Other·February 2, 2022

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility Patients. Based on the comprehensive assessment of a Patient, the facility must ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patients’ choices. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. § 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. The facility failed to ensure Patient 1 received appropriate wound care and treatment services. Patient 1, who had type 1 diabetes (a condition in which the body does not make insulin; thus, could not control the amount of sugar in the blood. With diabetes, the wounds tend to heal more slowly and progress more quickly) developed a fluid filled blister on his right lateral malleolus (right ankle) on 3/25/2021 that measured 2.5 centimeters (cm, unit of measurement) (length, extent from end to end or "head to toe") x 2.5 cm (width, extent from side to side) x 0.5 cm. (depth, deepest point of the wound). The wound increased in size to 2.8 cm x 2.8 cm x unable to determine [UTD, due to wound base covered by slough/necrotic (dead tissue due to reduced blood supply) tissue] and ruptured (opened) on 4/9/2021 and to 3 cm x 3 cm on 4/23/2021. The facility failed to: 1. Consult a wound specialist in a timely manner (when the wound ruptured on 4/9/2021) in accordance with Patient 1's Skin Care Plan that resulted in the rapid deterioration and delayed healing of the Patient's wound. 2. Follow up with Patient 1's primary physician to determine if additional laboratory work was needed to help assist in the healing process of the patient's wound. Patient 1's last laboratory level for albumin (a protein made by the liver where its main role is to provide nourishment to the tissues and transport hormones, vitamins, drugs, and other substances such as calcium throughout the body and albumin levels facilitate wound healing), dated 10/15/2020 was low and the patient did not have additional labs ordered when the patient's wound to the right lateral malleolus (right ankle) increased in size in 4/9/2021, 4/23/2021, and 4/30/2021. These deficient practices resulted in the increase of Patient 1's right ankle wound to 8.6 cm x 7.4 cm x 1.2 cm on 4/30/2021 and developing a diabetic right ankle wound infection. Patient 1 was transferred to a general acute care hospital (GACH) on 5/3/2021 and the GACH indicated that amputation (surgical removal of a body part) of the right foot was considered. An unannounced visit was conducted at the facility on 9/10/2021 at 12:05 PM to investigate allegations regarding quality care concerns which included Patient 1 not receiving appropriate treatment of wound services. 1. A review of Patient 1's Admission Record indicated the facility admitted the patient, a 63 year old, on 10/26/2017 and readmitted on 1/27/2020 with diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (inability to move one side of the body), hypertension (high blood pressure), and long term use of insulin (a medicine to control blood sugar in people who have type 1 diabetes). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/31/2020, indicated that the patient had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated the patient was assessed requiring extensive assistance (patient involved in activity; staff provide weight bearing support) from staff for transferring, dressing, eating, and toileting. A review of Patient 1's Situation-Background-Assessment-Recommendation (SBAR, a technique used to provide a communication framework between members of the health care team about a patient's condition), dated 3/25/2021, indicated the facility informed Nurse Practitioner 1 (NP 1) at 12:45 PM that Patient 1 developed a blister on the patient’s right lateral malleolus (right ankle). NP1 ordered for a new wound treatment. A review of Patient 1's physician's order, dated 3/25/2021, indicated an order to treat the right lateral malleolus (right ankle) with normal saline (NS, a mixture of salt and water that is similar to bodily fluids), betadine (an antiseptic used for skin disinfection), and to cover the wound with a dry dressing once a day for 30 days. A review of Patient 1's care plan titled, "Skin Care Plan," dated 3/25/2021, indicated the facility had a concern about a fluid-filled blister that the patient developed on the right lateral malleolus (right ankle). The care plan interventions included for a wound specialist consultation, and to notify the physician for signs of skin breakdown and adverse changes. During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the Quality Assurance Nurse (QA Nurse) stated the patient developed a blister on the right lateral malleolus (right ankle) on 3/25/2021. The QA Nurse stated that Patient 1's record titled, "Non-Pressure Sore Skin Problem Report (NPSSPR)," dated 3/25/2021, indicated the wound on the patient’s right lateral malleolus (right ankle) had the following measurements on the following dates: 1. 3/25/2021 - 2.5 cm x 2.5 cm x 0.5 cm, clear fluid filled (blister). 2. 4/1/2021 - 2.5 cm x 2.5 cm x 0.5 cm, clear, fluid filled. 3. 4/8/2021 - 2.5 cm x 2.5 cm x 0.5 cm, clear, fluid filled. 4. 4/9/2021 - 2.8 cm x 2.8 cm x unable to determine, blister now ruptured. 5. 4/16/2021 - 2.8 cm x 2.8 cm x UTD 6. 4/23/2021 - 3 cm x 3 cm x UTD During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated that the facility informed the patient's Physician 3 (PHY 3) and Nurse Practitioner 1 (NP 1) on 3/25/2021 that the patient developed a blister on his right ankle and obtained a wound treatment order which the facility carried out (to do something because the doctor has told an individual or placed an order to do it). The QA Nurse stated that the facility also asked the vascular surgeon (PHY 1, a specialized physician that deals with arteries, veins, and lymphatic circulation) to see the patient because he was the physician who found a blockage on the patient's lower extremity when he developed a blister on his left heel in August 2020. The QA Nurse stated that PHY 1 conducted an arterial duplex scan (a test to see how blood moves through the arteries and veins) on the patient's lower extremity on 4/1/2021 but did not find any blockage. A review of Patient 1's SBAR, dated 4/9/2021, indicated that the patient's right ankle blister ruptured, and the facility notified NP 1. NP 1 gave new orders for wound treatment. The SBAR also indicated the facility called PHY 1's office to schedule an appointment for 4/20/2021 at 10 AM for evaluation of wound site as ordered. During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated Patient 1's "NPSSPR," dated 3/25/2021, indicated the wound measurement of the right lateral malleolus (right ankle) remained the same 4/9/2021 (2.8 cm x 2.8 cm x UTD) and 4/16/2021 (2.8 cm x 2.8 cm x UTD) until it was re-measured by the treatment nurse on 4/23/2021 (3 cm x 3 cm x UTD) during a wound dressing change. The QA Nurse stated the facility staff did not report the increase in wound size to the physicians or to NP 1 because the difference was not significant. A review of Patient 1's SBAR, dated 4/30/2021, indicated the patient had a change in condition with sacrococcyx moisture associated skin damage (MASD, skin breakdown due to prolong exposure to moisture), diabetic ulcer (open wounds or sores usually found of on the bottom of feet) on right lateral (to the side of) fifth (5th) metatarsal (the long bones in the foot that connects the ankle to the toes), right lateral foot, and right lateral malleolus (right ankle). During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated Patient 1's "NPSSPR," dated 4/30/2021, indicated the patient developed two new wounds on the patient’s right foot. The first wound was on the right lateral 5th metatarsal that measured 2.4 cm x 1.5 cm x 0.1 cm and the second wound was on his right lateral foot that measured 3.6 cm x 2.1 cm x 0.1 cm. The QA Nurse stated the facility tried to inform the patient's primary physician (PHY 3) about the new wounds, but PHY 3 was not available, so the facility was not able to get a hold of PHY 3. The QA Nurse stated since the vascular surgeon (PHY 1) would not see the Patient until three months later, the facility decided to ask the facility's in-house podiatrist and wound specialist (PHY 2) to evaluate the wounds of the Patient. During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated that Patient 1's "Lower Extremity Wound Assessment (wound specialist notes)," dated 4/30/2021, indicated the wound measurement of the right lateral malleolus (right ankle) increased from 3 cm x 3 cm x UTD to 8.6 cm x 7.4 cm x 1.2 cm. The assessment indicated treatment plan for debridement (medical removal of dead, damaged, or infected tissue). The QA Nurse stated that the facility did not ask assistance from the wound specialist (PHY 2) until 4/30/2021 because Patient 1 was under the care of the vascular surgeon (PHY 1) when the blister ruptured. A review of Patient 1's physician's order, dated 4/30/2021, indicated a new order for treatment of the right lateral malleolus (right ankle), to irrigate (steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination) with Dakin's (used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores) solution, pat dry, then wet to dry dressing with Dakin's solution full strength, cover with dry dressing with kerlix (a woven gauze used for wound absorbency and protection) roll. During a telephone interview and a concurrent record review, on 10/13/2021 at 2:30 PM, the QA Nurse stated Patient 1's SBAR, dated 5/3/2021 at 3 PM, indicated the patient developed a fluid-filled blister on his left heel and right ankle diabetic ulcer infection. The QA Nurse stated that the facility notified the wound specialist (PHY 2) and obtained a new order for antibiotic therapy because the wounds were infected. The SBAR indicated that Clindamycin (medication used to treat skin infections) 300 milligram (mg, a unit of measurement) one tablet twice a day (BID) for 10 days was ordered for diabetic ulcer infection. A review of Patient 1's physician's order, dated 5/3/2021 at 3:30 PM, indicated Clindamycin 300 mg by mouth (PO) BID for 10 days for right ankle diabetic infection. A review of Patient 1's SBAR, dated 5/3/2021 at 6:30 PM, indicated the patient had fever, weakness, and desaturation (oxygen levels less than normal range, normal range from 96 to 100 %). The SBAR indicated that the patient's vital signs (four main vital signs routinely monitored by medical professionals and health care providers include the following: body temperature, pulse rate, respiration rate/breathing rate, and blood pressure) at 6:30 PM was 100.7 degrees Fahrenheit (F, measurement of temperature), blood pressure (BP)=105/62, heart rate (HR)=84, respiration rate (RR)=20, and oxygen saturation (SpO2, percentage of oxygen level in the body) was 93% on room air. At 8:30 PM, the vital signs were 100.0 F, BP=110/58, HR=84, RR=22, SpO2=88%. Patient also started to have congestion and was suctioned and O2 was administered at 2 liters per minute (LPM, rate of O2 administered) via nasal cannula (NC, a tubing used to deliver supplement O2 for difficulty breathing). O2 was titrated (slowly increased to improve O2 saturation) and Patient 1 did not improve and 911 (a phone number used to contact the emergency services) was called at 9 PM. A review of Patient 1's record from GACH 2 titled, "Emergency Physician Notes," dated 5/3/2021, indicated that GACH 2 admitted Patient 1 at 9:33 PM due to shortness of breath. Upon physical examination, the note indicated the patient had wound ulcers on bilateral feet (both feet). The record indicated that his condition was critical. Patient 1 required blood transfusion due to severe anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Patient 1's record from GACH 2 titled, "Discharge Summary Narrative Report," dated 5/20/2021, indicated Patient 1 had bilateral heel ulcers, stage IV (most serious stage that extends below the subcutaneous fat into deep tissues, muscles, tendons, ligaments, and bone) and debridement was done on 5/17/2021 with amputation considered. During a telephone interview, on 10/13/2021 at 2:30 PM, the QA Nurse stated that the facility transferred the patient to a General Acute Care Hospital 2 (GACH 2) at 9 PM on the same day (on 5/3/2021) via 911 for further evaluation because the patient became weak, desaturated, and developed a fever. The QA Nurse stated that the patient did not return to the facility after the transfer. During a telephone interview, on 10/15/2021 at 10:05 AM, PHY 1 (vascular surgeon) stated that on 4/1/2021, the facility asked him to evaluate Patient 1's blister on his right lateral malleolus (right ankle). PHY 1 stated that he conducted an arterial duplex scan on the Patient's lower extremity but did not find any blockage. PHY 1 stated that he did not give the Patient any treatment order when Patient 1 went to his office on 4/20/2021 for a check-up. PHY 1 stated that he was a vascular surgeon and not a "wound doctor." PHY 1 stated that he did not prescribe wound treatment orders. PHY 1 stated, "My role in the patient's wound was only to ensure that he had no blockage in his blood vessels." During a telephone interview and record review, on 10/15/2021 at 11:45 AM, Licensed Vocational Nurse 3 (LVN 3) stated Patient 1's NPSSPR, dated 3/25/2021, indicated LVN 3 documented the patient's wound measurement on his right lateral malleolus (right ankle) on 4/16/2021 was 2.8 cm x 2.8 cm x UTD and on 4/23/2021 was 3 cm x 3 cm x UTD. LVN 3 stated he did not report the increase in wound size to the patient's physician because the difference in size was not significant. During a telephone interview, on 11/3/2021 at 8:15 AM, NP 1 stated that he worked under the supervision of the patient's PHY 3 (primary physician). NP 1 stated that on 3/25/2021, the facility informed him that Patient 1 developed a blister on his right lateral malleolus (right ankle). NP 1 stated that he did not see the blister but gave a wound treatment order based on the information that the licensed nurse provided him. Du