Health inspection·March 13, 2023

42 CFR 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-- (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. 42 CFR 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. 22 CCR 72311 Nursing Service-General (a) Nursing Service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 2/16/22, the California Department of Public Health conducted an unannounced visit at the facility to investigate a complaint which alleged a licensed nurse failed to immediately consult with Resident 1's physician after a significant change in his physical and mental status, that licensed staff did not monitor Resident 1's physical condition following the event, and that staff did not notify a family member of Resident 1's clinical status when he was no longer able to make his own medical decisions. The investigation validated Resident 1 experienced a hypoglycemic (low blood sugar level) event on 10/29/20 at 12:54 p.m. This event required emergency treatment by ambulance staff with intravenous (administered directly into the vein) medication. Resident 1 remained in the skilled nursing facility after emergency hypoglycemic treatment. The facility failed to ensure licensed nurses conducted blood sugar monitoring and change of condition physical assessments after the hypoglycemic event. This failure resulted in Resident 1 experiencing a second hypoglycemic episode later that day (10/29/20) at 6:00 p.m. The second event required emergency transport to a general acute care hospital (GACH) emergency department (ED) and resulted in hospitalization and care in the intensive care unit (ICU-a unit that cares for patients with potentially life-threatening medical conditions) for nine days with diagnoses of hypoglycemia and sepsis (a potentially life-threatening condition caused by the body's response to an infection). During a telephone interview on 2/17/21, at 7:43 a.m., Family Member (FM) 1 stated she received a telephone call from Social Service Assistant (SSA) 2 on 10/20/20, to discuss Resident 1's planned discharge from the facility. FM 1 stated SSA 2 called the day of discharge, 10/29/20, to request FM 1 transport Resident 1 from the facility. FM 1 stated she was not informed of Resident 1's change in condition during the telephone call. FM 1 stated she arrived at the facility on 10/29/20 in the late afternoon. FM 1 reported a staff member met her in the facility parking lot and requested she sign Resident 1's discharge paperwork. FM 1 stated a few minutes later SSA 2 and a nurse (she did not know the nurse's name) came out to the facility parking lot and told her Resident 1 had been very sick all day and refused to go to the GACH ED. FM 1 stated she instructed the staff members to send Resident 1 to the ED. FM 1 stated when Resident 1 was evaluated at the ED, GACH 1 staff notified her that Resident 1 had sepsis, and an infection in his kidneys and bladder. FM 1 further stated Resident 1 required transfer to a second GACH (GACH 2) and admission to an ICU for sepsis. During a record review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnosis), dated 2/17/21, the document indicated Resident 1 was an elderly male admitted to the facility on 10/9/2020. Resident 1's diagnoses included, "COVID-19 [a serious contagious respiratory infection transmitted from person to person] ... Type 2 Diabetes Mellitus [a disease which affects the body's ability to utilize sugar that results in elevated blood sugar levels which can lead to more rapid development of infections], Diabetic Chronic Kidney Disease [decrease in kidney function caused by damage to kidney blood vessels from high blood sugars] ... Heart Failure [the heart muscle does not pump well] ..." During a record review of the Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 10/16/20, the assessment indicated Resident 1's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation, and memory recall) score was 8, which indicated moderate cognitive impairment. BIMS scores range from a low of one to a high of 15, a low score indicates more severe cognitive status. During a concurrent interview and record review on 2/17/21, at 12:51 p.m., with Minimum Data Set Coordinator (MDSC), Resident 1's clinical record was reviewed. Resident 1's progress note titled, "General Note," dated 10/29/20, at 12:30 p.m., indicated, "...CN [charge nurse] went into pt [patient-Resident 1] room ... Before lunch CN went to check on pt, pt was drowsy, not alert and was not responding. Called [ambulance company], 2 EMTs [emergency medical technicians- ambulance technicians] arrived and checked bs [blood sugar] 31 [according to professional reference - normal range blood sugar levels were 70-99 mg/dL (milligrams/deciliters- unit of measurement)]. [Ambulance staff] gave pt [name of medication used to raise blood sugar level in the body] IV ... Pt refused to be transferred to hospital ... SBAR [Situation-Background-Assessment-Recommendation- an assessment tool for communication between healthcare members] faxed to MD [medical doctor]." During review of Resident 1's progress note titled, "...Change in Condition Evaluation," dated 10/29/20, at 12:54 p.m., it indicated under Mental Status Evaluation, "Altered level of consciousness ... Sudden change in level of consciousness [state of being awake or aware of surroundings] or responsiveness ... most recent blood glucose [the main sugar found in the blood]... 31 ... [MD] ... notification 10/29/20 1:53 p.m., [via FAX-facsimile]...Recommendation of Primary Clinician ... pending ..." MDSC stated the SBAR was faxed to the physician and according to the documentation there was no response from the physician. MDSC stated she reviewed Resident 1's clinical record and was unable to find any documentation which indicated Resident 1 had received a nursing assessment or monitoring before, or during his episode of low blood sugar of 31 mg/dl at 12:30 p.m. MDSC stated Resident 1's clinical "General Note" dated 10/29/30, at 12:30 p.m., had no documentation to indicate the nurse called MD to immediately notify him, nor to FM1 regarding Resident 1's "dangerously" low blood sugar. MDSC stated the nurse should have called the physician immediately for a low blood sugar treatment order and should have notified FM1 of his medical condition. During a record review of Resident 1's progress note titled, "General Note," dated 10/29/20, at 6:30 p.m., the General Note indicated, "...pt's blood sugar was 32 .. pt unresponsive [not reacting to stimuli such as speaking or pain] ...pt is moving extremities but no verbal response ... [FM1] is here to pick up patient [for discharge] informed her of pt condition she said to call 911 ..." During a concurrent interview and record review, on 2/17/21, at 2:59 p.m., with the Director of Nursing (DON), Resident 1's " SBAR Summary for Providers," dated 10/29/20, at 12:54 p.m., was reviewed by the DON. The DON stated Resident 1 was found with altered level of consciousness on 10/29/20 and the licensed nurse called emergency services. She stated when the EMTs arrived Resident 1's blood sugar was 31mg/dL. The EMTs gave him (medication) to raise his blood sugar and were going to transport Resident 1 to the ED for evaluation. She stated Resident 1's condition was considered an emergency, life threatening, and Resident 1's decision making ability was impaired, and he was unable to make health care decisions. The DON further stated the nurse should have called the doctor immediately and sent Resident 1 to the ED, and FM 1 should have been notified immediately. She stated the nurses did not follow change of condition assessment procedures. The DON stated when FM 1 was at the facility on the evening of 10/29/20 to pick up Resident 1 for discharge, Resident 1 had a second episode of hypoglycemia with altered mental status and FM 1 instructed staff to transfer him to the ED. During a telephone interview on 2/18/21, at 9:14 a.m., with SSA 2, SSA 2 stated she spoke with FM 1 on 10/20/20 to discuss his scheduled discharge on 10/29/20. SSA 2 stated the next time she spoke with FM 1 was by telephone on 10/29/20 to set up a discharge time for the same day. SSA 2 stated FM 1 arrived to pick up the resident on the evening of 10/29/20 and waited in the parking lot. SSA 2 stated she went with Licensed Vocational Nurse (LVN) 1 to pack Resident 1's belongings and found Resident 1 in his bed unresponsive. SSA 2 stated she was not aware Resident 1 had a change of condition earlier in the day. SSA 2 stated if she had been informed, she would not have called FM 1 and set up a discharge time for Resident 1. SSA 2 stated LVN 2 entered Resident 1's room and started checking him while SSA 2 went with LVN 1 to notify FM 1 that Resident 1 was not feeling well and not ready for discharge. During a telephone interview on 2/22/21, at 10:40 a.m., with LVN 1, she stated on 10/29/20 at 12:30 p.m., she went to check Resident 1's blood sugar and found him not responsive. LVN 1 stated she did not check Resident 1's blood sugar after finding him unresponsive. LVN 1 stated she called an ambulance. When the EMTs arrived at 12:54 p.m., they checked Resident 1's blood sugar and it was extremely low, 31mg/dL [mg/dL- milligram/deciliters- unit of measurement]. LVN 1 stated the EMTs gave the resident intravenous medication to raise his blood sugar. LVN 1 stated while the EMTs were helping Resident 1, she asked Resident 1 if he wanted to go to the ED with the EMTs and Resident 1 refused. LVN 1 stated she believed Resident 1 did not want FM 1 notified because he was worried it would delay his discharge. LVN 1 stated Resident 1 was not transferred to the ED on 10/29/20 at 12:54 p.m. LVN 1 stated she believed Resident 1 would have been appropriate for discharge if his blood sugars were stable on 10/29/20. LVN 1 stated as she looked back at Resident 1's medical condition and his altered mental status, FM 1 should have been notified when Resident 1 had the first episode of low blood sugar at 12:54 p.m., because Resident 1 was unable to make decisions for himself due to his altered mental status. LVN 1 stated she did not call the physician and instead sent a fax to the physician to inform him that Resident 1 had a change in his condition and a low blood sugar of 31 mg/dL on 10/29/20 at 12:54 p.m. LVN 1 stated she did not receive a response from the physician and was unsure the physician received her fax. She stated Resident 1 remained in the facility after the low blood sugar of 31mg/dL event. LVN 1 stated she should have conducted a follow up change of condition assessment, but she did not do it. LVN 1 stated the failure to transfer Resident 1 to the hospital may have been the cause for Resident 1's second hypoglycemic incident on the evening of 10/29/20. During a telephone interview on 2/22/21, at 2:19 p.m., with the DON, she stated she reviewed Resident 1's clinical record and according to a Nursing Note dated 10/29/20, at 12:54 p.m., Resident 1 was found nonresponsive and not capable of making a medical care decision. She further stated the nurse should have contacted FM 1 when Resident 1 had the first hypoglycemic episode at 12:54 p.m., on 10/29/20. The DON stated after the EMTs treated Resident 1 for hypoglycemia at 12:54 p.m., the facility policy indicated nurses were to conduct an assessment and monitor Resident 1's physical condition frequently until he was stable, which did not occur. The DON stated she would have expected the nurses to conduct nursing assessments at least every 30 minutes, which did not occur. The DON stated she reviewed Resident 1's Medication Administration Record (MAR) dated 10/29/20, and the evening shift nurse did not perform Resident 1's blood sugar check at 4:30 p.m., in accordance with the physician order. The DON reviewed Resident 1's MAR and stated Resident 1's blood sugar check was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m, and 9:30 p.m. She stated she was unable to find any documentation to indicate why Resident 1's blood sugar was not checked at 4:30 p.m., on 10/29/20. She further stated Resident 1's hospitalization could have been avoided if the nurse had called the physician and obtained orders for treatment to prevent the second hypoglycemic episode, and if the evening nurse had checked Resident 1's blood sugar at 4:30 p.m., as scheduled. The DON stated Resident 1's usual blood sugar ranged from 70 md/dl to 298 mg/dl, and blood sugars of 31 or 32 mg/dL were dangerously low. During a telephone interview with LVN 2 on 3/1/21 at 3:01 p.m., she stated on 10/29/20 Registered Nurse (RN) 1 asked her to check Resident 1 because he had low blood sugars earlier in the day (at 12:54p.m.). LVN 2 stated she went to Resident 1's room at approximately 6 p.m. and saw LVN 1 with SSA 2 in the room attempting to wake Resident 1, who was not responsive. LVN 2 stated Resident 1 was scheduled for discharge and FM 1 was waiting for him in the facility parking lot to transport him home. LVN 2 stated she sent LVN 1 and SSA 2 to tell FM 1 he was not responsive. LVN 2 stated FM 1 requested Resident 1 be transferred to the ED right away, which was done. LVN 2 stated she reviewed Resident 1's clinical record, which indicated his blood sugar was not checked at 4:30 p.m., as directed by the physician order. LVN 2 stated FM 1 should have been notified of his change in medical condition when Resident 1 had the first hypoglycemic event, but that did not occur. During a record review of Resident 1's physician orders titled, "Order Review Report," dated October 2020, the document indicated, "...blood glucose fingerstick [small blade to draw blood from the fingertip for testing] monitoring QID [four times daily] before breakfast, lunch, dinner, & HS [bedtime] ..." During a record review of Resident 1's GACH 1 ED physician notes, untitled, dated 10/29/20, at 8:07 p.m., the notes indicated, "...72-year-old male who was brought in by ambulance to the ED with c/o [complaints of] low blood sugar ... impression/diagnosis ... 1. Acute bladder outlet obstruction [blockage preventing urine from exiting the bladder] ...2. acute [sudden onset] gross hematuria [moderate, visible blood in the urine] ... 3. acute cystitis [inflammation of the bladder, caused by infection and accompanied by frequent painful urination] ... 4. sepsis ... Medical decision ... patient presents ... unresponsiveness which is presumably due to low blood sugar ... Patient will require transfer [to another hospital, GACH 2] ... will require evaluation by urology [physician who specializes in diseases of the genitourinary tract (kidneys, and bladder)] ... critical care statement ... real possibility of a deteriora