Health inspection·March 23, 2023

F 686 Code of Federal Regulations §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. California Code of Regulations, Title 22 § 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. (1) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (2) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. § 72315. Nursing Service – Patient Care. (a) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) 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 1/31/2023, at 8:30 AM., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment of Patient 2. As a result of the investigation, the CDPH determined the facility failed to provide pressure ulcers/injury (PIs, injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care, and treatments for Patients 4, 5, 6, 7, 8, and 9 by failing to: 1. Implement the facility's policies titled, "Pressure Injury Risk Assessment" and "Quality of Care-Pressure Injuries," when licensed nurses (in general) did not update the care plans, assess, and measure PIs, or follow the physician's orders to treat the following: a. Patient 4's Stage 3 PIs (full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore) located on the right and left buttock, and Stage 2 PI (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) located on the sacral region (at the bottom of the spine). Licensed Nurses also failed to ensure Patient 4, who was six feet and four inches (6'4") tall, had a long enough and fitting bed to decrease the pressure on the patient's PIs. b. Patient 5's Stage 2 PI located on the coccyx (tailbone). c. Patient 6's Stage 4 PI (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules) located on the Sacrococcyx (sacrum and coccyx/tailbone). d. Patient 7's Stage 2, facility acquired PI (a new pressure injury that developed after admission to the facility) located on the right buttock. e. Patient 8's Stage 1 PIs (redness, painful area on the patient skin that does not turn white/blanch) located on the right and left buttocks. f. Patient 9's Stage 1 PI located on bilateral (both) heels and a Stage 3 PI located on the coccyx. 2. Ensure Registry (a staffing agency which provide nursing personnel per shift or temporarily) Nurses (in general) received in-services (training) regarding PI treatments and assessments upon admission and weekly after. As a result, Patients 4, 5, 6, 7, 8, and 9 did not receive PI care and treatments. This failure placed the patients at risk for developing new PIs, worsening of the existing PIs, and infections that could lead to hospitalization. 1a. A review of Patient 4's Admission Record indicated the patient was a 75 year-old male and was admitted to the facility on 1/3/2023 with diagnoses that included, type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels), and muscle weakness. A review of Patient 4's Physician's Order, dated 1/3/2023, indicated to cleanse Patient 4's Stage 2 PI on the coccyx with wound cleanser (solution to clean the wound), pat dry, apply Medihoney (mixture of two honeys, used for wound care and contribute to wound healing), and cover the PI with foam dressing (dressing that can hold fluid/drainage) every "day" shift. A review of Patient 4's Generations Post-Acute Admission Data Collection (New Admission Assessment), dated 1/3/2023, at 9:51 PM, indicated Patient 4 had two Stage 3 PIs (one on the right and one on the left buttocks), and a Stage 2 PI with redness on the sacral area. The skin integrity (the health of the skin) review section which required PI wound measurements was left blank. A review of Patient 4's Braden Scale (an assessment tool to assess the risk of PIs) for Predicting Pressure Sore Risk, dated 1/3/2023, indicated Patient 4 was at high risk for developing PIs. A review of Patient 4's Care Plan for actual impairment in skin integrity, dated 1/4/2023, indicated nursing interventions included to provide pressure relieving mattress. A review of Patient 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/10/2023, indicated the patient had an intact cognition (ability to think and process information). The MDS indicated Patient 4 was admitted to the facility with one Stage 2 PI, and two Stage 3 PIs (locations not indicated). A review of Patient 4's Generations Weekly Skin Evaluation, dated 1/10/2023, at 3:01 PM, indicated Patient 4 had Stage 2 and Stage 3 PIs. There was no documented evidence that the weekly assessments were done for Patient 4's PIs in January 2023. The description section for these PIs were blank. A review of Patient 4's Care Plan, dated 1/12/2023, indicated Patient 4 was admitted with Stage 3 PIs on the right and left buttocks and a Stage 2 PI on the coccyx related to decreased mobility. The care plan indicated the goal was for Patient 4's PIs to heal and remain free from infection. The nursing interventions included to administer treatments as ordered (specific and follow the facility's policies/protocols for prevention and treatments of PIs). A review of Patient 4's Treatments Administration Record for January 2023, indicated the patient did not receive treatments for Stage 2 PI on the coccyx area, and the Stage 3 PIs on the left and right buttocks on 1/23/2023. The record indicated Patient 4 did not receive treatments for the Stage 3 PIs on the left and right buttocks from 1/25/2023 to 1/31/2023. During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) and a review of Patient 4's Physician Orders, Skin Assessments, and Care Plans, on 1/31/2023, at 12:40 PM, LVN 1 stated Patient 4 had a Stage 2 PI on the coccyx area and two Stage 3 PIs with active orders for PIs treatments. LVN 1 stated Patient 4's PI assessments did not include measurements or description of the PIs. LVN 1 stated Patient 4's admission assessment for the PIs, dated 1/3/2023, was incomplete. LVN 1 stated the admission assessment needed to be completed with accurate PIs' description and measurement to identify any new changes in Patient 4's PI. LVN 1 stated Patient 4's PIs needed to be monitored closely to evaluate the effectiveness of PIs treatments. LVN 1 reviewed Patient 4's care plans for PI, dated 1/10/2023 and stated the care plan was not updated to address Patient 4's needs. LVN 1 stated the care plan did not specify the type of mattress Patient 4 (who was 6'4" tall) needed to relieve the pressure on the patient's PIs. During a concurrent observation and interview on 2/2/2023 at 10:21 AM, Patient 4 was lying on a low air loss mattress (LAL mattress that operates using a blower-based pump that was designed to circulate a constant flow of air). Patient 4 had both feet resting on two seat pads positioned over the foot of the bed with patient's knees bent. Patient 4 stated Family Member 1 (FM 1) placed the seat pads at the foot of the bed because the patient was too tall for the bed. Patient 4 stated he was 6'4" tall and the bed was a standard twin size bed. Patient 4 stated he had to sleep with his knees bent. Patient 4 stated it was difficult for him to turn and reposition in the bed. Patient 4 stated the Licensed Nurses (in general) changed his (the patient) dressings every other dy. 1b. A review of Patient 5's Admission Record indicated the patient was a 72 year-old female and was admitted to the facility on 1/20/2023 with diagnoses that included type 2 diabetes and muscle weakness. A review of Patient 5's Braden Scale for Predicting Pressure Sore Risk, dated 1/20/2023, indicated Patient 5 was at high risk for developing PIs. A review of Patient 5's New Admission Assessment, dated 1/20/2023, at 7:30 PM, indicated the patient was admitted with a PI that was not blanchable (discoloration of the skin that does not turn red when pressed), redness on both heels, and a Stage 2 PI on the coccyx area. The skin integrity review section that included sizes, measurements, and description of the PI was blank. A review of Patient 5's Physician's Order, dated 1/20/2023, indicated to cleanse Patient 5's Stage 2 PI on the coccyx with normal saline (salt water), pat dry, apply Santyl (ointment that removes dead tissue from wounds so that they start healing), and cover the PI with foam dressing every day, for wound care, for 21 days. A review of Patient 5's Care Plan for actual skin impairment due to Stage 2 PI on the coccyx, dated 1/20/2023, indicated the interventions included to keep the patient's skin clean and dry. A review of Patient 5's Treatments Administration Record for January 2023, indicated the patient did not receive treatments for the Stage 2 PI on 1/23/2023. A review of Patient 5's MDS, dated 1/26/2023, indicated the patient had an intact cognition. The MDS indicated Patient 5 had two Stage 1 a Stage 2 PIs (location no indicated). A review of Patient 5's Generations Weekly Skin Evaluation, dated 1/27/2023, at 5:46 PM, indicated the patient's skin was intact (no PI). A review of Patient 5's Medication Administration Audit Report, dated, 1/27/2023, indicated to cleanse Patient 5's Stage 2 PI on the coccyx region with normal saline, pat dry, apply Santyl, and cover with foam dressing. During a concurrent interview with LVN 1 on 1/23/2023 at 12:40 PM, and a review of Patient 5's New Admission Assessment, dated 1/20/2023, LVN 1 stated Patient 5's admission skin assessment was incomplete. LVN 1 stated the weekly skin evaluation, dated 1/27/2023, indicated Patient 5's skin was intact "when it was not." LVN 1 reviewed Patient 5's care plan for actual skin impairment, dated 1/20/2023, and stated the care plan was not specific to addressed Patient 5's PI treatments. 1c. A review of Patient 6's Admission Record indicated the patient was a 87 year-old female and was admitted to the facility on 11/16/2021 with diagnosis that included Stage 4 PI on the sacral area. A review of Patient 6's untitled Care Plan, initiated on 3/30/2022, indicated Patient 6 had a Stage 4 PI and the goal was for the PI to show signs of healing. The care plan indicated the nursing interventions including to assess, monitor PIs weekly. The care plan indicated to measure length, width, depth of the PIs. A review of Patient 6's Physician Order, dated 5/10/2022, indicated to cleanse Patient 6's Stage 4 PI on the Sacrococcyx with wound wash solution, apply collagen (protein), lightly pack the PI with Calcium Alginate (dressing used for moderate to heavily draining PIs), and cover the PI with foam dressing or abdominal pad (pad used for large wounds that require high absorbency) every "day" shift. A review of Patient 6's MDS, dated 11/10/2022, indicated the patient had severe impaired cognition. The MDS indicated Patient 6 had a Stage 4 PI (location not indicated). A review of Patient 6's Generations Weekly Skin Evaluation, dated 11/28/2022, indicated the Patient had a Sacrococcyx Stage 4 PI. There was no other information documented, and the skin integrity review section which required PI's description and measurements was blank. A review of Patient 6's Generations Weekly Skin Evaluation, dated 12/5/2022, 12/12/2022, 12/19/2022, 12/26/2022, 1/9/2023, 1/16/2023, 1/23/2023, and 1/30/2023 indicated Patient 6's skin was intact (no PIs). During a concurrent interview, on 1/31/2023 at 12:40 PM, and a concurrent review of Patient 6's Generations Weekly Skin Evaluations, dated 12/5/2022, 12/12/2022, 12/19/2022, 12/26/2022, 1/9/2023, 1/16/2023, 1/23/2023, and 1/30/2023, LNV 1 stated the nurses (in general) did not assess Patient 6's PI and documented Patient 6's skin as intact. LVN 1 stated Patient 6's care plan for Stage 4 PI indicated the PI needed to be measured weekly. During a wound observation on 1/31/2023 at 3:35 PM, Patient 6's PI on the Sacrococcyx region was observed with RN 1. RN 1 was asked to measure and describe the PI; RN 1 stated the wound was "small round 0.25 x 0.25 x 0.25", surrounding skin dry and clear and no exudate. The wound was observed to be small around the size of a q tip head, no drainage, no malodors. The wound bed could not be visualized. Surrounding skin appeared clean and dry. The patient denied pain during the observation. A review of the facility's document titled, "Generations: Missing Treatment TAR (Treatment Administration Record), wound treatments documentation," dated 2/3/2023, indicated PI treatments administrations were not documented as done for Patient 6 on 1/14/2023, 1/15/2023, 1/28/2023, and 1/29/2023. 1d. A review of Patient 7's Admission Record indicated the patient was an 87 year-old male and was admitted to the facility on 12/28/2022 with diagnosis that included diabetes mellitus. A review of Patient 7's New Admission Assessment, dated 12/28/2022, at 4:30 PM, indicated Patient 7 did not have a history of skin issues. The skin integrity review section did not indicate the presence of PIs upon admission. A review of Patient 7's MDS, dated 1/3/2023, indicated the patient had moderate impaired cognition. The MDS indicated Patient 7 had a stage 2 PI (location not indicated). A review of Patient 7's physician order's, Generations Weekly Skin Evaluations, and progress notes, dated 1/3/2023 to 1/23/2023, there was no documentation indicating the facility identified or obtained orders to treat a stage 2 PI for Patient 7. A review of Patient 7's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation note, dated 1/23/2023 at 10:38 AM, indicated the patient had a new Stage 2 PI in the right buttock area. The evaluation note did not indicate a description or measurement of the PI, the section was blank. A review of Patient 7's Physician Order, dated 1/23/2023, indicated to cleanse Stage 2 PI on the right buttock area