Every finding on record at Kaiser Foundation Hospitals

The following represents the findings of the California Department of Health during an abbreviated survey for complaint number 2668181 conducted on 11/06/2025. The following condition of participation was not met: 484.54 Condition of participation: Comprehensive Assessment of Patients- See tag G510

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on interview and record review the home health agency’s licensed staff did not complete a full assessment for one of three sampled patients (Patient 1) when staff did not assess the skin under Patient 1’s cervical collar. This resulted in pressure ulcers (skin breakdown) and unnecessary hospitalization. Record review of the agency’s policy and procedure titled “Ongoing Assessments” dated 4/13/2023 showed “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits.” Record review of Patient 1’s clinical document “Home Health Plan of Care” dated 9/4/2024 showed Patient 1’s Start of Care was 9/4/2024 with the current certification period 9/4/2024 to 11/2/2024. Diagnoses included a stroke. Cognitive functioning showed Patient 1 required “…Considerable assistance in routine situations. Patient 1 is not alert and oriented or is unable to shift attention and recall directions more than half the time. Skin assessment showed “Patient presents with impaired skin integrity, a positive score per Braden Scale and insufficient equipment to maintain skin integrity.” (Braden Scale: used to assess a patient’s risk for developing pressure ulcers) Interventions included daily skin inspections. Record review of Patient 1’s clinical document “OASIS Start of Care” dated 9/4/2024 showed Patient 1 wore a cervical collar around his neck due to a C1 fracture. (C1: cervical fracture of the spine). There were no documented interventions/goals regarding the collar. Record review of Patient 1’s clinical document “Skilled Nursing Visit(s)” (SNVs) showed visits took place on 9/12/2024, 9/26/2024, and 10/4/2024. There was no documentation in the clinical record which showed Patient 1’s skin had been assessed under the cervical collar. During a concurrent interview and record review of Patient 1’s document “Skilled Nursing Visit(s) on 11/6/2025 at 12:32 p.m. with the Senior Director for Home Health (SDHH), the SDHH confirmed there was no documentation which showed staff had assessed the skin under the collar. The SDHH stated “Even if they have a collar that is to remain on at all times, the skin still needs to be assessed.” Record review of Patient 1’s clinical document “Skilled Nursing OASIS Transfer W/Out DC” dated 10/7/2024 showed Patient 1 had transferred to the hospital for a “Suspected Infection.” Record review of Patient 1’s clinical document “ED Provider Notes dated 10/6/2024 showed Patient 1 arrived at the ED (Emergency Department) with family reporting “Drainage and skin breakdown on the right side of neck.” A family member reported to the ED physician they had noticed the sore 2 days ago and had asked the home health nurse to evaluate it but “They never did.” Several attempts were made to interview RN 1 without success. Record review of Patient 1’s clinical document “Discharge Summary” dated 10/16/2024 showed Patient 1 presented to the ED on 10/6/2024 with “Right submandibular and clavicular wounds 2/2 pressure from cervical collar.” Patient 1 was admitted to the hospital and treated with IV (intravenous) antibiotics and wound care. He was discharged 10/15/2024. Record review of Patient 1’s clinical document “OT Evaluation” visit dated 9/5/2024 showed Patient 1’s primary diagnosis was fracture of the first cervical vertebrae. The OT documented “After patient assessment and discussion with the patient’s caregiver the following goals were identified: pressure ulcer prevention, to make transfers easier for caregivers. Neck brace: In place.” There was no further description of the skin under the brace or condition of the support pads. Review of the visit notes dated 9/13/2024 showed Occupational Therapist 1 (OT 1) documented “OT instructed caregivers in application of Aspen collar (cervical collar) and replacing pads as patient has been wearing Aspen collar since hospitalization and pads soiled. OT demonstrated and caregiver return demonstrated.” Review of the visit notes on 9/23/2024 showed “Family declines need to demonstrate aspen collar pad changing this visit as report no issues.” During an interview on 11/13/2025 at 9:11 a.m. OT 1 stated skin integrity was to be checked by any staff member visiting the patient. OT 1 stated the collar was removable and held closed by Velcro. OT 1 stated if OT sees any skin breakdown anywhere on a patient’s body, they take a picture and notifies the doctor. OT stated they would then arrange for the Registered Nurse to see the patient for a more in-depth assessment of the wound.

The following reflects the findings of the California Department of Public Health during a Recertification survey conducted from 6/27/23 through 6/30/23. Representing the Department: Health Facilities Evaluator Nurses: 32717 and 44946 The unduplicated census was 3,264. Sample size was 17. There was one deficiency. (See Tag G682).

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure that infection control procedures were followed during wound treatment for one of 17 sampled patients (Patient 1). The registered nurse (RN) did not sanitize hands and change gloves during the wound care dressing change and applied ointment directly to the wound from the tubing. This failure had the potential to result in cross contamination and spread of infection. During a review of Patient 1’s “Home Health Certification and Plan of Care," dated 5/24/23, indicated Patient 1's start of care date was 5/24/23 with diagnoses, including type 2 diabetes mellitus (condition that affects the way the body processes blood sugar), other chronic osteomyelitis (infection of the bone), personal history of diabetic foot ulcer (open wound that occurs in patients with diabetes), acquired absence of right foot, diabetic neuropathic arthropathy (bone and joint changes that occur due to loss of sensation), and acquired absence of other left toes. During an observation on 6/28/23 at 1:06 p.m., in Patient 1’s home, RN 1 did not change her gloves and did not perform hand hygiene after removing the old dressing and cleaning the wound and before putting on the clean dressing on the left anterior (front) leg wound. During an observation on 6/28/23 at 1:10 p.m., RN 1 did not change her gloves and did not perform hang hygiene after removing the old band-aid and cleaning the wound and before putting on the new, clean band-aid on the left middle toe wound. RN 1 applied the Iodosorb (antibacterial agent which cleans the wound, reduces pain, and speeds up the healing process) ointment directly to the wound from the tube and the tip of the Iodosorb tube touched the wound upon application. During an interview on 6/28/21 at 1:14 p.m. with RN 1, RN 1 stated gloves should be changed and hand hygiene should be performed after removing an old dressing and cleaning, and before applying on a new dressing. During an observation on 6/28/23 at 1:18 p.m., RN 1 did not change her gloves and did not perform hand hygiene after removing the old dressing and cleaning the wound, and before putting on the clean dressing on the left lateral (side) of the foot wound. During an interview on 6/29/23 at 9:00 a.m. with the Quality Coordinator (QC), QC stated after taking off the old dressing and cleaning the wound, the gloves should be taken off and hand hygiene performed prior to putting on new gloves and placing the new dressing on the wound to prevent contamination. During an interview on 6/29/23 at 9:10 a.m. with the Home Health Site Director (HHSD), HHSD stated the ointment should be squeezed out from the tube before application and the tube should not touch the wound to prevent contamination. HHSD further stated the outside of the tube is not clean, and it might be contaminated. During a review of Patient 1’s “Care Plan (CP)," which indicated wound # 12 is a diabetic ulcer located on the left lateral foot and treatment order is to cleanse wound with normal saline, pat dry with gauze, leave open to air, may cover with dry dressing and secure with transparent adhesive dressing. During a review of Patient 1’s “Care Plan (CP)”, the CP indicated that wound # 13 is a neuropathic ulcer located on the left 2nd toe and treatment order is cleanse with normal saline, oat dry, apply Iodosorb gel to wound bed when available, cover with Band-Aid when available. During a review of Patient 1’s “Care Plan (CP)”, the CP indicated that wound # 15 is a diabetic ulcer located on the left anterior leg and treatment order is cleanse wound with normal saline, pat dry with gauze, may apply skin prep to peri wound (surrounding area of the wound edge), cover wound with foam dressing. During a review of the agency’s document titled, “Wound Care Assessment and Treatment," dated 2/10/23, that indicated, “Critical Elements: Performs hand hygiene, don gloves; removes and discards soiled dressing in plastic bag while maintaining clean field throughout procedure; doffs gloves, performs hand hygiene; dons gloves, cleans the wound with normal saline solution or another prescribed wound cleanser; doffs gloves, performs hand hygiene; dons gloves, applies ordered wound treatment/dressing to wound.” During a review of the agency’s policy and procedure (P&P) titled, “Topical skin drug administration, home care,” dated May 22, 2023 indicated, “Applying lotion, cream, or ointment: Using an applicator or your gloved hand, apply the prescribed amount of medication to the affected area.”