Other·June 30, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00840990 Representing the Department, HFEN # 45524 State Citation (B) was written 42 CFR §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. 22 CCR § 72311(a)(2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (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 05/23/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate about resident neglect. The facility failed to provide Resident 1 with the necessary treatment and services to prevent formation and progression of a pressure ulcer (also known as decubitus ulcer or bedsore, injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence). The facility failed to ensure: 1. Resident 1 was repositioned every two hours in accordance with the plan of care and the facility's policy on Prevention of Pressure Ulcers/Injuries. 2. Perform daily skin check on Resident 1, as indicated in the plan of care, to promptly identify the formation of pressure ulcers. As a result, Resident 1 developed a blister (a small bubble on the skin filled with serum [clear liquid part of the blood] caused by friction, burning, or other skin damage and it is a Stage II pressure sore [the sore digs deeper below the surface of the skin]) to the left buttock that was identified by Family Member 1 (FM 1) on 5/15/2023 and not identified by the staff. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 9/26/2022 with diagnoses including cerebral vascular disease (CVA - stroke, a term for conditions that affect blood flow to your brain either by a clot or by a ruptured blood vessel), diabetes mellitus (abnormity elevated blood glucose[sugar] levels), and generalized muscle weakness. A review of Resident 1's Assessment of Decubitus Ulcer Potential, dated 10/9/2022, indicated Resident 1 scored 23 points (score above 16 indicates high risk for developing pressure sores. A review of Resident 1's Care plan initially developed on 10/9/2022 and revised on 5/19/2023 for the resident's potential for skin breakdown and pressure ulcers related to Resident 1's fragile and sensitive skin and total incontinence (inability to voluntarily control passage of stools and urine). The care plan goals included for Resident 1's skin to remain intact (not damaged), no skin breakdown, and no pressure ulcer. The care plan interventions included: 1. May turn and reposition every two hours, 2. Assess skin condition upon admission, daily, quarterly, and as needed. 3. Use heel protectors (a medical device usually constructed of foam, air-cushioning, gel, or fiber-filling, and is designed to offload [keep off] pressure from the heel of a non-ambulatory individual to help prevent decubitus ulcers on the boney heel area of the foot), foot cradles (a frame that is installed at the foot of the bed to keep sheets/blankets off legs/feet) as ordered. 4. Monitor increase swelling, skin discoloration/breakdown every shift and report to the medical doctor (MD). 5. Perform body checks as ordered. A review of Resident 1's Nursing Readmission Evaluation / Data Collection form, dated 10/9/2022, indicated Resident 1's did not have pressure ulcers on readmission. A review of Resident 1's History and Physical (H&P) exam, dated 10/10/2022 and completed by the MD, indicated Resident 1 did not have capacity to make medical did not have lesions (an abnormal change in structure of an organ or part due to injury or disease) on visible body areas. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/18/2023, indicated Resident 1's cognition (the mental ability to make decisions of daily living) was severely impaired (inability to understand and make decisions). The MDS indicated Resident 1 was dependent on staff to move in bed, transfers, locomotion (movement) on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS further indicated Resident 1 was not able to walk and could not move on one side of the body (arms and legs). A review of Resident 1's care plans dated 5/10/2023, indicated Resident 1 had developed deep tissue pressure injuries on the left foot dorsal (the upper part of the foot) area, the right foot dorsal / lateral (the upper and side part of the foot) area, a blister on the right toe, and on the right heel. The approaches for each of the pressure ulcer care plan included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow every two hours repositioning program. 4. Perform daily body check for redness, open areas, and report to MD. A review of Resident 1's Care Plan dated 5/10/2023, indicated Resident 1 had a skin tear on the right buttock. The approaches included to: 1. Provide pressure relieving mattress for wound management 2. Initial assessment followed by weekly body check. 3. Follow every two hours repositioning program 4. Perform daily body check for redness, open areas, and report to MD. A review of the Physician's Orders for Resident 1, dated 5/10/2023, indicated to provide a low air loss mattress (LOLM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and, treat and prevent pressure ulcers) on bed for wound management every shift and wound consult and follow up care until resolved for Resident 1. A review of the Physician's Order for Resident 1, dated 5/18/2023, indicated to cleanse the resident's left buttock Stage II pressure sore with normal saline (wound cleaning solution) Pat dry. Apply Xeroform gauze, cover with dry clean dressing daily every day shift. On 5/23/2023 at 9 a.m., during an interview, FM 1 stated that during one family visit 5/15/2023 she found Resident 1 had a blister to her left buttock and the nursing staff were not aware of it. FM 1 stated Certified Nursing Assistant 1 (CNA 1) who was assigned to Resident 1, stated Resident 1 was not frequently turned because she was in, "so much pain" and pushed them (staff) away most of the time. On 5/23/2023 at 11:15 a.m., during an observation, Resident 1 was lying in bed with both feet wrapped with bandages (wound care material) that extended from the toes to the ankles. Resident 1's foot was resting directly onto the mattress and was not wearing the heel protectors as indicated in the plan of care. On 5/23/2023 at 12:53 p.m., during an interview, CNA 1 stated Resident 1 gets guarded (protected), screams, and pushes staff back when moved because pain. CNA 1 Resident 1 was turned every two hours to prevent pressure ulcers but there was no documentation to provide to the surveyor to indicate Resident 1 was turned every two hours. CNA 1 further stated that on Monday, 5/15/2023, she discovered a blister on Resident 1's left buttock and informed the treatment nurse (TN). On 5/23/2023 at 1:19 p.m., during an interview, the TN initially stated Resident 1's family discovered Resident 1 had pressure ulcer on the left buttock. Then, the TN stated staff identified the left buttock pressure ulcer before Resident 1's family arrived at the facility on 5/15/2023. The TN stated there was no documented evidence the nursing staff was the first to identify the pressure ulcer to left buttock for Resident 1. The TN further stated, the MD's order was obtained on 5/18/2023. During an observation and concurrent interview with the wound care specialist Medical Doctor (MD 1) on 5/24/2023 at 1:47 pm, MD 1 stated he assessed Resident 1's left buttock wound as a Stage II pressure ulcer. MD 1 stated Resident 1's left buttock pressure ulcer wound bed (the base of the wound) was bright pink with no drainage. MD 1 stated the left buttock pressure ulcer measured 0.5 centimeters (cm) long by 0.9 cm wide. MD 1 further stated Resident 1 had also two blisters on the left lower flank (area of the side of the body between the shoulder and the hip). When asked the potential effect for not assessing and identifying pressure ulcers, MD 1 stated Resident 1 was at risk for pressure ulcer and wound infection. A review of the facility's policy and procedures (P&P) titled, "Prevention of Pressure Ulcers/Injuries," revised in 7/2017, indicated, "the purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific factors." The P&P indicated that, "among other factors for prevention as mobility/Repositioning at least every two hours for residents who are reclining and dependent on staff for repositioning and monitoring by evaluating, reporting, and documenting potential changes in the skin." The facility failed to provide Resident 1 with the necessary treatment and services to prevent formation and progression of a pressure ulcer for Resident 1. The facility failed to ensure: 1. Resident 1 was repositioned every two hours in accordance with the plan of care and the facility's policy on Prevention of Pressure Ulcers/Injuries. 2. Perform daily skin check on Resident 1, as indicated in the plan of care, to promptly identify the formation of pressure ulcers. As a result, Resident 1 developed a blister to the left buttock that was identified by FM 1 on 5/15/2023 and not identified by the staff. The above violation had a direct relationship to the health, safety, and security of Resident 1.