Other·December 2, 2022

F684 FCR § 483.25 Quality of care § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: Tittle 22 CCR§ 72311. Nursing Service – General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. On 9/27/22 at 1:50 pm., the California Department of Public Health conducted an unannounced visit to the facility to investigate a complaint regarding neglect of Patient 1. The facility failed to ensure Patient 1 received the proper care and services by failing to: 1. Implement measures to provide a safe environment that is free of hazards for Patient 1 who was confused and had a behavior of repeatedly scooting (slide in sitting position) self in the wheelchair. 2. Thoroughly investigate the cause of Patient 1's skin wound on the left calf. 3. Assess Patient1’s wheelchair and provide measures to prevent Patient 1 from rubbing her legs on the footrest and the nylon seat pad. 4. Supervise Patient 1 and intervene promptly when staff observed Patient 1 rubbed the back of her leg on the nylon pad and the footrest of the wheelchair. As a result, Patient 1 was transferred to the General Acute Care Hospital (GACH) on 1/18/22, and was diagnosed with sepsis (severe infection in the blood) with two left calf lesions/wounds (damaged tissue) measuring at 5.0 cm (centimeter) by 1.0 cm and 5.0 cm by 6.0 cm. A review of the admission record indicated Patient 1 was a 93-year-old female, admitted to the facility on 11/1/15, and readmitted on 9/30/19, with the diagnoses that included dementia (a progressive brain disorder that results in a decline in memory and though process) without behavioral disturbance. A review of the Minimum Data Set (MDS, a Patient’s assessment and care screening tool), dated 1/13/22, indicated Patient 1 had moderately impaired memory and cognition (ability make decision and reason). The MDS indicated Patient 1 required extensive assistance (patient involved in activity and staff provide weigh bearing support) with one-person assist for transfers, eating, toilet use and personal hygiene. A review of the GACH record with photograph of Patient 1’s calf lesions, dated 1/19/22, timed at 1:22 AM, indicated the patient had two lesions on the left calf as follow: a. First lesion measured at 5.0 cm by 1.0 cm with yellow slough (yellow moist, loose, and stringy tissue that impedes wound healing) and black necrotic tissue (dead skin). b. Second lesion measured at 5.0 cm by 6.0 cm with yellow slough, redness and purulent drainage (a white, yellow, or brown fluid which is a sign of infection). A review of the Discharge Transfer Report from the GACH record, dated 1/20/22 timed at 3:38 PM, indicated Patient 1 was admitted to the GACH on 1/18/22 at 9:06 AM, with diagnoses of severe sepsis and significant left calf lesions. A review of the Microbiology test result (a test to check the presence of disease-causing organism or bacteria/infection), dated 1/22/22, indicated there is heavy growth of staphylococcus (a type of bacteria) in the wounds on the left calf. The result indicated the wound cultures were obtained on 1/18/22. A review of the Wound Notes from the GACH record, dated 1/19/22 at 10:02 AM, indicated Patient 1 had a left posterior (back) calf lesion/ulcer) related to trauma. A review of the Progress Notes from GACH record, dated 1/19/22, timed at 10:49 AM, indicated Patient 1 was to receive Metronidazole (an antibiotic) 500 milligrams (mg) one tablet taken by mouth three times a day three times a day (TID) for cellulitis (skin cells infections) with purulent drainage/abscess, and treat the left calf wounds with Venelex ointment (ointment used to cover wounds and help rid of smells and relieve wound pain) 788 mg-87 mg/g (gram) topical ointment twice a day (BID). During an interview and concurrent review of Patient 1's clinical records on, 9/28/22 at 3:18 PM, with the MDS Nurse the Investigation Report, dated 1/10/22 timed at 4:30 PM, indicated Patient 1 was observed with fresh wound on the left calf. Patient 1 did not know what happened. The incident report indicated Patient 1 stays in the wheelchair for a long time. Patient 1’s care plan indicated, the patient was at risk for injury due to poor safety awareness and the intervention included to provide safe and clutter free environment. The MDS Nurse stated, Patient 1's plan of care did not indicate the patient’s risk or cause of the left calf skin tear and the interventions to prevent further skin tear. A review of Patient 1’s treatment record, dated 1/10/22, indicated Patient1's left calf wounds were cleansed with Normal Saline (NS) a solution with water and salt, pat dry, apply Neosporin (an antibiotic or medication to treat infection) and cover with wet to dry dressing every day for twenty-one days. A review of the Lower Extremity Wound Assessment, dated 1/12/22, indicated Patient 1 had a skin tear with 100% pink wound bed (sign of wound healing), erythema (skin redness due to injury or inflammation-causing condition) on the edges and had scant drainage that measured 9.5 centimeter (cm) in length, 9.5 cm width and 0.3 cm depth. A review of the treatment record, dated 1/12/22, indicated Patient 1's left calf wounds were cleansed with Normal Saline (NS) a solution with water and salt, pat dry, apply Neosporin collagen sheet (a pad with gel that promotes wound healing) and cover with wet to dry dressing every day for twenty one days. During an observation and concurrent interview on 9/28/22 at 3:32 PM, the MDS Nurse demonstrated how she observed Patient 1 scoot and get up from the wheelchair. The MDS Nurse indicated when Patient 1 scoot and got up from the wheelchair, the back of Patient 1's leg touched the footrest and the nylon pad on the seat of the wheelchair. The MDS Nurse stated, Patient 1 liked to sit on the wheelchair for a long time. The MDS Nurse stated there was no record indicated facility’s staff provide interventions to prevent injury for Patient 1's while using the wheelchair. During an interview on 10/28/22 at 2:23 PM, the Treatment Nurse/Licensed Vocational Nurse (LVN 1) stated Patient 1 scoots back and forth while in the wheelchair and attempts to get up. LVN 1 state, when the footrest on the wheelchair on the upward position, the patient’s left calf rubs against the footrest of the wheelchair and the wound dressing come off. During an interview and record review on 10/28/22 at 2:53 PM, The DON stated facility’s staff were not thoroughly investigating the cause of the skin tear on Patient 1’s left calf. The DON stated Patient 1's plan of care was not developed to ensure Patient 1 behavior of scooting and getting up from the wheelchair were monitored for risk of injury. Patient 1’s wheelchair was not assessed for risk of injury and immediately remove the hazards that caused the skin tear on Patient 1’s left calf. A review of the facility's undated policy and procedure, titled "Accidents/Incidents Prevention," indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards as well as identifying at risk of accidents and incidents and the provision of adequate care plan with procedures to prevent accidents. The facility will monitor accidents and injuries, assess, and reassess patients with injuries and thoroughly investigate all injuries and accidents. The facility failed to ensure Patient 1 received the proper care and services by failing to: 1. Implement measures to provide a safe environment that is free of hazards for Patient 1 who was confused and had a behavior of repeatedly scooting self in the wheelchair. 2. Thoroughly investigate the cause of Patient 1's skin wound on the left calf. 3. Assess Patient1’s wheelchair and provide measures to prevent Patient 1 from rubbing her legs on the footrest and the nylon seat pad. 4. Supervise Patient 1 and intervene promptly when staff observed Patient 1 rubbed the back of her leg on the nylon pad and the footrest of the wheelchair. As a result, Patient 1 was transferred to the GACH on 1/18/22, and was diagnosed with sepsis and with two left calf lesions measuring at 5.0 cm by 1.0 cm and 5.0 cm by 6.0 cm. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.