Resident sustained pressure wounds while in care- UNSUBSTANTIATED

It was alleged that a resident sustained pressure wounds while in care.

LPA review of home health nursing notes revealed that from the dates of 05/03/2022 – 6/08/2022 No skin issues were noted and R1’s skin was clear at time of assessment by home health nurse. On 6/10/2022 nursing notes stated “Non-Blanchable redness noted to outer right foot. No other skin issues noted.´ On 6/15/2022 nursing notes stated “Skin: at time of assessment, unstageable wound to right lateral foot, wound care performed per MD order. educated staff with positioning of patient to and use of prophylactic equipment (heel booties), to protect the wound bed.”

LPA review of medical records dated 2/15/2022 – 03/08/2022 revealed that R1 had a Braden score of 14-18 during various visits and hospitalizations for that period. Of note in these medical records:

02/24- 3/08/2022 Doctor’s Orders stated that R1 was “at risk (Braden score 15-18) Patient will be turned Q2 hr. Physician ordered for R1 to be encouraged to be as active as possible, heels will be protected, R1 was placed on pressure reduction surface, staff were to manage moisture, nutrition, friction and sheer, and advance to higher level of risk as indicated.

2/25/2022 Consultation note for nutrition evaluation Comment: No wounds/pressure injuries/Ulcers per review of nursing notes dated 2/24/2022. Braden score: 17.

03/01/2022 Braden score: 14 Preventive interventions. Abnormalities/redness. Location: Coccyx and heels.

03/01/2022 Progress notes: Patient is refusing to be floating on pillows and wants to lay on his right side which is red. Educated patient on redness of skin and patient still wants to lay on his right side. All safety measures in place call light within reach.

Medical records revealed that on 03/08/2022 R1 was transferred to Country Crest Post-Acute for rehabilitation.

Continued on LIC9099-C

Home health staff stated at time of admission in April 2022 R1 had clear skin, no pressure injuries.

Resident Services Director stated that R1 had gone to the hospital prior to the start of care for an unrelated illness, then R1 went to the Country Crest skilled nursing facility. R1 was admitted back to the facility on hospice in April 2022 when they came out of skilled nursing. R1 developed pressure injures because of pain that they chronically had (due to unrelated illness). R1 kept scooting back to their comfort zone no matter how many times we re-positioned R1.

Administrator stated The one (pressure injury) on R1’s foot was because no matter how we positioned R1's foot they would move it. The one on R1’s bottom R1 would reposition themselves or comfort no matter how many times we repositioned R1.

It was determined that when R1 returned to the facility from a subsequent stay in skilled nursing their skin was clear with no pressure injuries per home health and hospice staff interviews and nursing notes. Per nursing notes dated 6/15/2022 R1 developed unstageable wound to right lateral foot which continued to be cared for by home health at the facility until R1 was moved out of the facility into another RCFE facility with home health and hospice care.

Residents who have or develop any condition or care requirements relating to Stage 3 and 4 pressure injuries may be permitted to be accepted or retained in a facility, provided these clients have been diagnosed as terminally ill and are receiving hospice services in accordance with a hospice care plan required in Section 85075.1 and treatment of the prohibited health condition is specifically addressed in the hospice care plan. [Title 22, CCR, Section 85075.1]

This allegation is UNSUBSTANTIATED.

Continued on LIC9099-C

It was alleged that a client was left in a soiled diaper for an extended period of time.

During staff interviews it was learned that the facility has a 2-hour check rotation. 3 of 6 staff stated they were checking R1 at least hourly and rotating and changing R1. 1 staff stated they changed R1 “a lot.” 2 staff stated they checked and changed R1 at least every 2 hours.

Hospice staff did not recall seeing an overly saturated brief on R1 when home health visits were conducted.

Administrator stated R1 was changed a minimum of every 2 hours but sometimes it was more due to other health issues.

It was determined that staff were checking R1 at least every two hours, usually more often, therefore the allegation is UNSUBSTANTIATED.

Continued on LIC9099-C

It was alleged that the facility was not communicating with authorized representative.

3 of 6 staff stated that once hospice takes over, they communicate with the family. 2 staff were unsure of who notifies the family. 1 staff stated the facility notifies the family.

Hospice staff stated that they understood it to be their responsibility to update the family and hospice staff did talk to the family often and give them updates.

Resident Services Director stated that the hospice nurse was following R1 closely and keeping the family well informed. When a resident goes on hospice the hospice RN Manager is who guides the facility through the care of the resident.

Administrator stated When hospice takes over the care of our resident, they take over communication with the family on medical issues. We would contact the family and give updates on how R1 was doing, but the family wanted more medical information. Our staff is not medical. When it came to other issues like nutrition, change of condition or falls the administrator was contacting the family.

It was determined that hospice staff was communicating with the family on medical related issues therefore the allegation is UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was emailed to Executive Director Irene Davis. No deficiencies cited.