Health inspection·June 21, 2024

F684 42 CFR § 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. 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523. 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 5/6/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the recertification survey. The facility failed to identify and ensure Resident 75, who had an amputation site (surgical removal of part of the body, left lower leg), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), and a right lateral malleous (bony projection of the ankle) with arterial ulcer (injury to skin or underlying tissue caused by poor circulation, which in turn was caused by arterial insufficiency [reduced blood flow by the artery]) on the right lower leg, received necessary care and services in accordance with professional standards of practice by failing to: 1.Assess upon admission or on 3/20/2024, and document the condition, description, and measurements of Resident 75's right lateral malleous arterial ulcer of the right lower leg, as documented on the Admission Data Collection form dated 3/16/2024. 2.Develop a comprehensive and person-centered Care Plan to include the Physician's Order for treatment to Resident 75's right lateral malleous arterial ulcer. 3.Follow the Physician's Order for treatment to Resident 75's right lateral malleous lower leg arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. 4.Assess respiratory status for accurate rate of oxygen administration and monitor Resident 75 for any changes in condition (shortness of breath), per the Continuous Oxygen Therapy care plan developed on 3/22/2024. As a result, Resident 75 did not receive treatment to the right lateral malleous arterial ulcer of the right lower leg for over two weeks and was transferred to General Acute Care Hospital (GACH) 2 for altered level of consciousness (ALOC, resident is not as awake, alert, or able to understand or react to the surrounding environment). At the GACH 2, Resident 75 complained of shortness of breath, required four liters per minute of oxygen via nasal cannula (NC, a device that gives you additional [supplemental] oxygen through your nose) with 92% oxygen saturation (amount of oxygen traveling through the body in your red blood cells, normal oxygen saturation for a healthy adult between 95% and 100%) and complained of right ankle pain. The GACH 2 Emergency Department Note dated 4/27/2024, indicated Resident 75 developed soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the side of the smaller thinner calf bone (lateral malleous) with underlying osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), abnormal accumulation of fluid in the pleural space (the cavity between the lungs and chest wall) with pulmonary edema (fluid builds up in the lungs) and adjacent atelectasis (collapse of the whole lung or an area of the lung). Resident 75 died three days later on 4/30/2024. A review of General Acute Care Hospital (GACH) 1 Hospitalist Progress Note dated 3/14/2024, indicated Resident 75 was status post cardiac arrest (heart attack) and received two thoracenteses (procedure to remove fluid or air from around the lungs) with the last procedure on 2/27/2024. The GACH 1 progress note indicated Resident 75 was on three antibiotics for a diabetic infection of the left foot with questionable osteomyelitis (bone infection). A review of Resident 75's GACH 1 Complex Case Manager Note dated 3/14/2024, indicated the resident needed placement for physical therapy and wound care at the amputation site (surgical removal of part of the body, left lower leg). The note indicated Resident 75 should be able to return home with the help of family when independent. A review of Resident 75's GACH 1 Physician's Transfer Orders form dated 3/15/2024, indicated the resident had hypoxia (oxygen levels in the blood are lower than normal) when sleeping and required oxygen at two liters per minute when awake during the daytime. The Transfer Orders indicated the resident was not on antibiotics during to the transfer. According to a review of the Admission Record to the facility Resident 75 was admitted on 3/16/2024, with diagnoses including non-pressure chronic ulcer of the right lower leg (caused by poor circulation, which in turn was caused by venous or arterial insufficiency), after care following surgical amputation of the left lower leg and acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body). A review of Resident 75's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/16/2024, indicated Resident 75's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment) was dependent on facility staff with showering and transfers. The MDS indicated Resident 75 had one arterial ulcer (right leg), a surgical wound with application of nonsurgical dressings (left leg amputation) and required oxygen therapy. A review of Resident 75's Admission Data Collection form documented by the Admission Nurse dated 3/16/2024, indicated Resident 75 had clear lung sounds, no shortness of breath, and had 98% oxygen saturation on room air. The Admission Data Collection form indicated the resident was not on antibiotics, was a full code (if a person's heart stopped beating and/or they stopped breathing, all procedures would be provided to keep them alive), and had a right ankle diabetic ulcer. The Admission Data Collection form did not indicate Resident 75's right lateral malleous with arterial ulcer to the lower right leg. A review of the Physician's Order dated 3/17/2024, indicated for Resident 75 to receive treatment on the right lateral malleous with arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. According to a review of Resident 75's Treatment Administration Record (TAR), Resident 75 received treatment to the right lateral malleous with arterial ulcer on 3/17/2024. Further review of the TAR indicated the resident did not receive the Physician's Ordered treatment from 3/18 to 3/31/2024 (14 days). A review of Resident 75's History and Physical (H&P) dated 3/18/2024, indicated Resident 75 had the capacity to understand and make decisions. A review of the Physician's Order dated 3/19/2024, indicated Resident 75 was to receive oxygen at two liters per minute via NC continuously. May titrate up to three liters per minute, every shift for hypoxemic respiratory failure. A review of Resident 75's Admission Data Collection Form documented by the Treatment Nurse (Licensed Vocational Nurse 8) dated 3/20/2024, indicated a head-to-toe assessment was completed, four days after admission. The form indicated the resident denied pain, wound care was rendered (but there was no indication of the location of the wound) and tolerated well. The Admission Data Collection form indicated the resident had a left below the knee amputation (BKA) with staples and a skin abrasion (the surface layers of the skin [epidermis] has been broken) on the left flank (space between the lowest rib and hip). The Admission Data Collection form documented by the Treatment Nurse did not indicate a right ankle diabetic ulcer on the Admission Data Collection form dated 3/16/2024 documented by the Admission Nurse, nor did it indicate the condition, description, or any measurements of the right lateral malleous with arterial ulcer to the lower right leg. A review of a care plan dated 3/20/2024 indicated Resident 75 wanted to return the the community. The care plan intervention indicated to assess discharge plan needs with the resident and Interdisciplinary Team members. According to a review of Resident 75's Continuous Oxygen Therapy care plan developed on 3/22/2024, for the resident's acute respiratory failure with hypoxia, the goal indicated for the resident to have no signs or symptoms of poor oxygen absorption. The care plan interventions indicated to monitor for signs and symptoms of respiratory distress and assess respiratory status for rate, depth, and ease and report to the doctor. A review of Medication Administration Record (MAR) dated 4/5/2024 indicated Resident 75 received two liters of oxygen via nasal cannula and on the evening shift the resident's oxygen saturation was 98%, but the oxygen inhalation section indicated 96%. The MAR dated 4/6/2024 indicated on the morning shift Resident 75's oxygen saturation was 98% but the oxygen inhalation was 96% and during the night shift (same date) the oxygen saturation was 98% and oxygen inhalation was 97%. This indicated discrepancies in the monitoring of the resident's respiratory status. A review of Resident 75's At Risk for Skin Breakdown care plan developed on 4/5/2024 (almost three weeks after admission), for the resident's right lower leg with scattered arterial ulcers, had a goal for the resident to minimize the risk of skin breakdown every day. The care plan interventions indicated handling the resident gently during care, keep skin clean, dry, and comfortable at all times, and report any redness or open area. The care plan did not include the Physician's Order to provide treatment every day for 21 days to the right lateral malleous with arterial ulcer of the resident's right lower leg. A review of Resident 75's Social Services Note dated 4/16/2024, indicated discharge planning was in progress with the resident's family member and the discharge plan was to go to a lower level of care. A review of Resident 75's Weekly Wound Note dated 4/19/2024, indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous (contains both blood and liquid part of blood [serum]) exudate (fluid that leaks out of blood vessels into nearby tissues), the surrounding skin condition was normal, and not painful. The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. According to a review of the TAR dated 4/23/2024, Resident 75's right lateral malleous with arterial ulcer of the resident's right lower leg was provided treatment. This indicated the resident did not receive treatment for the arterial ulcer for over one month, as the last treatment documented was 3/17/2024. Further review of the TAR indicated Resident 75 did not receive the Physician's Ordered treatment from 4/24/2024 to 4/27/2024. A review of Resident 75's Weekly Wound Note dated 4/25/2024, indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous exudate, the surrounding skin condition was fragile (which indicated a change). The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. A review of the MAR dated 4/27/2024 for the morning shift indicated there was no documentation regarding Resident 75's oxygen saturation. For the afternoon shift the MAR indicated the resident received oxygen at two liters per minute, the oxygen saturation was 97% and under oxygen inhalation was 98%. A review of Resident 75's Nursing Progress Note dated 4/27/2024 at 11:05 AM, indicated the resident was alert and oriented, did not have signs or symptoms of acute distress or pain, and the resident's vital signs were within normal limits. The Nursing Progress Note indicated the resident was receiving oxygen via NC (with no documentation regarding the amount of oxygen administered to the resident) and the oxygen saturation was 97%. A review of the Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, or functional abilities) Record dated 4/27/2024 at 8:15 PM, indicated Resident 75 was found on the floor in a supine position (lying on the back or with the face upward). The COC indicated the resident did not have shortness of breath and was on continuous oxygen. The COC indicated under the vital signs portion the resident had an oxygen saturation of 97% and was on room air. The COC indicated at 8:25 PM, Resident 75 was noted with altered level of consciousness (the resident is not as awake, alert, or able to understand or react to the surrounding environment) and the facility obtained doctor's orders to send the resident out for a computerized tomography scan (CT, diagnostic imaging procedure to produce images of the inside of the body) of the head. According to a review of the Physician's Order dated 4/27/2024, Resident 75 was to be transferred to the GACH due to altered level of consciousness. A review of the GACH 2 Emergency Department Note dated 4/27/2024, indicated Resident 75 presented with cough, congestion and required four liters per minute of oxygen via NC at baseline (this indicated the facility should have given the resident four liter of oxygen continuously). The ED Note indicated an x-ray of the chest was done with findings including bilateral pleural effusions (abnormal accumulation of fluid in the pleural space) with pulmonary edema and adjacent atelectasis (collapse of the whole lung or an area of the lung). The note indicated an x-ray of the right ankle was done with findings including soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the lateral malleous (the bone on the outside of the fibula) with underlying lateral malleous osteomyelitis. A review of Resident 75's GACH 2 H&P Note dated 4/28/2024, indicated the resident complained of shortness of breath required four liters of oxygen via NC with 92% oxygen saturation and complained of right ankle pain due to osteomyelitis. A review of Resident 75's GACH 2 Discharge Summary Note dated 4/30/2024, indicated the resident was admitted to GACH 2 with shortness of breath and right ankle pain. The Note indicated a diagnoses of acute respiratory failure with hypoxia, severe bilateral pleural effusion, and chronic osteomyelitis. The note indicated the resident expired (the last emission of breath, death) on 4/30/2024 (three days after transfer from the facility). During a concurrent interview and record review, on 5/9/2024 at 11:58 AM with the Quality Assurance (QA) Nurse, Resident 75's Physician's Order Report dated 3/17/2024 was reviewed. The QA Nurse stated the treatmen