ARDEN REHAB & HEALTH CENTER
3400 ALTA ARDEN, SACRAMENTO, CA 95825
Citation Number: 030004419
Citation Date: 12/21/2007
Violation Date: 10/13/2005
Class: AA
Penalty: $ 100000.00

72311. Nursing Services-General. (a) Nursing service shall include, but not 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. (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 the patient care plan as necessary by the nursing staff and other personnel involved in care of the patient at least quarterly, and more often if there is a change of condition.

72315. Nursing Service-Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required Section 72311(b).

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 following citation was written as a result of an unannounced investigation for a facility self-reported event Complaint #CA00063176. The complaint was initiated on 09/21/06, with additional onsite visits on 10/13/06, 10/18/06, 11/01/06 and 11/30/06.

The Department determined that the facility failed to:

1. Initially and continually assess Patient A's care needs following a 10/03/05 right foot transverse fracture and the subsequent development on 10/09/05 of a pressure ulcer of the right heel and right upper foot, which became necrotic, infected, and gangrenous.

2. Develop and update care plans which identified the initial and continuing care needs of Patient A following a 10/03/05 a right foot transverse fracture and the subsequent development on 10/09/05 of a pressure ulcer of the right heel and right upper foot, which became necrotic, infected, and gangrenous.

3. Provide treatment and services to prevent the formation and progression of pressure ulcers from 10/03/05 to 11/28/05 when the facility did not identify the deteriorating condition of Patient A's pressure ulcers, notify the physician when the right foot pressure ulcer treatment was not effective in order to provide opportunity to change treatment and interventions. This resulted in an auto-amputation of the right foot.

4. Follow their March 2000 policy titled "Care of Resident in Cast" and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment" when they did not continually reassess and document their findings related to the complications of Patient A's right ankle fracture and the developing pressure ulcer. The facility did not provide assessments of patient's skin condition, pain level, or the circulatory/neurological integrity of the right lower leg as required.

The facility's multiple failures to: continually assess, identify care needs, obtain and carry out physician orders, and implement facility policies following a (10/03/05) fractured right tibia / fibula (ankle) resulted in Patient A's facility acquired pressure ulcer to the right foot. An auto (self) amputation of the right foot occurred on 11/28/05 and the patient expired on 12/15/05. The Certificate of Death for Patient A dated 12/23/05 indicated Patient A's immediate cause of death was "Sepsis With Pneumonia" and conditions leading to the cause of death were "Right Foot Gangrenous Lesions" and "Complication Of Right Ankle Fracture."

Patient A was an 89 year-old female, admitted on 05/14/04, with diagnoses which included a right fractured femur, dementia, atrial fibrillation and osteoarthritis. Patient A's comprehensive latest full Minimum Data Set MDS-(federally mandated assessment tool) of 12/14/04 and Quarterly MDS of 08/30/05 revealed that Patient A was totally dependent on staff for moving in bed, transferring to wheelchair, walking, bathing and toileting; as well as required extensive assistance for eating. These MDS assessments also documented that Patient A was nonverbal and sometimes understood what she was told. Under the Activities Section, the MDS documented that she was involved in Activities 1/3 to 2/3 of the time during waking hours. Under the Skin Section, the MDS data indicated that the patient had no skin breakdown in the past 90 days, no pressure sores, and had no skin lesions and no foot problems.

Review of the comprehensive MDS of 12/14/04, revealed that Patient A had triggered "Pressure Ulcer" risk on the Resident Assessment Protocol Summary Sheet (RAP-additional nursing assessment information). This part of the assessment revealed though Patient A had no current skin breakdown, she was at risk for pressure ulcers due to immobility and incontinence. The RAP Summary Sheet had a column checked that indicated the facility would "Continue to care plan with incontinence to prevent skin breakdown and maintain skin integrity." However, upon review of Patient A's care plans, there was no documented evidence that a care plan had been developed to prevent skin breakdown related to decubitus/pressure ulcer development, as documented on the RAP decision box of 12/14/04. A continued review of Patient A's care plans revealed that there had been no updating of the care plan after the Quarterly MDS review of 08/30/05, and no interventions noting the pressure ulcer risk and measures to be implemented by staff to prevent pressure ulcers from developing.

A review of the facility's undated policy for "Wound Care Protocol" indicated that "Any resident who is identified to have impaired skin integrity will be assessed and treated according to the protocols established by the facility."

On 10/03/05 at 6:30 a.m., a Nurse's Note written by a licensed nurse documented that the night shift charge nurse "informed me about Patient A's R (symbol for right) foot being possibly fx (fractured). Upon inspection R foot is flexed inward from below the ankle 45 (degrees) with bruising above the ankle." The licensed nurse documented that she notified the Nurse Practitioner (NP) working with the attending physician and a right foot x-ray was ordered. There was no documentation in the clinical record that Patient A was assessed for pain, or that a pain medication order was requested from the nurse practitioner. There was no documentation to indicate that the right foot was elevated or the nursing staff had asked for an order for ice to the foot. There was no documentation that orders for the care and treatment of the internally rotated, misaligned foot had been obtained. There was no documentation in the clinical record that nurses had assessed the internally rotated right foot color, sensitivity, temperature, and motion for neurological/circulatory integrity.

On 10/03/05 at 7:00 p.m. (twelve and a half hours later) a Nurse's Note documented that the right foot remained internally rotated (misaligned). There was no indication that a continuing assessment had been conducted to ensure the neurological and circulatory integrity of the right foot and that care was provided. There was no documentation that a pain assessment had been done to determine if increased pain medication might be required.

Review of the right foot x-ray report (dated 10/03/05, dictated at 6:44 p.m.) revealed that Patient A had "transverse fractures of the distal tibia and fibula" of the right leg. The x-ray report was documented to have been sent (faxed) to the facility on 10/03/05 at 7:31 p.m.

On 10/04/05 at 10:00 a.m. (twenty seven and a half hours since the injury was noted) documentation on the Nurse's Notes indicated that Patient A's right foot was bruised, swollen, red, and rotated inward. The facility attempted to notify the physician of x-ray results. At this time the licensed nurse also indicated that she gave the patient two Tylenol for pain (per an existing physician order for general pain). The physician called back on 10/04/05 at 11:44 a.m. The physician instructed the facility to make an appointment with the orthopedic clinic the next day (10/05/05) at 9:45 a.m. There was no documentation in the Nurse's Notes that the foot had been assessed for circulation and sensation, or that the doctor had been made aware of the condition/position (misalignment) of the foot or that orders for ice, elevation, or any other treatment were obtained.

[The internet reference article "Peripheral Vascular Injuries" on "emedicine" by Niels Rathlev MD dated 01/02/07, indicated that trauma injuries to the extremities may cause vascular injuries and if "Not recognized and treated rapidly injuries to major arteries, veins, and nerves may have disastrous consequences resulting in loss of life and limb." In addition this reference documented "The time interval between injury and evaluation must be considered. More than 6 hours of 'warm body' temperature- without cooling the extremity- results in irreversible nerve and muscle damage to patients."]

On 10/05/05, at 5:30 a.m., Nurses Notes continued with documentation that Patient A's right foot was bruised, swollen, red, and rotated inward. There was no documentation in the Nurse's Notes that indicated pain, circulation and sensation of the right foot was assessed.

Review of Patient A's care plans revealed that there had been no care plan development on 10/03/05 regarding the initial (unwitnessed) injury (misaligned foot), nor any updates to the care plan following 10/04/05 (after the x-ray revealed a foot fracture) regarding skin assessment for maintenance of circulatory and neurological integrity of the right lower leg/foot.

On 10/05/05, at 1:00 p.m. a Nurse's Note documented Patient A was seen in the orthopedic clinic and sent back to the facility with a "boot on the right leg with orders not to remove the boot unless during skin inspection..." There was no indication that the nursing staff had asked the physician regarding care and treatment of the immobilizing boot for Patient A.

Review of the physicians orders for October 2005 revealed an orthopedic physician's order dated 10/04/05, (probably misdated and written on 10/05/05) directed the nursing staff; "Do not remove E boot unless to inspect skin. Contact PCP (primary care physician) for skin condition @ the fx (fracture) site." [An E boot is a soft, padded, support boot often used initially with an ankle fracture to keep the ankle aligned and allow for swelling until it is decided if the ankle should be surgically repaired or that a full cast can be applied. The Mayo Clinic.com references that in the treatment of a broken ankle "doctors typically evaluate your injury and immobilize your foot or ankle with a splint... Restricting the movement of a broken bone in your foot or ankle is critical to healing". 04/23/07]

The facility had a policy in place at the time of Patient A's right ankle fracture and physician orders for boot/splint application, titled "Care of Resident in Cast" dated March 2000. This policy was reviewed by facility's Administrator on 11/01/06 and on interview stated this policy also applied to the care of residents with splints and immobilizer boots.

The policy documented the purpose was "to immobilize fractures, dislocations, and other injuries while healing occurs." This policy directed staff to "Keep casted limb elevated above the level of the heart as much as possible to minimize swelling." The policy also directed "Frequently assess neurovascular status." Among the directions listed were; "For instance, >inspect color of the extremity - pink, pale, cyanotic >in order to detect edema, note size of digits >simultaneously touch digits of affected and unaffected extremities and compare temperatures (hot, cold) >check capillary refill by pressing on the distal tip of one digit until it is white. Then release pressure and note how soon the normal color returns. It should return quickly >palpate distal pulses to assess vascular patency." The policy further directs staff to document in the progress notes, record results of neurovascular checks which includes cast condition, drainage/odor and skin condition.

On 10/05/05 at 2:00 p.m. a Nurse's Note indicated that the NP (Nurse Practitioner) had been in and given new orders for "Vicodin 1 tab for pain management." However review of the Nurses' Notes revealed that there had not been a continuing, ongoing assessment for the evaluation of Patient A's pain to the right foot nor skin assessment for the maintenance of circulation of the right lower leg as required per the facility's March 2000 policy titled "Care of Resident in Cast.

On 10/05/05 at 4:10 p.m. a Nurse's Note revealed "Will continue to monitor good C&S (circulation and sensation) to the R toes." However, the nurse did not document the current condition of the toes, or document if the boot had been removed to check skin condition as required per the facility's March 2000 policy titled "Care of Resident in Cast.

On 10/06/05 at 11:00 a.m., a Nurse's Note documented that "S/P (status post) fx L foot (with) splint in place." The note continued by stating "Will monitor (illegible) further swelling of L (symbol for left) foot (it was the right foot that had been fractured). There was no documentation that the right foot had been assessed for maintenance of circulation and neurological integrity of the right lower leg as required per the facility's March 2000 policy titled "Care of Resident in Cast. Review of Patient A's care plans revealed that there was no documentation regarding foot/boot instructions after the injury of 10/03/06, indicating what specific care was to be implemented regarding post fracture of the right foot such as: assessing for swelling, color, circulation, pain or numbness, etc. There was no care plan addressing how staff were to remove and reapply the "E boot" what clinical data was to be assessed in checking the condition of the skin under the boot; or the frequency for when the boot would be removed (for hygiene, and to assess pain, and the neurological integrity of the right lower leg.

On 10/09/05, at 3:00 p.m. (six and a half days after the initial injury), a licensed nurse noted that the skin to the right foot was checked, and there was black skin on the right heel and an 8 x 9 cm lesion with intact skin on top of the right foot. The 10/09/05 skin integrity sheet documented the right foot dorsal (top) had ecchymosis (bruising). These assessments of the injured area varied significantly. There was no documentation in the clinical record to indicate that prior to this date that anyone had removed the boot/splint to observe the skin.

The facility's undated policy titled "Wound Care Protocol" under the section "Wound and Pressure Ulcer Assessment" indicated that "all residents will be assessed using a uniform process assessment..." The purpose of the policy is identified "to provide assessment and documentation of wounds throughout the healing process". Procedures include "Assessment and documentation needs to include the following factors: >Anatomic location >Size (length, width, depth, tunneling, usually done in centimeters >Appearance of the wound bed and surrounding tissue >Pain or tenderness (may indicate infection, underlying tissue destruction, or vascular insufficiency)."

On 10/09/05 a "Pressure Ulcer Care Plan", was initiated by the facility and indicated that Patient A had an 8 x 9 cm (centimeter) black skin ulcer on the right heel. The only intervention at that time was a handwritten approach to apply Betadine to the right heel. The care plan did not address how staff was to remove and reapply the "E boot" and what clinical data was to be assessed in checking the condition of the skin under the splint; and the frequency when the boot would be removed for hygiene and skin assessment; pain assessment or the neurological integrity of the right lower leg.

On 10/10/05, a Physician's Progress Note written by the NP documented that she had been requested to see the resident (Patient A) secondary to "discolored skin on (symbol for right) leg." After examination the nurse practitioner documented that there was "redness on the right shin heel is black/necrotic/dry foot warm." The NP documented that the resident (Patient A) was being sent to the emergency room (ER) at the general acute care hospital (GACH).

The Springhouse publication titled "Nurse's Clinical Guide Wound Care" 3rd Edition 2005, described necrosis as dead, devitalized tissue and stated "Necrotic tissue must be removed before repair and healing can occur...Debridement involves removing necrotic tissue to allow underlying healthy tissue to regenerate." There was no documentation that wound debridement was attempted for Patient A.

Patient A's GACH clinical record was reviewed and revealed that she was admitted to the GACH on 10/10/05 and was treated for dehydration and possible sepsis. A WBC (White Blood Cell) count was done in the ER on 10/10/05 and was 18.1 (normal levels are 3.5 -12.5). According to the Addison-Westley publication "Laboratory and Diagnostic Test Handbook" 1996, An elevated WBC may indicate infection, inflammation, trauma, tissue necrosis..."

The attending physician (at the GACH) noted on the History and Physical, dated 10/10/05 that prior to this incident she (Patient A) had been fairly stable. He documented that at the nursing home, "The patient normally is up and about and is somewhat alert, but is aphasic..." and "She is a feeder and normally eats well."

An interview was conducted with Licensed Vocational Nurse 2 (LVN 2) on 10/13/06 at 10:30 a.m. LVN 2 stated that prior to the 10/03/05 fracture, although Patient A needed help, she usually ate well and enjoyed getting up to the dining room for meals. LVN 2 stated that Patient A was up and around the facility in a wheelchair most of the time during waking hours. She stated that although the resident was non-verbal, Patient A appeared to enjoy getting up, moving around the facility and going to activities

The Discharge Summary dated 10/13/05 from the GACH, the attending physician noted the following, "On admission, the patient was found to be profoundly ill..." He also noted that he had a long talk with the patient's son who thought that prior to this incident she had a good quality of life, she was "relatively happy" and had been stable for many years. The son had wished to treat the resident but not to include intubation or CPR. The physician noted that consequently she was admitted "and in fact has done well."

On 10/14/05, Patient A was re-admitted to the skilled nursing facility. The readmission Nurses Note dated 10/14/05, documented by the licensed nurse, that Patient A had a splint covered with an Ace bandage in place. However another Nurse's Note for 10/14/05, at 10:00 p.m. documented the right leg "cast" was in place. These assessments that described the right leg immobilizer varied during the same day.

The 10/19/05 MDS assessment for significant change documented that now Patient A was bedfast most or all of the time, had full loss of movement for one foot, totally dependent for bed mobility, was fully dependent on tube feedings for all nutrition, could not understand or be understood, and had an indwelling catheter. Documentation on the MDS Skin Condition Section also indicated that the resident had one Stage 4 pressure ulcer. (The 10/10/05 assessment of the right leg and foot documented by the NP, also mentioned redness of the right "shin". However this area was not mentioned on the re-admission MDS assessment).

The RAP sheet for the 10/19/05 MDS documented that Patient A was totally dependent for bed mobility and a care plan would be developed to "Provide all ADLs (Activities of Daily Living) and to avoid complications such as muscle wasting and contractures." Review of the care plans after the 10/14/05 admission, revealed that there was no care plan developed regarding avoiding complications related to the ankle fracture and the developing pressure ulcer such as assessing for hygiene and skin condition, pain, or the circulatory/neurological integrity of the right lower leg.

A pre-printed form titled "Care Plan on Continence/Elimination" dated as initiated on 10/19/05 was reviewed, and had a handwritten problem as "Risk for pressure ulcers." The goal of "Measurable Res (resident) Outcomes" was that the "Resident (Patient A) will be free from open areas daily X 3 months." There were no approaches written on the care plan other than the pre-printed approaches such as "Keep resident clean and dry, Provide good perineal care, Change res clothes when wet." There were no interventions specific to Patient A and the complicating factors (splint/cast care and skin breakdown) for the readmission of 10/14/05. There were no care plans identifying the necrotic right foot pressure ulcer (un-staged), which had been first identified in the facility on 10/09/05.

Continued review of the clinical chart and Nursing Notes revealed that there was no further documentation of the splint or condition of the right foot and leg until 10/24/05, at 2:30 p.m. (10 days after readmission) when a licensed nurse documented that the right foot was in a cast and the leg was within normal limits "above the knee." There was no documentation of the condition of the right leg under the splint or of the condition of the right foot and toes as required per the facility's March 2000 policy titled "Care of Resident in Cast and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

The Nursing Note on 10/26/05 at 2 p.m. revealed that a Licensed Vocational Nurse (LVN 1) documented that the right foot was in a splint wrapped with Ace bandage, and that she was unable to assess the right foot. LVN 1 documented she would ask the nurse practitioner (NP) to assess the foot. There was no documentation that the request to the NP had been done, and that the right foot was assessed.

Review of the Nursing Notes on 10/28/05 at 11:30 a.m. revealed that LVN 1 obtained an order from the physician to "Cleanse with NS (normal saline) & apply Accuzyme to necrotic area dorsal surface (top) QD (every day) x 1 month then reassess. Betadine paint apply to (symbol for right) heel necrosis QS (every shift) x 1 mon (month) then reassess then reapply the splint (symbol for right) foot." There was no clarification to this order as to how long the splint should be left off (for one month or re-applied every shift after painting with Betadine). There was no documentation in the Nurse's Notes or Treatment Administration Records that indicated the right foot was being treated with Accuzyme every day, or that the heel was being painted and re-assessed every shift. There were no treatment notes (Skin Integrity Sheet documentation) to indicate that this treatment was carried out.

The "US Department of Health and Human Services - Agency for Healthcare Research and Quality" clinical guidelines for pressure ulcer treatment document that antiseptic agents (such as Betadine) cause death of normal cells and stated "Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povodine iodine [Betadine], iodophor, sodium hypochlorite [Dakin's Solution], hydrogen peroxide, acetic acid). This reference also stated "Numerous studies, however, have documented the toxic effects of exposing wound healing cells to antiseptics."

Nursing Notes on 10/28/05, at 3:00 p.m., revealed that LVN 1 documented that the NP said it was okay to unwrap and assess the foot. At that time LVN 1 noted that there was necrosis on the top of the foot and right heel, and that she would refer the resident to the facility's Wound Consultant Nurse. There was no further documentation about the right foot until 11/02/05 at 9:00 p.m. (five days later); when a licensed nurse documented that the dressing was changed. There was no documentation regarding the assessment of the right decubitus/pressure ulcer including size, depth, color, drainage, and odor, foot circulation, neurological status, and pain levels as per the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

Review of the Nurse's Notes revealed that between 10/28/05 and 11/08/05 (eleven days), there was no documentation on the Nurse's Notes to indicate ongoing assessment regarding complications related to the ankle fracture and the developing pressure ulcer such as assessing for hygiene and skin condition or the circulatory/neurological integrity of the right lower leg as required per the facility's March 2000 policy titled "Care of Resident in Cast and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

Review of the Nursing Notes revealed that on 11/08/05, the Wound Nurse Consultant saw the patient and documented "Etiology of wounds unclear- per staff wounds caused from cast." The wound consultant identified a heel wound of 9 x 8.5 cm with thick necrotic tissue "Edges are loosening, minimal drainage..." She also identified a 14 x 11 cm wound on the ankle and a wound on top of the foot that was covered with black eschar (sloughing dead tissue). She noted three smaller areas on the foot as "intact black necrotic areas." The Wound Nurse Consultant recommended "referral due to severity of wound presentation." There was no indication that the wound consultant information had been passed on to the physician or that any new care or treatments were initiated. There were no new skin integrity sheets initiated that would describe the condition of the multiple ulcer areas as required per the facility's undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

The undated policy titled "Wound Care Protocol - The Healing Pressure Ulcer" provided by the Administrator and stated to be in effect at the time of the right ankle fracture (10/04/05) documented, "If a pressure ulcer fails to show evidence of progress towards healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated." ... "If deciding to retain the current regimen, the rationale for continuing the present treatment will be documented (e.g. why some, or all, of the plan's interventions remain relevant despite little or no apparent healing.)"

A Nursing Note on 11/09/05 at 1:30 p.m., by LVN 1 revealed that the Wound Consultant Nurse was notified regarding the necrosis of the right foot. In this note, LVN 1 documented that there was a 9 x 8.5 cm area of hard, black skin on the heel and open area on top of the foot that was 14 x 11 cm. LVN 1 noted there was no pedal pulse for the right foot. [The "Emergency Medicine Magazine" Volume 37, 2005 titled Common Fractures of the Knee and Lower Leg stated that a key aspect of evaluating neurologic and vascular status is monitoring of the pedal pulse. This article documented "Findings such as absent or decreased pulse should prompt immediate orthopedic consultation for vascular evaluation."]

An un-timed Physician's Progress Notes written by the NP, dated 11/09/05, indicated "dry leathery necrotic tissue on ant. (anterior) aspect of foot with necrotic R (right) heel..." This note also documented that the NP had discussed surgical treatment and podiatrist care of the pressure ulcers with Patient A's son and "Son OK for both. Will send referrals."

The internet resource Medline Plus Medical Encyclopedia provided the following documentation for treatment of gangrene (death of tissue in a part of the body); "In general, dead tissue should be removed to allow healing and prevent further infection." This source listed treatment options as: > An emergency operation to explore or remove dead tissue > Amputation of the affected body part > Repeated operations to remove dead tissue (debridement) > An operation to improve blood supply to the area > Antibiotics > Treatment in the intensive care unit for severely ill patients."

An 11/10/05 Physician's Progress Note at 12 noon, by the "Attending MD" documented Patient A's right lower leg had "Extensive necrosis, front and back of ankle, black eschar." The attending MD listed treatment as: "No CPR (cardiopulmonary resuscitation), No transfer to hospital, No re-insertion of the NG tube (naso-gastric tube- inserted through the nose down the esophagus for nutrition) if it comes out. OK to attempt ABX (antibiotics) x 1 only for next infection, Will leave cast off, do wound care locally." The MD also stated he had discussed this with the son. There were no orders documented to control pain and prevent progression of tissue damage and invasive infection. The physician orders did not provide for palliative care measures such as pain management to prevent Patient A from persistent or severe pain or care and cleansing of the wound to reduce the foul smelling discharge. There was no care plan documented on the clinical record to indicate that that end of life "comfort care" (palliative care) was addressed.

The internet article from ElderCare Online documented that the palliative care goal is to offer ways for the patient to be comfortable, ease pain and other physical discomfort. Palliative care helps the patient and family as the illness gets worse and strives to offer the best quality of life possible during this time.

Review of Patient A's clinical record revealed that from 11/09/05 until 11/21/05 (twelve days), there were no Nurse's Notes that documented the status of the resident's right foot/leg pressure ulcer areas or the circulatory/neurological integrity of the right lower leg as required per the facility's March 2000 policy titled "Care of Resident in Cast and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

On 11/21/05 documentation in the Nurse's Notes indicated the right heel was still necrotic and the top of the foot was open. It was also noted "Prognosis poor." There were no further Nurse's Notes that documented the status of the resident's right foot/leg pressure ulcer areas or the circulatory/neurological integrity of the right lower leg including the absence or presence of a pedal pulse as required per the facility's March 2000 policy titled "Care of Resident in Cast and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment".

An 11/25/05 Progress Note by the NP documented that Patient A grimaced whenever moved or if the right foot was touched and that she had a prn order for Vicodin. This note also documented "R foot is cold, mottled, (sign for no) pulses, covered with gauze, R ankle/foot not in alignment (symbol for secondary) to fx (fracture).

The Skin Integrity Sheet of 11/28/05 documented that right foot was black and "Foot falls off, dislocated, poor circulation." An interview with a Treatment Nurse (LVN 1) involved in the care of Patient A was conducted on 11/01/06 at 11:30 a.m. LVN 1 was asked the exact meaning of "foot falls off" as described on the Skin Integrity Sheet of 11/28/05. LVN 1 stated that if she had lifted the leg up without supporting the foot, the foot would have separated from the leg. She also stated the foot/leg was infected and that the odor from the wound in Patient A's room was so bad, they had to keep the door closed and use a fan to try to keep the odor from the nurse's station and other rooms.

On 12/01/05, a Physician's Progress Note documented "Pt (patient) seen, (symbol for right) foot imminent to auto-amputate." There were no Physician Progress Notes prior to the "auto-amputation" that described that this was the intended goal for Patient A's right foot.

Documentation on the 12/05/05 Skin Integrity Sheet revealed, right foot "foul odor foot falls off & dislocates." On 12/12/05 the Skin Integrity Sheet documented that the whole foot was black and "foul odor, foot dislocated gangrene." Neither note included an indication that the physician was notified of the worsening condition of the right foot and no new treatment orders were obtained or implemented.

On 12/15/05 a nurse's note at 11:00 a.m., documented that Patient A had expired. The Certificate of Death for Patient A dated 12/23/05 indicated Patient A's immediate cause of death was "Sepsis With Pneumonia" and conditions leading to the cause of death were "Right Foot Gangrenous Lesions" and "Complication Of Right Ankle Fracture."

The Department determined that the facility failed to:

1. Initially and continually assess Patient A's care needs following a 10/03/05 right foot transverse fracture and the subsequent development on 10/09/05 of a pressure ulcer of the right heel and right upper foot, which became necrotic, infected, and gangrenous.

2. Develop and update care plans which identified the initial and continuing care needs of Patient A following a 10/03/05 a right foot transverse fracture and the subsequent development on 10/09/05 of a pressure ulcer of the right heel and right upper foot, which became necrotic, infected, and gangrenous.

3. Provide treatment and services to prevent the formation and progression of pressure ulcers from 10/03/05 to 11/28/05 when the facility did not identify the deteriorating condition of Patient A's pressure ulcers, notify the physician when the right foot pressure ulcer treatment was not effective in order to provide opportunity to change treatment and interventions. This resulted in an auto-amputation of the right foot.

4. Follow their March 2000 policy titled "Care of Resident in Cast and the undated policy titled "Wound Care Protocol" "Wound and Pressure Ulcer Assessment" when they did not continually reassess and document their findings related to the complications of Patient A's right ankle fracture and the developing pressure ulcer. The facility did not provide assessments of patient's skin condition, pain level, or the circulatory/neurological integrity of the right lower leg as required.

The Department determined that the above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Patient A.