Health inspection·September 13, 2024

F686 Title 42 Federal Code of Regulations §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. Title 22 California Code of Regulations Section 72523. Resident Care Policies and Procedures. a) Written resident care policies and procedures shall be established and implemented to ensure that resident related goals and facility objectives are achieved. Title 22 California Code of Regulations Section 72315. Nursing Service – Resident Care. (f) Each resident shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (7) Carrying out of physicians’ 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 7/30/2024, the California Department of Public Health (CDPH) conducted an unannounced recertification survey. As a result of the investigation, and based upon observation, interview, and record review, CDPH determined the facility failed to provide care and services to prevent the development of pressure ulcers (PU) on the left and right hip of Resident 228 and failed to provide PU treatments for Resident 228 who was assessed as at risk for developing PU by the facility failing to: a. Ensure Treatment Nurses (TXN 1 and TXN 3) provided wound treatment to Resident 228’s right hip opened scratches /open wounds on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 as ordered by Resident 228’s Medical Doctor (MD) 1. b. Ensure TXN 1 and TXN 3 provided treatment to Resident 228’s right and left hips’ unstageable PU on 7/29/2024 as ordered by MD 1. c. Ensure TXN 3 notified MD 1 of Resident 228’s development of the avoidable unstageable PU on the right and left hips when Physician Assistant 1 (PA 1) identified those PUs on 7/24/2024. d. Ensure TXN 3 carried out PA 1’s verbal order to clean Resident 228’s unstageable PU on Resident 228’s right and left hips with Normal Saline and Betadine and to cover the PU with dressing on 7/24/2024. e. Ensure TXN 1 and TXN 3 implemented Resident 228’s Care Plan (CP) dated 5/30/2024 for impaired skin integrity and risk of worsening of a PU and to provide wound care treatment to Resident 228 as ordered by MD 1 and to report further skin breakdown to MD 1. As a result, on 7/24/2024, Resident 228 developed an avoidable unstageable PU on the right hip and worsened left hip unstageable PU. The unstageable PU on the right hip measured 5.5-centimeter (cm) length by 5 cm width with a depth of 0.2 cm, and the unstageable PU on the left hip measured 7 cm length by 4 cm width with a depth of 0.2 cm. A review of Resident 228’s Admission Record indicated the facility admitted Resident 228, an 83-year-old male on 2/23/2024 and readmitted on 5/30/2024 with diagnoses that included type two diabetes mellitus, end stage renal disease, and dependence on renal dialysis. A review of Resident 228’s Minimum Data Set (MDS) dated 3/4/2024 indicated Resident 228 had moderately impaired cognition. The MDS indicated Resident 228 was at risk for developing PU due to occasionally moist skin and very limited mobility. A review of Resident 228’s Admission Body Assessment (ABA) dated 5/30/2024 indicated Resident 228 was admitted to the facility with an unstageable PU on the left hip which measured 1 cm. length by 1.5 cm width. A review of Resident 228’s Braden Scale form dated 5/30/2024 indicated Resident 228 was at risk to develop a PU due to occasionally moist skin and very limited mobility. A review of Resident 228’s untitled CP for impaired skin integrity and risk of worsening of a PU dated 5/30/2024 indicated for staff to provide treatment to Resident 228’s PU as ordered by MD 1 and to report further skin breakdown to MD 1. A review of Resident 228’s Non-Pressure Sore Skin Problem Report (NPSSPR) of the right hip dated 6/22/2024 indicated there was open red and moist scratches on Resident 228’s right hip. During a concurrent interview with TXN 1 on 7/31/2024 at 4 PM and record review of Resident 228’s TAR dated from 6/1/2024 to 7/31/2024 for the right hip and the CP for impaired skin integrity and risk of worsening of PU dated 5/30/2024, Resident 228’s TAR for the right hip indicated blank spaces on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024. TXN 1 stated Resident 228 missed five days of treatment on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024. The CP indicated for licensed staff to provide wound care treatment as ordered and to report further skin breakdown to MD 1. TXN 1 stated Resident 228’s right hip started as a scratch on 6/22/2024. TXN 1 stated not providing treatment as ordered would cause the right hip unstageable PU to worsen. TXN 1 stated Resident 228’s CP was not implemented because treatment for the open wound on the right hip was not provided to Resident 228 as per MD 1’s order. TXN 1 stated missing treatments would contribute to the development of an avoidable PU. During a concurrent interview with RN 3 and record review of Resident 228’s TAR on 8/1/2024 at 2:34 PM, Resident 228’s TAR for the right hip dated from 6/1/2024 to 7/31/2024 was reviewed. Resident 228’s TAR indicated blank spaces on 7/6/2024,7/20/2024,7/21/2024,7/25/2024 and 7/29/2024. RN 3 stated Resident 228 missed treatment for the right hip open wound on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024, and for unstageable PU on 7/29/2024. RN 3 stated five days of missed treatments would result in worsening of the PU. A review of Resident 228’s Physician’s Order (PO) dated 6/22/2024 indicated for licensed staff (TXN 1 and TXN 3) to cleanse Resident 228’s right hip open scratches/wounds with NS, pat dry and apply calmoseptine and cover the wound with Optifoam every day for 14 days and re-evaluate. A review of Resident 228’s PO dated 7/22/2024 indicated for licensed staff (TXN 1 and TXN 3) to paint Resident 228’s right hip’s open wounds with Betadine and cover the wound with Optifoam every day for 14 days and re-evaluate. A review of Resident 228’s Physician’s Assistant Wound Assessment Notes (PAWAN) dated 7/24/2024 at 3:06 PM indicated the following: - Resident 228’s left hip had one unstageable PU, which measured 7 cm length by 4 cm width with a depth of 0.2 cm. - Resident 228’s right hip had one unstageable PU which measured 5.5 cm length by 5 cm width with a depth of 0.2 cm. - Resident 228’s PAWAN indicated PA 1 recommended for licensed staff (TXN 1 and TXN 3) to cleanse Resident 228’s right and left unstageable PU with NS and Betadine, cover the PUs with dry dressing, offload and reposition. A review of Resident 228’s PO dated 7/26/2024 indicated for licensed staff (TXN 1 and TXN 3) to clean Resident 228’s left hip red scab with NS, paint with Betadine, and cover the unstageable PU with Optifoam for 14 days. A review of Resident 228’s PO, dated 7/27/2024 indicated for licensed staff (TXN 1 and TXN 3) to clean Resident 228’s right hip PU with NS, apply Santyl ointment daily, and cover the right hip PU with Optifoam for 14 days. A review of Resident 228’s Skin and Wound Progress Report (SWPR) for the right hip dated 7/27/2024 indicated Resident 228 had an unstageable PU on the right hip. The SWPR indicated unstageable PU on Resident 228’s right hip had increased in size and color. During a concurrent observation of Resident 228 in Resident 228’s room and an interview with Resident 228 on 7/31/2024 at 9:15 AM, Resident 228 was lying on Resident 228’s right side with bilateral knees, left elbow, and left wrist contracted. Resident 228 stated Resident 228 did not know how Resident 228 developed the unstageable PU on Resident 228’s right and left hips. During an interview on 7/31/2024 at 10:49 AM with Registered Nurse 3 (RN 3), RN 3 stated the unstageable PU on Resident 228’s right hip was a new PU, and the PU was developed in the facility. RN 3 stated the right hip unstageable PU started as a scratch on 6/22/2024. RN 3 stated Resident 228 was admitted with a left hip PU. During a concurrent interview with TXN 1 on 7/31/2024 at 3:58 PM and record review of Resident 228’s Treatment Administration Record (TAR) dated from 7/26/2024 to 7/31/2024 for the left hip, Resident 228’s TAR indicated missing treatment for the unstageable PU on 7/29/2024. TXN 1 stated the TAR for 7/29/2024 was blank. TXN 1 stated TXN 1 was unsure if Resident 228 received treatment for the unstageable PU on 7/29/2024. TXN 1 stated there was no documented evidence on Resident 228’s clinical record to indicate why the treatment was missed. TXN 1 stated missing the treatment would result in worsening of Resident 228’s left hip unstageable PU. During a concurrent observation of Resident 228’s right and left hip unstageable PU in Resident 228’s room and interview with the facility’s Director of Nursing (DON) and RN 3 on 8/1/2024 at 10:32 AM, the DON and RN 3 assessed Resident 228’s right and left unstageable PUs. The DON stated the wound bed for the left hip unstageable PU was moist, pink, and purple with yellow slough surrounded the PU. The DON stated the left hip unstageable PU had no tunneling. The DON stated Resident 228’s left hip PU had gotten worse because there was drainage and slough on the wound bed. The DON stated the wound bed for Resident 228’s right hip unstageable PU was pale, red, moist, and surrounded with yellow slough ( yellow or white material which consist of dead cells that accumulate in the wound). The DON stated the right hip unstageable PU had gotten worse due to the slough on the wound bed. During a concurrent interview with the DON on 8/2/2024 at 8:14 AM and record review of Resident 228’s PAWAN dated 7/24/2024, the DON stated the DON received the PAWAN dated 7/24/2024 from PA 1 in the morning of 8/2/2024. The DON stated PA 1 determined the PUs on Resident 228’s left, and right hip were unstageable on 7/24/2024. The DON stated, TXN 1 notified MD 1 on 7/27/2024 (three days after PA 1 assessed the PU on 7/24/2024) regarding Resident 228’s right hip because the right hip PU had increased in size. The DON stated, not having the PAWAN for Resident 228 in Resident 228’s medical record timely resulted in the delay in treatment for Resident 228’s right and left hip unstageable PU and the PU got worse. During a concurrent interview with the DON on 8/2/2024 at 11:40 AM, and record review of Resident 228’s TAR for the right hip wound dated from 6/1/2024 to 7/31/2024 indicated blank spaces on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024. The DON stated, unfilled boxes on the TAR indicated treatment for the right hip open wound was not done on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024, and 7/29/2024. The DON stated not providing treatment as ordered would result in the development of new PU and worsening of the current PU. The DON stated the DON was made aware of Resident 228’s right unstageable PU on 7/29/2024 but was not aware the left hip unstageable PU worsened. The DON stated, the right hip PU could have been prevented by providing the wound treatment as ordered and implementing the CP. During an interview with TXN 3 on 8/2/2024 at 1:03 PM, TXN 3 stated TXN 3 accompanied PA 1 on 7/24/2024. TXN 3 stated orders were not initiated because staff were waiting for PA 1 to fax or email the PAWAN to the facility. TXN 3 stated the PA 1’s notes should have been in Resident 228’s chart. TXN 3 stated it was not acceptable for the TXNs (TXN 1 and TXN 3) to not provide treatment for three days. TXN 3 stated she did not follow up with PA 1 for the PAWAN when she did not receive the PAWAN from PA 1. TXN 3 stated the risk of delaying treatment would result in the development of new PU and or worsening of the current PU. During an interview with PA 1 on 8/2/2024 at 3:10 PM, PA 1 stated PA 1 assessed Resident 228 for treatment for the “left and right hip wounds” on 7/24/2024. PA 1 stated PA 1 was accompanied by TXN 3 and stated Resident 228 had an unstageable PU on the left and right hip. PA 1 stated PA 1 gave verbal orders to TXN 3 for repositioning Resident 228, cleaning the PUs with NS and Betadine, cover the PU with dry dressing. PA 1 stated the expectation for staff when receiving a verbal order was to implement the order as soon as possible (the same day). PA 1 stated PA 1 had computer glitches/email problems, so facility staff (DON) did not receive PA 1’s PAWAN of Resident 228’s PUs on the right and left hips until 8/2/2024. A review of the facility’s undated Policy and Procedure (P&P) titled, “Pressure Injury Prevention and Management,” indicated the facility will establish and utilize a systematic approach for pressure ulcer prevention and management, starting with a prompt assessment and treatment. The P&P indicated the attending physician will be notified of the presence, progression towards healing, or lack of healing upon identification of injuries. The P&P indicated interventions will be documented in the care plan and communicated to all relevant staff. The facility failed to provide care and services to prevent the development of a PU and failed to provide treatment to the PU for Resident 228 who was assessed as at risk for developing PU by failing to: a. Ensure TXN 1 and TXN 3 provided treatment to Resident 228’s right hip opened scratches /open wounds on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 as ordered by Resident 228’s MD 1. b. Ensure TXN 1 and TXN 3 provided treatment to Resident 228’s right and left hips’ unstageable PU on 7/29/2024 as ordered by MD 1. c. Ensure TXN 3 notified MD 1 of Resident 228’s development of the avoidable unstageable PU on the right and left hips when PA 1 identified those PUs on 7/24/2024. d. Ensure TXN 3 carried out PA 1’s verbal order to clean Resident 228’s unstageable PU on Resident 228’s right and left hips with Normal Saline and Betadine and to cover the PU with dressing on 7/24/2024. e. Ensure TXN 1 and TXN 3 implemented Resident 228’s CP dated 5/30/2024 for impaired skin integrity and risk of worsening of a PU and to provide wound care treatment to Resident 228 as ordered by MD 1 and to report further skin breakdown to MD 1. As a result, on 7/24/2024, Resident 228 developed an avoidable unstageable PU on the right hip and worsened left hip unstageable PU. The unstageable PU on the right hip measured 5.5 cm length by 5 cm width with a depth of 0.2 cm, and the unstageable PU on the left hip measured 7 cm length by 4 cm width with a depth of 0.2 cm. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 228.