and treatment administration record (TAR) from 11/2023 through 2/29/2024 were reviewed. The MAR and TAR indicated there were no documented assessments of Resident 1’s right BKA stump condition. The MDSN confirmed the MAR and TAR did not indicate the licensed nurses were assessing Resident 1’s right BKA stump wound. During a concurrent interview and record review on 3/6/2024 at 12:55 p.m., with the MDSN, Resident 1’s Admission Skin Assessment, dated 11/12/2023, was reviewed. The Admission Skin Assessment indicated the right BKA stump had 26 staples. The MDSN stated the assessment was completed by a licensed nurse upon Resident 1’s admission to the facility. The MDSN stated the assessment should have but did not describe the condition of Resident 1’s right BKA stump wound. The MDSN stated the assessment should have included documentation of wound appearance including wound size, presence of redness or drainage (signs of infection), if the wound was open or closed and the condition of the wound dressing. The MDSN stated the assessment does not give a thorough evaluation or documentation of the right BKA wound. During a concurrent interview and record review on 3/6/2024 at 1 p.m., with the MDSN, Resident 1’s Admission Skin Assessment, dated 2/1/2024 was reviewed. The Admission Skin Assessment indicated Resident 1 had one open blister and one closed blister on the right thigh, one closed blister on the right stump, one open blister on the right medial (inner) stump and one open blister on the back of the right stump. The MDSN stated the Admission Skin Assessment was completed by a licensed nurse upon Resident 1’s readmission to the facility on 2/1/2024. The MDSN stated the Admission Skin Assessment for Resident 1’s right stump and thigh did not include the description what the right BKA stump wound looked like. The MDSN stated the Admission Skin Assessment documentation should have included information about the appearance of the wound including the size, the color and presence of drainage, progress in healing process, and the condition of the dressing. The MDSN stated the documentation of the blisters noted in the Admission Skin Assessment did not include the size of each blister but should have. A review of Resident 1’s Skin Progress Note, dated 2/9/2024, documented by TN 1, indicated the wound care physician saw Resident 1’s right BKA stump with a wound of the skin on 2/9/2024, and ordered to cleanse with normal saline ([NS]-water and salt solution used to clean wounds) pat dry, apply Silvadene cream (medicated cream used to treat and prevent infections), ABD pad, then cover with rolled gauze, monitoring in progress. During an interview on 3/6/2024, at 1:10 p.m., the MDSN stated the Skin Progress Note dated 2/9/2024, did not indicate TN 1 notified Resident 1’s family or primary physician of Resident 1’s right BKA stump change of condition (wound of the skin/necrotic tissue). A review of Resident 1’s Comprehensive Skin Evaluation /Assessment, dated 2/12/2024, indicated the resident was assessed to have a right BKA stump skin wound and was measured 10 centimeters ([cm] a unit of measurement of length) in length with 34 cm in width and undetermined depth. The assessment indicated the right BKA stump skin wounds may be due to a tight wrapping per wound care physician. The assessment indicated the treatment was to clean the right BKA stump with NS, pat dry, apply Silvadene following application of ABD and to cover with rolled gauze as ordered on 2/9/2024. During a concurrent interview and record review on 3/6/2024 at 1:15 p.m., with the MDSN, Resident 1’s Wound Care Progress note, dated 2/16/2024 was reviewed. The Wound Care Progress note indicated the treatment for the right BKA stump skin wound (with unspecified severity) start date was 2/9/2024. The Wound Care Progress note indicated the wound had a 0% slough (yellow/white material found in wound bed), had 80% necrotic (dead) tissue, 10% granulation (healing tissue), and 10% epithelial (new tissue). The MDSN stated Resident 1 began receiving treatment to the right BKA stump wound with the facility ‘s wound care consultant physician on 2/9/2024. The MDSN stated after Resident 1’s readmission on 2/1/2024, the resident developed a new skin wound with necrotic tissue on his right BKA stump. A review of Resident 1’s Nurses Progress Notes, dated 2/18/2024 and timed at 5:55 pm, indicated Resident 1 was transported to a GACH to rule out a possible infection of BKA stumps. The Nurses Progress Notes indicated that on 2/18/2024 at 4:58 p.m., Resident 1’s wife complained the resident had bilateral discoloration of BKA stumps, and the right BKA stump appeared darker brown in color than the left BKA stump. A review of Resident 1’s GACH Admission Sheet record, dated 2/19/2024, indicated Resident 1 arrived to the GACH on 2/19/2024 at 3:42 am. A review of Resident 1’s GACH History and Physical (H/P) dated 2/19/2024, indicated Resident 1 presented to the GACH from a Skilled Nursing Facility (SNF) due to worsening of the right BKA incision wound. The H/P indicated Resident 1’s right BKA was done in October 2023 and left BKA was completed in January 2024. The H/P indicated Resident 1’s diagnosis was right BKA