Health inspection·September 20, 2023

F725 Sufficient Nursing Staff FCR §483.35 Nursing Services §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. Title 22 CCR § 72315 (d) Nursing Service- Patient Care (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing, and grooming of hair, oral hygiene, shaving or beard trimming, cleaning, and cutting of fingernails and toenails. The patient shall be free of offensive odors. CCR §72329.1. (a) Nursing Service – Staff (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g). CCR § 72523(a) - 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. On 8/9/2023 at 10:30 am., the California Department of Public Health conducted an unannounced complaint investigation regarding quality of care and treatment. As a result of the investigation, the Department determined the facility failed to: 1. Provide incontinent (unable to hold urine or feces) care to Patients 1 and 2 2. Ensure sufficient nursing staff was available to provide nursing services to Patients 1 and 2. These violations resulted in hyperpigmentation (skin darkening) with scarring (a growth of tissue marking the spot where skin has healed) on the perianal (area around the anus) area for Patient 2 and had the potential for skin breakdown for Patient 1. During a review of Patient 1's Admission Record, the Admission Record indicated the facility admitted Patient 1, a 96 year old female, on 9/10/2022, with diagnoses that included age related osteoporosis (brittle bones) and Alzheimer's disease (a brain disorder that causes a gradual decline in memory, thinking, behavior and social skills). During a review of Patient 1's care plan on Activities of Daily Living (ADL)/Self-Care Deficit revised on 12/15/2022, the care plan indicated for staff to assist Patient 1 with toileting needs and/or provide incontinent care after incontinent episodes. The care plan indicated for staff to follow bed mobility/ADL standard of care. During a review of Patient 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 6/12/2023, the MDS indicated Patient 1 had severe cognitive (ability to understand) impairment. The MDS indicated Patient 1 required extensive assistance (patient involved in activity, staff provide weight-bearing support) with one-person physical assistance for toilet use and dressing and minimal assistance with one-person physical assistance for transfers, walking, and personal hygiene. During an observation on 8/11/2023 at 6:30 am, there were two Certified Nursing Assistants (CNAs) and two Licensed Vocational Nurses (LVNs) on duty. Certified Nursing Assistant 1 was sitting in front of Nursing Station 3 and Licensed Vocational Nurse 1 was sitting inside Nursing Station 3. Licensed Vocational Nurse 2 was inside a patient's room changing a patient and Certified Nursing Assistant 2 was inside a patient's room changing another patient. During an interview on 8/11/2023 at 6:34 am, Certified Nursing Assistant 1 stated there were only two CNAs for 51 patients in Station 3. During an observation on 8/11/2023 at 6:42 am, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) entered Patient 1's room and there was a strong urine smell coming from Patient 1's room. LVN 1 and CNA 1 stated the urine smell came from Patient 1. LVN 1 assisted CNA 1 to change Patient 1's adult brief. LVN 1 stated, Patient 1's adult brief was soaked with urine. LVN 1 touched Patient 1's bed and stated the middle part of Patient 1's bed was wet. During an interview on 8/11/2023 at 6:52 am, CNA 1 stated she changed Patient 1's adult brief when she started her shift at 11 pm but could not get to the second round of adult brief change since she had to cover for half of the 51 patients on the floor. CNA 1 stated, the "scheduler" would put a staff name on the sign-in sheet and "they (staff) just don't show up." During an interview on 8/11/2023 at 6:55 am, LVN 1 stated there were two CNAs and two LVNs during the 11 pm - 7am shift. LVN 1 stated, he tried helping the CNAs with incontinent care, but he had his own work to complete. During a review of Patient 2's Admission Record, the admission record indicated the facility admitted Patient 2, an 80 years old female, on 9/2/2019 and readmitted on 12/27/2022, with diagnoses that included urinary tract infection (UTI- infection that affects part of the urinary tract) and schizoaffective disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems). During a review of Patient 2's care plan on ADL/self-care deficit revised on 11/25/2022, the care plan indicated for staff to assist Patient 2 with toileting needs and/or provide incontinent care after each incontinent episode. During a review of Patient 2's MDS dated 6/1/2023, the MDS indicated the patient had moderately impaired (poor decision making) cognitive (ability to understand) skills for daily decision making. During an interview on 8/11/2023 at 6:58 am, CNA 2 stated he was not able to change Patient 2, the whole night. CNA 2 stated Patient 2 was combative and required 2 CNAs to provide care. CNA 2 stated he could not ask CNA 1 and the nurses because everyone was busy. CNA 1 stated there were 2 CNAs for the 11 pm - 7 am shift and he was only able to change the patients assigned to him once, except Patient 2. During an observation on 8/11/2023 at 7:20 am, staff were preparing to serve breakfast. During an observation on 8/11/2023 at 8:15 am, staff took out the last breakfast trays. During an observation on 8/11/2023 at 9:30 am, there was a strong urine smell from Patient 2's room. During a concurrent interview with CNA 2, CNA 2 stated he could smell urine and stated the smell came from Patient 2 because he had smelled it earlier that day. CNA 2 stated he had not changed Patient 2's adult brief because he was assisting with breakfast and the CNAs from the previous shift did not endorse to him that Patient 2's adult brief needed to be changed. CNA 2 removed Patient 2's adult brief while patient was lying in bed. Patient 2's adult brief was soaked with urine and the urine seeped through the adult brief into Patient 2's bed sheet underneath. CNA 2 turned Patient 2 towards the patient's left side in order to clean Patient 2's back. There were clear and raised bumps around Patient 2's perianal area. During a concurrent interview with CNA 2, CNA 2 stated he had not seen the clear and raised bumps around the perianal of Patient 2 and stated, "This is new." During an interview with the facility's Treatment Nurse (Tx Nurse) on 8/11/2023 at 2:15 pm, the Tx Nurse stated, Patient 2's skin was clear. The Tx Nurse stated she checked Patient 2's skin that day and did not find any concerns with Patient 2's skin. During an observation of Patient 2's skin with the Tx Nurse on 8/11/2023 at 2:40 pm, there were raised bumps scattered around Patient 2's perianal area, spanning 1-2 inches around Patient 2's perianal area. During a concurrent interview with the Tx Nurse, the Tx Nurse stated there were bumps around Patient 2's perianal area and this is a new skin condition for Patient 2. During a review of the facility's census dated 8/11/2023, the census indicated there were 51 patients at Station 3. During a record review of Patient 2's Admission Skin Assessment dated 8/11/2023 and Patient 2's clinical record, there was no documented evidence that Patient 2 had previous skin rash, discoloration, or a skin condition on the perianal area. During a review of Patient 2's Change of Condition (COC) dated 8/11/2023, the COC indicated dry discoloration around Patient 2's perianal area. During an interview with the Minimum Data Set Nurse (MDSN 1) on 8/11/2023 at 3:29 pm, the MDSN 1 stated, being soaked wet with urine caused by incontinence can result to diaper rash and can appear with raised bumps on the skin. During a concurrent observation and interview with the Director of Nursing (DON) on 8/11/2023 at 4:32 pm, Patient 2 scratched her perineal area. DON stated there were bumps scattered around the periphery of the anal opening of Patient 2. During a review of Patient 2's record titled "SNF (Skilled Nursing Facility) Wound Care Progress Notes" dated 8/17/2023, the progress notes indicated Patient 2's Wound 1 was described as perianal hyperpigmentation with scarring. During a concurrent observation and interview with the Director of Nursing (DON) on 8/11/2023 at 4:32 pm, Patient 2 scratched her perineal area. DON stated there were bumps scattered around the periphery of the anal opening of Patient 2. During a review of Patient 2's record titled "SNF Wound Care Progress Notes" dated 8/17/2023, the progress notes indicated Patient 2's Wound 1 was described as perianal hyperpigmentation with scarring. During a review of the facility's Staff Schedule for July 2023, the schedule indicated Station 3 had a projected CNA staffing of 3-4 CNAs for the 11 pm - 7am shift except on 7/24/2023 and 7/29/2023 where only two CNAs were scheduled on the projected staffing for 7/24/2023 and 7/29/2023. During a review of the facility's Sign-in Sheet dated 7/29/2023, the sign in sheet indicated two CNAs signed in to work with a census of 50 patients and one CNA from the 3 pm to 11 pm shift who worked up to 3 am. During a review of facility's Sign-In Sheets for July 2023, the sign in sheets indicated the following call-off trends for Station 3: 7/15/2023, 7/18/2023, 7/20/2023, 7/21/2023, 7/22/2023, 7/27/2023 and 7/28/2023. During a review of the facility's schedule for August from 8/1/2023 to 8/9/2023, the schedule indicated Station 3 CNA staffing for the 11 pm to 7 am morning shift projected to have 3 to 4 CNAs on schedule. During a review of the facility's Sign-In Sheets for August 2023, the sign in sheets indicated call-off trends from CNAs on the following dates, 8/4/2023, 8/6/2023 and 8/8/2023. During a review of the facility's Assessment Tool dated 8/1/2023, the assessment tool indicated the facility considered both census numbers and acuity levels that impact staffing needs, and staffs accordingly. The assessment indicated the facility had 47 patients that required one to two staff assistance, 40 patients were totally dependent, and three patients were independent with toileting; 41 patients required one to two staff for assistance and 50 patients were totally dependent with bathing. During a review of the facility's undated Policy and Procedure(P&P) titled "Incontinent Care" the P&P indicated to keep incontinent patients clean, dry, and free of odor, and to prevent skin breakdown. As a result of the investigation, the Department determined the facility failed to: 1. Provide incontinent care to Patients 1 and 2. 2. Ensure sufficient nursing staff was available to provide nursing services to Patients 1 and 2. These violations resulted in hyperpigmentation (skin darkening) with scarring (a growth of tissue marking the spot where skin has healed) on the perianal (area around the anus) area for Patient 2 and had the potential for skin breakdown for Patient 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patients 1 and 2.