Health inspection·February 11, 2022

F686 §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. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (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). On 11/29/2021, at 11:20 am, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to provide wound care services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to promote healing of the existing pressure injury for Resident 1 by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) followed Resident 1's care plan and notified Treatment Nurse 1 (TN 1) so TN 1 could notify Physician 1 (MD 1) of the changes in Resident 1's skin condition, on the resident’s sacral coccyx (tailbone, the bottom of the spine), on 11/1/21, 11/2/21, 11/4/21, and 11/5/21. 2. Ensure TN 1 revised Resident 1's Care Plan for stage 4 pressure injury (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules) to address the frequency in which Resident 1 should be turned and repositioned in bed and avoided positioning the resident on the pressure injury site. 3. Ensure Resident 1 was not lying on the resident's back directly on her pressure injury site. 4. Ensure nursing staff followed the facility's policy and procedure (P&P) to avoid the use of plastic backed chux (under pad with plastic backing to protect the mattress from getting wet) and thick linen on the low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). As result, Resident 1 developed an avoidable unstageable pressure injury (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. When the slough or eschar is removed, a stage 3 [full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore] or stage 4 pressure will be revealed) on the resident's sacral coccyx extending to right and left buttocks (back of a hip that forms two rounded fleshy parts on which a person sits). A review of Resident 1's Admission Record indicated the resident was an 85-year-old female who was admitted on 1/26/12 and readmitted on 9/17/21. Resident 1’s admitting diagnoses included diabetes mellitus (high blood sugar) and dependence on renal dialysis (a treatment for kidney failure that rids your body of unwarranted toxins, waste products and excess fluids by filtering your blood). A review of Resident 1's Care Plan titled, "Pressure Injury Prevention," initiated on 12/12/20 and revised on 9/19/21, indicated the resident was assessed at risk for development of pressure injury due to impaired mobility and incontinence of bowel and bladder (lack of voluntary control over urination or defecation). The nursing interventions included daily body checks for open areas, skin redness and to notify the physician for any changes in skin condition. A review of Resident 1's Braden Scale for "Predicting Pressure Sore Risk" (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure injury), dated 9/3/21, indicated Resident 1 scored 17 (a total score of 15-18 indicates a resident is at mild risk for developing a pressure injury). A review of Resident 1's Nursing Admission Assessment, dated 9/17/21, indicated Resident 1 had a healed scar on the sacral coccyx. The assessment indicated Resident 1 was readmitted to the facility without a pressure injury. A review of the Resident 1's Transfer Record, dated 11/6/21, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (call for emergency services) due to weakness and decline in activities of daily living function. The transfer record did not indicate Resident 1 had an unstageable pressure injury. A review of GACH 1's Admission Record, dated 11/6/21, indicated Resident 1 admitted to GACH 1 on 11/6/21 with diagnoses that included sepsis (life-threatening response to infection that can lead to tissue damage, organ failure, and death) and unstageable pressure injury. A review of GACH 1's Operative Report, dated 11/11/21, indicated Resident 1 received excisional debridement (surgical removal of dead tissues) of the pressure injury on the sacral coccyx with ostectomy (surgical removal of the bone) in preparation for future wound closure. The operative report indicated a total area of debridement was 14 x 8 centimeters (cm). The operative report indicated Resident 1 had a stage 4 pressure injury on the sacral coccyx with necrosis (dead tissues) and infection. A review of GACH 1's Wound Care Nurse (WCN) Report, dated 1/16/21, indicated Resident 1 was admitted to GACH 1 on 11/6/21 due to sepsis and unstageable pressure injury. The report indicated the Transfer Summary from the facility did not mention Resident 1's pressure injury or treatment. The report indicated on 11/9/2021 WCN spoke to the facility’s Director of Nursing (DON) and the DON was not able to provider further information regarding Resident 1's pressure injury. The report indicated on 11/11/21, Resident 1 received debridement of the pressure injury on the sacral coccyx and the unstageable pressure injury became a stage 4 pressure injury. A review of GACH 1's Discharge Instructions, dated 11/16/21, indicated Resident 1's sacral coccyx unstageable pressure injury was debrided on 11/11/21. The discharge instructions indicated Resident 1 was discharged back to the facility on 11/16/21 with a stage 4 pressure injury of the sacral coccyx extending to the right and left buttocks. A review of Resident 1's Care Plan for stage 4 pressure injury on the sacral coccyx extending to right and left buttocks, dated 11/16/21, indicated the goal was for Resident 1's pressure injury to heal in 30 days. The nursing interventions included for staff to assist the resident with turning/repositioning for skin pressure relief and provide a low air loss mattress. The nursing interventions did not address the frequency of turning/repositioning of Resident 1 in bed or to avoid positioning the resident on the pressure injury A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/22/21, indicated the resident was assessed with good short- and long-term memory recall ability. Resident 1 required extensive assistance (staff provide weight-bearing support) for bed mobility with two persons physical assist. The MDS indicated Resident 1 was incontinent of bowel and bladder. During multiple observations of Resident 1 on 11/29/21 at 11:30 a.m., 11:45 a.m., 12:45 p.m., 1:20 p.m., and 2:22 p.m., Resident 1 was lying in bed on her back. During an observation of Resident 1's pressure injury treatment on 11/29/21 at 11:45 a.m., the resident had a stage 4 pressure injury to her sacral coccyx extending to right and left buttocks. TN 1 measured the pressure injury as 9 cm in length by 17 cm in width, 3.2 cm in depth with undermining (destruction of tissue extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) of 1.7 cm at 8-11 o'clock. The wound bed (base of the wound) had a large amount of yellow slough (dead tissue). TN 1 cleansed the pressure injury with Normal Saline (sterile mixture of salt and water), applied Santyl ointment (medicine that removes dead tissues from wound so the wound can start to heal), applied collagen powder (medicine that helps accelerate the healing of pressure injury), packed the pressure injury with calcium alginate (absorbent wound dressing) and covered the pressure injury with foam dressing (dressing that absorbs fluid from pressure injury wounds). Resident 1 was lying on a plastic backed chux with a thick folded linen on a low air loss mattress. During an interview on 11/29/21 at 2:28 p.m., CNA 1 stated he was the caregiver assigned to Resident 1 on the morning shift of 11/01/21, 11/2/21, 11/4/21, 11/5/21 and 11/6/21. CNA 1 stated Resident 1's skin on her sacral coccyx and buttocks were black in color and the surrounding skin was brown when he conducted the resident's body check on those dates. CNA 1 stated he did not report the changes in Resident 1's skin color on the sacral coccyx and buttocks until 11/6/21 when he observed the opened skin on Resident 1's sacral coccyx. CNA 1 stated he thought Resident 1's normal skin color on the sacral coccyx and buttocks were black. CNA 1 stated he turned and repositioned Resident 1 on a side lying position by placing a thin pillow under the resident's shoulder and waist area. CNA 1 stated he did not fully turn the resident to her side as the lower back (sacral coccyx and buttocks) of the resident remained on contact with the mattress. CNA 1 stated he was not informed by any nursing staff members that Resident 1 should be fully turned to a side lying position to offload (take pressure off) the pressure injury on the sacral coccyx and buttocks to promote pressure injury healing. CNA 1 stated he did not receive training to avoid using plastic backed chux and thick linen on Resident 1's low air loss mattress for pressure management. CNA 1 stated he was unable to turn and reposition Resident 1 every two hours in bed as he was busy taking care of other residents. During an interview and concurrent review of Resident 1's Nursing Admission Assessment, on 11/29/21 at 3:05 p.m., the DON stated on 11/6/21, she transferred Resident 1 to GACH 1 due to the resident having shortness of breath. The DON stated during the transfer process, Registered Nurse 1 (RN 1) found out that Resident 1 had an unstageable pressure injury on the sacral coccyx extending to right and left buttocks. The DON stated RN 1 did not measure Resident 1's pressure injury as the resident was leaving the facility via 911. The DON stated on 11/1/21, CNA 1 did not immediately report the changes in Resident 1's skin color (black color) on the sacral coccyx and buttocks to RN 1. The DON stated Resident 1 did not receive appropriate nursing interventions for the pressure injury from 11/1/21 to 11/6/21. The DON stated Resident 1's pressure injury could have been prevented. A review of Resident 1's Nursing Admission Assessment, dated 11/16/21, indicated Resident 1 was readmitted from GACH 1 with a stage 4 pressure injury of the sacral coccyx extending to right and left buttocks. During an observation and concurrent interview on 11/29/21 at 3:45 p.m., Resident 1 was lying on her right side and speaking in Vietnamese. Resident 1 stated she was "always" lying on her back on all shifts. Resident 1 stated this afternoon was the first time that her lower back (sacral coccyx and buttocks) was not on contact with the mattress after her caregiver positioned her on her side. Resident 1 stated she felt good when her wound (pressure injury) was not pressing on the mattress A review of the facility's P&P, titled "Body Check Daily Report," dated 8/5/2021, indicated for CNAs to conduct daily body checks for each assigned resident, complete the daily body check form and submit the form to TNs for review. The policy indicated for TNs to monitor areas of skin breakdown noted on daily body check report and responsible for the treatment. A review of the facility's P&P, titled "Prevention and Care of Pressure Ulcers," dated 8/05/2021, indicated for staff to: a. Identify residents at risk for the development of pressure injuries. b. Identify the potential skin problems on the residents' care plan. c. Turn and reposition the resident as often as needed for the individual resident. d. Ensure proper bed making such as no wrinkles in bed linen, no excess padding of bed for incontinent residents. A review of the facility's P&P, titled "Skin Assessment," dated 7/17/21, indicated for staff to continually observe and monitor resident for changes and implement revisions to the plan of care as needed. Develop comprehensive, interdisciplinary plan of care including preventions and wound treatments as have indicated. The policy indicated for staff to provide safe and effective care to prevent the occurrence of pressure injuries. A review of the facility's P&P, titled "Alternating Pressure, Low Air Loss, Gel, Water Mattress, use of," dated 8/5/21, indicated for staff not to place a sheet on top of the mattress. According to an article titled, "A Laboratory Study Examining the Impact of Linen Use on Low-air-loss Support Surface Heat and Water Vapor Transmission Rates Volume 59 - Issue 8 - August 2013 ISSN 1943-2720" indicated the use of multiple layers of linen, plastic backed chux and plastic backed diaper can adversely affect the ability of the low air loss bed to manage the microclimate (temperature and humidity of the skin). This will block the airflow and may potentially trap heat and moisture against the patient's skin that may increase the risk of skin breakdown. The facility failed to provide wound care services to prevent pressure injury and failed to promote healing of the existing pressure injury for Resident 1 by failing to: 1. Ensure CNA 1 followed Resident 1's care plan and notified TN 1 so TN 1 could notify MD 1 of the changes in Resident 1's skin condition, on the resident sacral coccyx, on 11/1/21, 11/2/21, 11/4/21, and 11/5/21. 2. Ensure Resident TN 1 revised Resident 1's Care Plan for stage 4 pressure injury to address the frequency in which Resident 1 should be turned and repositioned in bed and avoided positioning the resident on the pressure injury site. 3. Ensure Resident 1 was not lying on the resident's back directly on her pressure injury site. 4. Ensure Nursing Staff followed the facility's policy and procedure to avoid the use of plastic backed chux and thick linen on the low air loss mattress. As result, Resident 1 developed an avoidable unstageable pressure injury on the resident's sacral coccyx extending to right and left buttocks. The above violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.