Health inspection·October 10, 2024

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was provided dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) care and services consistent with professional standards of practice when: Residents Affected - Few 1. Resident 1 was unable to attend his scheduled dialysis session and his make-up dialysis session due to transport being unavailable; and, 2. Resident 1's monthly labs from the dialysis center were not available in Resident 1's medical record. The failure of unavailable transportation led to a delay in dialysis care for Resident 1 with a potential to alter Resident 1's health status. The failure to include Resident 1's labs in his medical record had the potential for a lapse in Resident 1's care between the facility and the dialysis center. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2022 with diagnoses that included hypertension, end stage renal disease (chronic disease where the kidneys are permanently damaged and can no longer function) and dependence on dialysis. During a review of Resident 1's Electronic Health Record (EHR), in the orders section, indicated Resident 1 would attend scheduled hemodialysis (a process of filtering the blood of a person whose kidneys are not working normally) sessions three times a week. The specific days were Monday, Wednesday, and Friday at 2 PM. The order indicated Resident 1 was to be picked up at 1:30 PM by .[name of transportation company] . During an interview on 9/6/24, at 1:25 PM, with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 1 did not go to his scheduled dialysis session on 8/16/24. The ADON stated Resident 1's next dialysis session was made for 8/19/24. During an interview on 9/6/24, at 1:33 PM, with Licensed Nurse (LN) 1, LN 1 stated Resident 1 had missed a regularly scheduled dialysis session due to transportation issues. LN 1 further stated she would have preferred to make an appointment for a make-up session on the same day a resident missed a session or as soon as possible. During an interview on 9/6/24, at 2:08 PM, with LN 2, LN 2 stated dialysis was very important. LN 2 Page 1 of 3 055039 055039 10/10/2024 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated it was concerning that Resident 1 went four days without receiving dialysis treatment. LN 2 further stated four days was a long wait and that a make-up session should have occurred the very next day after a missed session. During an interview on 9/6/24, at 2:19 PM, with LN 3, LN 3 stated there could be many complications that occur with missing dialysis appointments. During an interview on 10/10/24, at 12:55 PM, with the Nursing Secretary (NS), the NS stated she did not try calling the two private transportation and ride-sharing companies to request services for medical transport. The NS further stated she did not call an ambulance for an emergency pick-up either. The NS stated she did not notify the resident's family for a possible pick-up as well. During a phone interview on 10/11/24, at 2:25 PM, with the Primary Doctor (PD), the PD stated she could not recall if anyone called her from the facility regarding Resident 1 missing his dialysis appointment. During a concurrent interview and record review on 10/10/24, at 2:50 PM, with the DON and LN 6, a facility contract titled, NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated 1/16/2024 was reviewed. The DON confirmed the facility was responsible for providing transportation for residents to and from the dialysis center. During a phone interview on 10/16/24, at 3:25 PM, with the Dialysis Nurse (DN) 1, DN 1 stated Resident 1 did not attend his scheduled dialysis session on 8/16/24 due to transport not being available at the facility. A review of an undated facility policy and procedure titled, PRE AND POST DIALYSIS MONITORING, in the section Before Dialysis Procedure, indicated, .If resident is cleared to go to dialysis center, arrange transportation services and secure transfer information for the dialysis center . 2. During a concurrent interview and record review on 10/10/24, at 1:50 PM, with LN 6, LN 7, and the DON, Resident 1's [ dialysis center] Labs, dated 4/29/24 to 5/29/24 were reviewed. LN 6 stated labs were being done at the dialysis center monthly for Resident 1. LN 6 confirmed the facility did not have any lab results for Resident 1 since 5/29/24. The DON stated the charge nurses were responsible for reviewing the labs. The DON further stated the PD would review the labs only if they were critical values (abnormal lab values that require a physician's attention) and did not review them monthly. During a phone interview on 10/11/24, at 2:25 PM, with the PD, the PD stated she did not review the monthly labs for Resident 1. The PD further stated that unless labs were critical, she would not review them. The PD stated she did not order a monthly lab draw for Resident 1 because he got them done at the dialysis center. During a phone interview on 10/16/24, at 3:25 PM, with the Dialysis Nurse (DN) 1, DN 1 stated the facility had to request labs from the dialysis center to view them. DN 1 further stated Resident 1 was getting labs drawn monthly as well some labs were drawn every two weeks. DN 1 stated Resident 1's last lab draw was on 8/14/24. A review of an undated facility policy and procedure titled DIALYSIS CARE, in the section Procedures, indicated, .Information such as the following, shall be documented on resident's medical record 055039 Page 2 of 3 055039 10/10/2024 Good Samaritan Rehab and Care Center 1630 N. Edison Street Stockton, CA 95204

F 0698 .Laboratory tests as indicated . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055039 Page 3 of 3