Health inspection·June 28, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00900199. Representing the Department, HFEN # 43321. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: § 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: Title 22 California Code of Regulations: § 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 5/15/2024, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 had a wound to his left extremity (arm) and the facility delayed care to the resident. On 5/16/2024, the CDPH made an unannounced visit to the facility to investigate the allegations. The facility failed to provide treatment and care services in accordance with the professional standards of practice for Resident 1 by failing to: 1.Ensure Licensed Nurses accurately assessed and documented Resident 1's skin condition when the resident was identified with left upper extremity fluid filled blisters (small pocket of fluid in the upper skin layers, a common response to injury or friction) on 5/12/2024. On dated 5/12/2024 at 7:26 pm, 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm written by five different nurses (Licensed Vocational Nurse 2 (LVN 2), LVNs 3, 5, and 6 and Registered Nurse 2 (RN 2), indicated the same verbiage. 2. Follow its Policy and Procedure (P&P) titled, "Charting and Documentation of Assessments" which indicated, changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record 3. Follow its P&P titled, Wound Care Documentation which indicated nurses should document any change in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 4. Implement Resident 1's care plan titled, "Risk for developing pressure sore, and other types of skin breakdown related to fragile skin." Which indicated staff would assess the resident's skin integrity during care and to notify the resident's physician of any changes. 5. Initiate a care plan to address Resident 1's left upper extremity blisters on 5/12/2024. 6. Inform a Wound Care Specialist (WCS-medical professional who specializes in treating wounds) pertinent information regarding Resident 1's including his diagnosis of diabetes and presence of brown drainage from Resident 1's wound on 5/12/2024. 7. Ensure Licensed Nurses identified the signs and symptoms of infection and report any suspicion of infection on Resident 1 to the attending physician and or the Wound Care Specialist 1. As a result, Resident 1 was admitted to General Acute Care Hospital (GACH 1) with a diagnoses of cellulitis (a deep bacterial infection of the skin characterized by redness, swelling and tenderness) of the left arm and sepsis (a serious condition in which the body responds improperly to an infection). Resident 1 received three different types of antibiotics in the Emergency Department and was recommended to have wound debridement (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). The lack of comprehensive documentation in the facility had the potential to ineffectively facilitate the communication between the interdisciplinary team regarding the resident's condition and response to care. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on 10/26/2023 and re-admitted on 2/19/2024. Resident 1's diagnoses included type 2 diabetes mellitus abnormal blood sugar), chronic kidney disease (progressive damage and loss of function in the kidneys), history of urinary tract infections (an infection in any part of the urinary tract system which is the system of organs that makes urine), dementia (impaired inability to remember, think, or make decisions that interferes with doing everyday activities), and benign prostatic hyperplasia (prostate gland enlargement) with lower urinary tract symptoms. A review of Resident 1's care plan titled "Risk for developing pressure sore, and other types of skin breakdown related to fragile skin due to (d/t) aging process, dementia, diabetes mellitus type 2 (DM 2)," dated 10/26/2023, indicated a goal was to minimize the risk of skin breakdown / pressure sore through the next assessment of 7/28/2024. The care plan Interventions indicated staff will assess the resident's skin integrity during care and to notify the resident's medical doctor of any changes. A review of Resident 1's care plan titled "Bruising. At risk for skin discolorations, bruising secondary to: (fragile skin, aging process, poor fluid/dietary intakes, antiplatelet therapy, locomotion impairment, cognitive impairment (dementia)," initiated on 10/26/2023 indicated a goal to reduce the risk of skin discolorations and injury through appropriate interventions daily through the next assessment. Interventions included to administer medications as ordered, assess skin condition daily during care and with weekly body checks, and notify the medical doctor as indicated. A review of Resident 1's admission assessment, dated 2/19/2024, indicated Resident 1 was noted with bilateral (both) upper extremities (arm) bruising. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment tool), dated 4/29/2024, indicated Resident 1 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 did not exhibit behaviors of hitting or scratching on self. The MDS indicated Resident 1 needed setup or clean up assistance in eating and staff supervision in oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 1 had no pressure injury (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices), venous ulcer (wounds that occur when the veins in the legs do not push blood back up to the heart as well as they should), arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot) or other skin problems. A review of Resident 1's Weekly Skin Report for 5/2024 indicated Resident 1 did not have a pressure ulcer, vascular ulcer (wounds on the skin that develop because of problems with blood circulation), diabetic ulcer (open wound or sore that can be difficult to heal), or other acquired skin conditions in the first week of May 2024. A review of Resident 1's Change of condition / Interact Assessment Form (COC Form), dated 5/12/2024 at 12:04 pm, indicated Resident 1 was identified with left upper extremity fluid filled blisters. A review of Resident 1's non-pressure sore skin problem report, dated 5/12/2024, indicated Resident 1 was identified with left upper extremity fluid filled blisters. A review of Resident 1's Physician Order, dated 5/12/2024 at 12:15 pm, indicated an order of "[Treatment] Left Upper Extremity: Cleanse with NS (normal saline), pat dry, apply Xeroform (type of gauze with antimicrobial [agent that kills or stops the growth of microorganisms] properties) then wrap with rolled gauze, everyday shift for fluid filled blisters for 21 days." The order also indicated to monitor fluid filled blisters everyday shift. A review of Resident 1's Treatment Administration Record (TAR) for 5/2024 indicated Resident 1 received wound treatments on 5/12/2024, 5/13/2024 and 5/14/2024. There was no documentation of Resident 1's wound assessment and inspection conducted. A review of Resident 1's Nurses Notes dated 5/12/2024 at 7:26 pm, 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm written by five different nurses (Licensed Vocational Nurse 2 (LVN 2), LVNs 3, 5, and 6 and Registered Nurse 2 (RN 2), indicated the same verbiage of "Resident vital signs within in normal range. Awake. Alert and oriented times two with periods of confusion. Reality orientation provided. No acute distress noted. Skin is dry and warm to touch. Afebrile. On 72-hour monitoring for skin infection. No active bleeding. No verbalization of pain or any discomfort. Continue treatment as ordered. Maintained safety and hazard free environment. Call light within easy reach. All needs met and attended to promptly. Frequent visual check rendered. Will continue to monitor." Notes on 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm had additional same exact verbiage of "Resident on monitoring for skin infection Tx (treatment) ongoing tolerated well denies any pain or discomfort @ (at) this time. All needs met by staff call light win reach will continue to monitor for any changes." A review of Resident 1's Change of Condition / Interact Assessment Form, dated 5/14/2024 at 9 am, indicated Resident 1 was identified of having behavior of refusing to eat, was stating he is very sad and does not want to be in the facility. The COC form also stated Resident 1 was noted picking on the blister on his skin despite it being wrapped with rolled gauze. A review of Resident 1's Physician Order, dated 5/14/2024 at 10 am, indicated an order to transfer Resident 1 to GACH 1 due to generalized weakness and variable food intake. A review of Resident 1's GACH note titled "ED Provider Assessment Note," dated 5/14/2024 at 1:19 pm by the Emergency Room Medical Doctor (EMRD), indicated Resident 1 arrived at the emergency department with "Left upper extremity with maceration (A softening and breaking down of skin resulting from prolonged exposure to moisture), ulceration (formation of a break on the skin) of the dorsal (back part) left forearm with erythema (redness) and induration (An area of hardness in the skin) circumferential (surrounding) with warmth and blistering extending up into the posterior shoulder." The ED Provider Assessment note indicated Resident 1 received cefepime (Antibiotic), vancomycin (Antibiotic) and metronidazole (Antibiotic) per infection disease recommendations for severe skin infection. The note indicated CT scan ( [computed tomography ] a medical imaging technique used to obtain detailed internal images of the body) was consistent with cellulitis. The note indicated that because of the severity of left upper extremity wound, general surgery recommended operating room for debridement but Resident 1's responsible party was not ready to make that decision at this time. ERMD 1's note indicated diagnoses of severe sepsis (a serious condition in which the body responds improperly to an infection), cellulitis, and urinary tract infection (An illness in any part of the urinary tract, the system of organs that makes urine). A record review of Resident 1's GACH Integumentary / Skin Wound note, date 5/14/2024 at 3:30 pm, indicated Resident 1 had left arm draining wound / cellulitis with two upper arm closed blood blister. A review of Resident 1's CT of the left forearm, left elbow and left humerus without contrast result from GACH 1, dated 5/14/2024 at 3:33 pm, indicated the reason for the CT scan was cellulitis and necrotizing soft-tissue infection (NSTI, diverse disease process characterized by extensive, rapidly progressive soft tissue inflammation and necrosis [cell death]). The impression of the scans indicated findings compatible with known cellulitis. A review of Resident 1's care plan titled "Blister, skin integrity impairment secondary to fluid filled blister to left upper extremity," created on 5/15/2024 by the MDSN (confirmed by Data History) but initiated on 5/12/2024 (backdated), indicated a goal to resolve the blister without complications through the next assessment. Interventions included to administer medications as ordered, apply pressure relief devices as appropriate and/or ordered, assess for causative factors that caused development and attempt to prevent recurrence, assess for s/s (signs and symptoms) of inflammation or infection i.e. Odor, pain, drainage, swelling, warm to touch, etc. and notify MD (medical doctor) as indicated / needed, assess skin condition daily during care and with weekly body checks, observe universal precautions while providing treatment, and provide treatment as ordered. A review of the care plan titled "Risk for infection. Resident is at: Moderate risk for infection secondary to: Fluid Filled Blister to LUE (left upper extremity)," created on 5/15/2024 by the MDSN (confirmed by Data History) but initiated on 5/12/2024 (back-dated), indicated a goal to reduce the risk for Multidrug-Resistant Organisms (MDRO - group of bacteria that have become resistant to certain antibiotics so these antibiotics can no longer be used to control or kill the bacteria) transmission daily until the next assessment. Interventions included to administer antibiotics if ordered, monitor signs and symptoms of infection, notify medical doctor if any signs and symptoms of infections were observed, and perform wound care if indicated. During an interview on 5/16/2024 at 11:07 am, Licensed Vocational Nurse (LVN) 1 stated, (Certified Nurse Assistant (CNA) 2 alerted him about Resident 1's arm on 5/12/2024. LVN 1 stated he observed Resident 1's left arm was full of blisters from his forearm up to his upper arm. LVN 1 stated the biggest blister he observed was about five by five inches and about 10 inches of the outer side of Resident 1's arm was covered with blisters. LVN 1 stated he was not sure how Resident 1 got the blisters and it looked like a burn with fluid in it. LVN 1 stated fluid was dripping from the blisters. LVN 1 also stated he was not able to provide any evidence of documentation of the wound assessments including the description of the blisters observed in Resident 1. During an interview on 5/16/2024 at 11:36 am, Registered Nurse (RN) 1 stated he assessed Resident 1 for his change of condition on 5/12/2024 and observed the resident with one to two small blisters on his left forearm. RN 1 described the blisters as "fluid filled watery on top of the skin surface." RN 1 stated, one blister was the size of a dime and the other was smaller than the size of a dime. During interviews on 5/16/2024 at 12:05 pm and 2:33 p.m., Treatment Licensed Vocational Nurse (TLVN) 1 stated on 5/12/2024 he observed Resident 1's left forearm with multiple blisters; the biggest one measuring about 10 x 12 inches. TLVN 1 stated Resident 1's wound had light brown fluid mixed with clear liquid coming out of it. TLVN 1 stated he noted discoloration around Resident 1's left forearm including redness around the blister. TLVN 1 stated there was no documentation regarding the sizes of the blisters and the description of the skin around the blisters. TLVN 1 also stated he did not do a care plan because MDS nurse (MDSN) created the care plans in the facility and was not present on 5/12/2024. During an interview on 5/16/2024 at 1:40 pm, CNA 2 stated the last time she took care of Resident 1 was on 5/12/2024 and on 5/9/2024 (Thursday). CNA 2 stated that on 5/9/2024 she gave Resident 1 a shower where she observed him with a skin tear on his left arm. CNA 2 stated she informed LVN 1 on 5/9/2024 of Resident 1's skin tear. CNA 2 further stated the same area where Resident 1 had the skin tear on 5/9/2024 was the same area she saw him with blisters on 5/12/2024. CNA 2 further stated "I didn't notice until close to lunch (on 5/12/2024), he was scratching a little bit on his arm. I noticed he had blister on his skin. He took off his jacket and noticed full of redness and blisters. He has a lot of discoloration before, but these blisters