Other·November 15, 2023

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 10/10/23, the California Department of Public Health (CDPH) conducted an unannounced recertification survey. As a result of the investigation, CDPH determined that the facility failed to provide care and services to prevent the development of pressure ulcers/pressure injuries (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for Resident 22 who was assessed as high risk for developing pressure ulcers, by failing to: 1. Assess Resident 22's skin condition on the buttocks (bottom), coccyx (tail bone), sacral (a triangular shape bone at the bottom of the spine) area, and feet for redness or open sores (injuries that involve a break in the skin and leave the internal tissue exposed) during resident care as indicated in Resident 22's care plan on prevention of pressure ulcer/pressure injury, and according to the facility's Policy and Procedures titled, "Prevention of Pressure Injuries." 2. Float (raise) Resident 22's bilateral (both) heels with a pillow while the resident was in bed and during turning and repositioning, as indicated in Resident 22's care plan titled, "Pressure Ulcer." 3. Apply heel protectors to both of Resident 22's heels while in bed, every "day shift" (7a.m. to 7p.m.) as ordered by the physician on 10/2/23. As the result of these failures, Resident 22 developed an avoidable Stage 3 pressure ulcer (full thickness tissue loss, fat tissues may be visible, but bone, tendon, or muscle was not exposed) on the left posterior heel (back of heel) on 10/1/23, and an avoidable deep tissue pressure injury (DTPI- intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration due to damage of underlying soft tissue) of the buttocks and sacral coccyx area on 10/13/23. A review of Resident 22's Admission Record indicated Resident 22 was self-responsible (holding oneself accountable). The Admission Record indicated the facility admitted this 86 years old male on 9/2/23 with diagnoses that included diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) and hypertension (high blood pressure). A review of Resident 22's Admission Skin Assessment dated 9/2/23, indicated Resident 22 was admitted to the facility without pressure ulcer/pressure injury. A review of Resident 22's Braden Scale for Predicting Pressure Sore Risk (a tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer), dated 9/2/23, indicated Resident 22 was at high risk for developing a pressure ulcer. Resident 22 had a Braden Scale score of 11 (a score of 10-12 indicates high risk for developing a pressure ulcer). Resident 22 was at high risk for developing a pressure ulcer due to "very" limited sensory perception (ability to respond meaningfully to pressure related discomfort), skin was often moist, confinement to bed, "very" limited mobility (ability to change and control body position), probable inadequate nutrition (usual food pattern) and potential for friction (mechanical force exerted on the skin that is dragged across any surface) and shear (force on the skin in a direction parallel to the body) problem. A review of Resident 22's initial care plan for prevention of pressure ulcer/pressure injury dated 9/2/23, indicated Resident 22 was at risk for skin breakdown due to needing assistance in bed mobility (ability to move around in bed), diabetes mellitus and low back pain. The care plan interventions included for nursing staff to assess Resident 22's skin condition during care and to report to the physician if redness and/or an open area was noted. The care plan interventions also included for nursing staff to ensure no open sores/areas on the resident's feet/toes and to notify the physician promptly for any change in sensation, color, or temperature of resident's lower extremities (legs and feet). A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/6/23, indicated Resident 22 was assessed with good short and long-term memory recall (process of retrieving information from the past). The MDS indicated Resident 22 required extensive assistance (staff provide weight-bearing support) in bed mobility with one-person physical support and was always incontinent of bowel and bladder (lack of voluntary control over defecation and urination). A review of Resident 22's Physician's Progress Notes dated 10/1/23, indicated on 10/1/23, Medical Doctor 1 (MD1) conducted a physical examination of Resident 22's heels. MD1's assessment of Resident 22's left posterior heel indicated Stage 3 pressure ulcer with surrounding purpura (redness) and no purulent discharge (a thick and milky discharge from the wound). MD1's assessment of Resident 22's Stage 3 pressure ulcer of the left posterior heel did not indicate the size of the pressure ulcer. A review of Resident 22's Physician's Order dated 10/2/23, indicated that staff were to apply heel protectors to both of Resident 22's lower extremities while in bed every "day shift". A review of Resident 22's Care Plan titled, "Pressure Ulcer," dated 10/2/23, indicated Resident 22 had altered skin integrity (health of the skin) related to Stage 3 pressure ulcer of the left posterior heel. The care plan interventions included to float Resident 22's heels with a pillow while in bed, apply heel protectors to both of Resident 22's heels, and to turn and reposition Resident 22 every two hours in bed, and whenever necessary. During observations on 10/10/23, at 10a.m., 11:15a.m., 12:25p.m., and 2:20p.m., Resident 22 was lying on Resident 22's back while in bed and both of the resident’s heels were resting directly on the pillow (heels were not floated). Resident 22 was not wearing heel protectors until 2:20 p.m. when Resident 22's heel protector was observed only on the left foot. During a concurrent observation and interview on 10/10/23 at 2:20 p.m., Resident 22 was lying on Resident 22's back while in bed, alert and coherent. Certified Nursing Assistant 1 (CNA 1) stated she was the caregiver of Resident 22. Resident 22's heels were observed resting directly on the pillow (heels not floated). Resident 22 was wearing a heel protector only on the left foot. Resident 22 stated, "Today" (10/10/23) was the third day that the heel protector was applied on Resident 22's left foot. Both of Resident 22's heels had a dry and intact wound dressing. CNA 1 stated she did not know why Resident 22 had wound dressing on both heels. Resident 22 stated that he was always lying on his back in bed and was not turned and repositioned every two hours while in bed. Resident 22 stated that he did not refuse to be turned or repositioned while in bed. CNA 1 stated she was not made aware by licensed nursing staff (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]) that Resident 22 needed to be turned and repositioned every two hours while in bed. CNA 1 stated Resident 22's heels should be floated on the pillow to prevent more pressure on the wounds (PU/PI). CNA 1 stated pressure on the PU/PI could worsen the condition of Resident 22's PU/PI due to further skin breakdown for Resident 22. CNA 1 did not turn and reposition Resident 22 to a side lying position in bed and the resident's heels were not floated on the pillow before CNA 1 left Resident 22's room after the interview. During observations on 10/11/23 at 9:17 a.m., 10:21 a.m. and 11:45 a.m., 10/12/23 at 11:28 a.m. and 3:15 p.m. and on 10/13/23 at 11:30 a.m., Resident 22 was lying on Resident 22's back while in bed. Resident 22 had bilateral heel protectors, and both heels were resting directly on the mattress (heels were not floated on the pillow). During Resident 22's treatment observation on 10/12/23, at 11:28 a.m., in the presence of Director of Nursing (DON), CNA 1, Treatment Nurse 1 (TN 1) Resident 22 was lying on his back in bed with bilateral heel protectors and the heels were resting directly on the mattress. The DON assessed Resident 22's left posterior heel as unstageable pressure ulcer (UTD- full thickness tissue loss when the stage of PU/PI was not clear due to the PU/PI covered by dead tissue and the base of the PU/PI cannot be seen to determine the stage) with moderate amount of yellow green slough and black color slough in the center of the wound base and the surrounding area of the wound edge was red in color. The DON stated that Resident 22's pressure ulcer had progressed from Stage 3 to UTD. TN 1 measured Resident 22's left posterior heel UTD pressure ulcer as 1.5-centimeter (cm) in length (L) x (by) 1.3 cm in width (W), no depth, no undermining (damage underneath the wound edge in multiple directions) and no tunneling (wound damage in one direction deeply underneath the skin). Resident 22's right heel skin was clear and intact. Resident 22's buttocks and sacral coccyx were observed with deep red colored with intact skin, not moist or shiny. TN 1 measured the reddened skin on Resident 22's buttocks and sacral coccyx area as 9 cm (L) x 16.5 cm (W). A review of Resident 22's Physician's Order dated 10/12/23, at 12:35 p.m., indicated for Resident 22 to use low air loss mattress (LAL-a mattress that provides a flow of air to assist in managing the heat and humidity of the skin) for preventative use. During an observation on 10/12/23, at 3:15 p.m., with CNA 2 and TN 1, Resident 22 was lying on his back on a LAL mattress with bilateral heel protectors and both heels were resting directly on the mattress. TN 1 stated Resident 22 had the LAL mattress to help with the healing of the redness on the buttocks and sacral coccyx while Resident 22 was lying on his back while in bed. During a concurrent interview and record review of Resident 22's clinical record on 10/12/23, at 4:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated LVN 1 was doing rounds in the hallway on 10/1/23, at 2 p.m., when Resident 22's granddaughter notified LVN 1 of Resident 22's complaint of pain on the left heel. LVN 1 stated, when LVN 1 entered Resident 22's room, MD 1 was assessing Resident 22's roommate (Resident 23). LVN 1 stated that LVN 1 informed MD 1 of Resident 22's left heel pain. LVN 1 stated LVN 1 did not assess Resident 22's skin condition or size of Resident 22's pressure ulcer of the left posterior heel because MD 1 was holding Resident 22's left heel while assessing Resident PI/PU. LVN 1 stated she was not notified by any staff of any changes in Resident 22's skin condition on the resident's buttocks and heels. During observation of Resident 22's buttocks area on 10/13/23, at 11:30 a.m., in the presence of the DON, TN 1, Resident 22 was lying on the right side and his buttocks and sacral coccyx areas were purple with skin intact. TN 1 measured Resident 22's purple skin on the buttocks and sacral coccyx areas as 12 cm (L) x 13 cm (W). The DON and TN 1 did not stage the PI on Resident 22's buttocks and sacral coccyx area during the interview. During a concurrent interview and record review of Resident 22's clinical record on 10/13/23, at 1:35 p.m., the DON stated the facility had turning and repositioning scheduled every two hours for residents who were at high risk for skin breakdown, to prevent the development of pressure ulcer/pressure injury. The DON stated, the Charge Nurses (LVNs and RNs) were responsible for notifying the CNAs of residents who were assessed as high risks for skin breakdown and needed to be turned and repositioned every two hours while in bed. Resident 22's repositioning schedule did not contain information indicating that Resident 22 was turned and repositioned every two hours while in bed on all shifts from 9/2/23 to 10/12/23. During a concurrent interview and review of the facility's "Resident Repositioning Schedule" with the DON on 10/13/23, at 5:07 p.m., the DON stated, the written copy of the "Resident Repositioning Schedule" was placed on the back of each CNA's identification card. The "Resident Repositioning Schedule" indicated to reposition the resident every two hours as follows: 7-9 am-Back 7-9 pm-Door 9-11 am-Window 9-11 pm-Back 11 am-1pm-Back 11 pm-1 am -Window 1-3 pm-Door 1-3 am-Back 3-5 pm-Window 3-5 am -Door 5-7 pm-Back 5-7 am-Window During a phone interview with MD 1 on 10/13/23, at 6:32 p.m., MD 1 stated he was the physician who assessed Resident 22's left heel on 10/1/23, after MD 1 was made aware by LVN 1 of Resident 22's complaint of pain on the left heel. MD 1 stated Resident 22's wound on the left posterior heel was a pressure ulcer and not a diabetic ulcer. MD 1 stated, "I was the first one to discover it (pressure ulcer)." A review of the facility's undated Policy and Procedures (P&P) titled, "Prevention of Pressure Injuries", indicated that staff are to inspect the resident's skin daily when performing or assisting with personal care or activities of daily living to identify any signs of pressure injuries, inspect pressure points such as sacrum, heels, buttocks, coccyx, elbows, and to reposition the resident as indicated on the care plan. The facility failed to provide care and services to prevent the development of pressure ulcers/pressure injuries for Resident 22 who was assessed as high risk for developing pressure ulcers, by failing to: 1. Assess Resident 22's skin condition on the buttocks, coccyx, sacral area and feet for redness or open sores during resident care as indicated in Resident 22's care plan on prevention of pressure ulcer/pressure injury, and according to the facility's Policy and Procedures titled, "Prevention of Pressure Injuries." 2. Float Resident 22's bilateral heels with a pillow while he was in bed and during turning and repositioning, as indicated in Resident 22's care plan titled, "Pressure Ulcer." 3. Apply heel protectors to both of Resident 22's heels while in bed, every "day shift" as ordered by the physician on 10/2/23. As the result of these failures, Resident 22 developed an avoidable Stage 3 pressure ulcer on the left posterior heel on 10/1/23, and an avoidable deep tissue pressure injury of the buttocks and sacral coccyx area on 10/13/23. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 22.