Other·October 5, 2023

The following reflects the findings of the California Department of Public Health during an abbreviated, extended survey of complaints. Event ID: SHQV11 Class AA Citation Representing the Department of Public Health- 41119, RN, HFEN. 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: (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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which includes the care to be given, the objectives to be accomplished and the professional responsible for each element of care. Objectives shall be measurable and time-limited. (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. 22 CCR  72313 - Nursing Service -Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. On 11/2/22, at 9:16 a.m., an unannounced visit was initiated at the facility to investigate Facility Reported Incident (FRI): CA00809584 which alleged a resident death in the facility on 10/29/22. The investigation validated the allegation when multiple facility failures were identified. 1. Licensed nurses failed to assess, recognize, and act on the clinical changes to Resident 7 on 10/28/22. Licensed Nurses failed to determine the need for a higher level of care and to notify the MD for Resident 7's change in condition and clinical decline. 2. Resident 7 was admitted with known insulin (a medication used to control blood sugar) dependent diabetes mellitus (body's inability to produce insulin) and known history of diabetic ketoacidosis (DKA - serious life-threatening complication of diabetes that can lead to death). Resident 7 experienced episodes of vomiting, refusing fluids and meals, and refusing medications. The change of condition and clinical decline were not communicated to the physician. Insulin was not administered as ordered for high blood sugar, and high blood sugars were not rechecked after readings of 388 mg/dl (milligrams per deciliter [a unit of measure]). 3. Licensed nurses did not develop and implement a person-centered comprehensive care plan for the diagnosis of Diabetic Ketoacidosis (DKA) despite a history of multiple hospitalizations due to DKA. 4. Pharmacy recommendations regarding Resident 7's insulin medication was not communicated to the MD. 5. The MD's order dated 8/29/22, for laboratory (lab-facility that performs blood test) testing for a hemoglobin A1C (tests which average blood sugar levels over 2-to-3-month period) was not carried out. These violations were a substantial factor in the death of Resident 7. Resident 7 was found unresponsive and died at the facility on 10/29/22. Resident 7's "Face Sheet" (FS), indicated, Resident 7 was admitted to the facility on 5/30/18, and after a hospital stay, re-admitted to the facility on 8/29/22 , with diagnoses that included Diabetes Mellitus (elevated blood sugar) with Ketoacidosis (excess blood acids) and long-term use of insulin. Resident 7's "Minimum Data Set" (MDS- a resident assessment tool used to identify mental and physical functioning) assessment dated 8/12/22, indicated Resident 7's Brief Interview for Mental Status (BIMS) score was "0" out of 15, which indicated severe cognitive impairment- [memory loss, poor decision making-skills]. Resident 7's General Acute Care Hospital (GACH) "Discharge Summary" (DS), dated 8/29/22, indicated, Resident 7 was discharged with a diagnosis of diabetic ketoacidosis (DKA). The DS indicated on 8/12/22, Resident 7 was transferred to the GACH from the facility for decreased intake of food, medication, and vomiting. The DS indicated, "patient was also hospitalized in 3/2022 and 5/2022 for DKA as well, presumably due to inadequate insulin regimen." Resident 7 was discharged to the skilled nursing facility on 8/29/22, with resolved hyperglycemia (high blood sugar). Resident 7's "Progress Note" dated 9/16/22, indicated, " pt BS [blood sugar] has been running high...On the last insulin check for my shift 1700 [5 p.m.] his BS was still high, I [licensed nurse] checked BP [blood pressure] and it was 68/49 and I asked CNA [Certified Nurse Assistant] if he was acting as he [meaning Resident 7] usually does, she stated "no, he usually eats dinner and he did not eat. I [licensed nurse] called 911 and, 911 is taking him to [hospital] in Fresno." Resident 7's "GACH DS", dated 9/23/22, indicated Resident 7 was admitted with a diagnosis of DKA. His BS was 1454 mg/dl (normal range 80-130 mg/dL) and his Hgb [red blood cell protein that carries oxygen] A1C [blood test that measures average sugar levels over past three months] was 9.1 (normal range is below 5.7). The DS indicated Resident 7 was discharged to the skilled nursing facility on 9/23/22 with a diagnosis of DKA. During an interview on 11/2/22, at 10:30 a.m., Licensed Vocational Nurse (LVN) 1 stated, CNA 2 and CNA 6 informed her that Resident 7 vomited on 10/28/22. LVN 1 stated that on 10/28/22, she observed Resident 7 self-induce [putting fingers in throat] vomiting on the bed twice and described the appearance as dark brown, pasty texture, and approximately half a cup in size. LVN 1 stated she did not document the vomiting in the progress note and did not initiate a change of condition but should have. LVN 1 stated, CNA 2 informed her that Resident 7's behavior was not his norm. LVN 1 stated, on 10/28/22, Resident 7 was restless, refusing his meal and refusing his oral medications. LVN 1 stated she should have called the physician for the change of condition but did not. During an interview on 11/2/22, at 10:54 a.m., CNA 2 stated, she worked the 10/28/22 A.M. shift and was assigned to care for Resident 7. CNA 2 stated, she observed Resident 7 vomit before breakfast and before lunch. CNA 2 stated she observed Resident 7 place his fingers in his mouth to self-induce vomiting which was not his norm. CNA 2 stated Resident 7 would normally eat his food but refused his meals that day. CNA 2 stated, Resident 7 had constant movement and took off his blanket. CNA 2 stated, she informed both LVN 1 and CNA 6 regarding Resident 7's changes because she felt "something was wrong". During an interview on 11/2/22, at 11:17 a.m., CNA 5 stated, she was familiar with Resident 7 and worked the morning shift on 10/28/22. CNA 5 stated, Resident 7 would normally drink a lot of water. On 10/28/22, she offered him water and he refused. The CNA stated, she offered Resident 7 breakfast and lunch, and he refused both trays as well as feeding assistance. CNA 5 stated, on 10/28/22, she observed Resident 7 placing his fingers in his mouth to self-induce vomiting. The CNA stated, she was not a nurse but felt Resident 7 was declining. CNA 5 stated, she felt something was wrong and informed LVN 1 that Resident 7's behavior was unusual. During a telephone interview on 11/2/22, at 4:38 p.m., with CNA 6, CNA 6 stated, she worked on 10/28/22, and was assigned to Resident 7 on PM shift. CNA 6 stated, during change of shift CNA 2 informed her to keep a close watch for Resident 7 as he did not eat, had vomited, and placed his fingers in his mouth to self-induce vomiting. The CNA stated, Resident 7 vomited before dinner and after dinner during her shift. The vomit was "watery", cup sized and brown in color. CNA 6 stated, Resident 7 refused his dinner and did not drink water when offered. The CNA stated, she cleaned Resident 7 and informed LVN 1 that he vomited. CNA 6 stated, she stayed overtime and worked the night shift. At approximately 4:30 a.m. on 10/29/22, when she was changing the water pitcher, she checked on Resident 7. His eyes were closed and appeared "lifeless". CNA 6 stated, she informed the Director of Staff Development (DSD) of Resident 7's changes at approximately 4:30 a.m. During a concurrent interview and record review on 11/4/22, at 1:45 p.m., with the Medical Records Director (MRD), the MRD reviewed the progress notes and stated there was no progress note indicating change of condition, physician notification or assessment done on 10/28/22. During a concurrent interview and record review on 11/4/22, at 2:29 p.m., with LVN 1, the facility Policy and Procedure (P&P) titled "Change in a Resident's Condition or Status" dated 5/2017, was reviewed. The P&P indicated, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition... 1.The nurse will notify the resident's Attending Physician or physician on call when there has been a(an):...significant change in the resident's physical/emotional/mental condition...3.Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR [situation, background, assessment, recommendation] 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status... " LVN 1 stated, the facility policy and professional standards were not followed when significant change in Resident 7's physical condition was not reported to the physician and there was no charting. During a concurrent interview and record review on 11/7/22, at 9:21 a.m., with the Director of Staff Development (DSD), the DSD stated, she worked from 11p.m. to 7:00 a.m. on 10/28/22. She was the nurse assigned to care for Resident 7. The DSD stated, she did not complete her documentation for the change of condition because she got busy. The DSD stated, she did not review Resident 7's chart before starting her shift but should have because she was unaware of Resident 7's medication refusal and not receiving his scheduled dose of insulin. The DSD stated, if she had reviewed Resident 7's chart she would have seen that Resident 7's blood sugar was 388 mg/dl two consecutive times and no BG (blood glucose) recheck was done. The DSD stated, Resident 7's refusal of medication, vomiting, and missed dose of insulin should have been reported to the physician but was not. The DSD stated, the nurse should have completed a change in condition and notified the physician but did not. During a review of Resident 7's "Ambulance Report " (AR), dated 10/29/22, the AR indicated, " ... On Scene: 04:44 a.m. ...64 y/o [year old], apneic [stop breathing], and pulseless. Pt was pronounced dead at 0448 ... " Resident 7's "Physician Orders" included an order starting 8/29/22, as follows: "...Insulin Lispro [fast-acting Insulin] 100 Units/Ml -Inject as per sliding scale: If 0-150=0 units If Blood Sugar is below 60 mg/dl Follow Diabetic Protocol and Notify MD; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401-500-12 units. If Blood Sugar is above 400 mg/dl Give 12 units and Notify MD, subcutaneously before meals related to Diabetes Mellitus due to underlying condition with ketoacidosis without coma." During a concurrent interview and record review with the MRD, on 11/2/22, at 1:03 p.m., Resident 7's Medication Administration Record's (MAR's) dated 8/2022 - 10/2022, indicated Resident 7's Blood Sugar was above 400 mg/dl. The MRD validated Insulin was not administered. The MRD validated there was no documented evidence the physician was notified for blood sugar readings of greater than 400 mg/dl per physician order on the following dates and times: 8/30/22 at 5:30 p.m. Blood sugar was 450 mg/dl. There was no documented evidence the physician was notified per physician order. 9/9/22 at 5:30 p.m. MRD stated that since there were no licensed staff initials in the box, that indicated the Insulin was not administered and there was no blood sugar level obtained. 9/28/22 at 7:30 a.m. Blood sugar measured 500 mg/dl and at 11:30 a.m. blood sugar measured 408 mg/dl. There was no documented evidence the physician was notified per physician order. 10/5/22 at 11:30 a.m. The MRD stated that since there were no licensed staff initials in the box, that indicated the Insulin was not administered and there was no blood sugar level obtained. There was no documented evidence the physician was notified per physician order. 10/10/22 at 9:00 p.m. The MRD stated that since there were no licensed staff initials in the box, indicated the Insulin was not administered and there was no blood sugar level obtained. There was no documented evidence the physician was notified per physician order. Centers for Disease Control and Prevention (CDC), article "Diabetic Ketoacidosis", reviewed March 25, 2021, indicated the following: "...DKA is a serious complication of diabetes that can be life-threatening...DKA develops when your body doesn't have enough insulin to allow blood sugars into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body...Causes of DKA Very high blood sugar and low Insulin levels lead to DKA. The two most common causes are: Illness... Missing Insulin shots..." Resident 7's "GACH DS", dated 8/29/22, indicated, Resident 7 was discharged from the GACH to the facility with a diagnosis of diabetic ketoacidosis (DKA). Resident 7's "GACH DS", dated 9/23/22 , indicated Resident 7 was admitted to the GACH with a diagnosis of DKA. Centers for Disease Control and Prevention (CDC), article "Diabetic Ketoacidosis", indicated the following: "...DKA is a serious complication of diabetes that can be life-threatening...Elevated ketones are a sign of DKA, which is a medical emergency and needs to be treated immediately." During a concurrent interview and record review on 11/7/22, at 9:33 a.m., with the DSD, Resident 7's "Care Plan" (CP) dated 4/16/22, was reviewed. The CP indicated," ...The resident has Diabetes Mellitus...The resident will be free from any s/sx [signs/symptoms] of hyperglycemia [elevated blood sugar] ...Administer medications as per MD orders. Monitor/document for side effects and effectiveness." The DSD stated, there was no revised interventions since 4/16/22, related to diabetes and there was no care plan developed for the diagnosis of DKA, following two hospital visits on 8/12/22, and 9/16/22, related to DKA. The diagnosis of DKA should have triggered the development of a care plan or a revision to the diabetes care plan. The DSD stated, the importance of the care plan was to alert staff of Resident 7's high risk of DKA, interventions to follow, and alert the staff on guidance regarding Resident 7's care. The facility policy and procedure titled, "Care Plans, Comprehensive Person-Centered", undated, indicated the following: "...8. The comprehensive, person-centered care plan will: ...g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; ...o. Reflect currently recognized standards of practice for problem areas and conditions ...13. Assessm