Other·March 21, 2024

CLASS A - 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 services- 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. (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. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. 22 CCR § 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. On 2/12/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to ensure quality of care for Resident 51, who was a newly admitted patient that required diabetic medication including insulin shots for a diagnosis of diabetes mellitus (DM - a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high). The facility failed to provide nursing services, such as notifications, ongoing assessments, and treatment as prescribed, when: * Resident 51's physician was not notified of at least six hypoglycemic (low blood sugar) episodes, which were sudden and/or marked adverse change in her signs, symptoms, or behaviors. * Resident 51 received multiple oral diabetic medications without continuous assessment of the patient's need for the medication with input (as necessary) from health professionals, such as physicians and pharmacists, involved in the care of the resident. * On 1/22/2024 and 1/24/2024 the facility failed to administer insulin as prescribed and did not check Resident 51's blood sugar, which is necessary prior to the administration of insulin. * Resident 51's blood sugar was not monitored at least twice daily in accordance with the standard of practice as stated by facility staff, such as Resident 51's physician, the pharmacy, director of nursing and licensed nurses. * Nursing staff did not notify the physician of Resident 51's repeated episodes of blood sugar that was less than 70, as required by the facility's policies and procedures entitled "Diabetic Care" and "Hypoglycemia" and the physician's orders. As a result, Resident 51 became unresponsive, was sent to the hospital, and was diagnosed with sulfonylurea induced hypoglycemia (a class of medications used for the treatment of non-insulin dependent diabetes mellitus which can cause significant hypoglycemia after the ingestion of one or two pills), and polypharmacy (simultaneous use of multiple drugs for the same ailment or condition). Findings: A record review of Resident 51's undated Admission Record indicated that Resident 51 was admitted to the facility on 1/10/24 with diagnoses that included diabetes mellitus [DM]. Resident 51 was 85 years old. A review of Resident 51's minimum data set (MDS- an assessment tool), dated 1/17/24 indicated a BIMS (brief interview for mental status - a tool to screen and identify the cognitive condition of residents) score of 1.0 which indicated severe cognitive impairment. A record review of Resident 51's physician orders, dated January 2024 indicated the following and for the following medications: * Glimepiride (a diabetic medication) 4 milligrams (mg), 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. * Insulin glargine (a diabetic medication) inject 10 units subcutaneous (under the skin) at bedtime for DM ordered on 1/10/24 at 10:14 P.M. * Sitagliptin (a diabetic medication) 50 mg 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. * Pioglitazone (a diabetic medication) 50 mg, 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. The physician's orders indicated that if blood glucose fell below 70 or above 350, the facility staff should notify the MD. The orders did not include parameters or instructions for the frequency of blood sugar monitoring Resident 51's blood sugar and did not address monitoring before medication administration. A record review of Resident 51's January 2024 medication administration record (MAR) indicated the following blood sugar results: * On 1/11/2024 at 9:00 P.M., blood sugar was 56. * On 1/20/2024 at 9:00 P.M., blood sugar was 60. * On 1/21/2024 at 9:00 P.M., blood sugar was 65. * On 1/22/2024 at 9:00 P.M., blood sugar was blank. * On 1/24/2024 at 9:00 P.M., blood sugar was blank. * On 1/29/2024 at 9:00 P.M., blood sugar was 41. * On 1/30/2024 at 9:00 P.M., blood sugar was 48. * On 1/31/2024 at 9:00 P.M., blood sugar was 43. A joint record review of Resident 51's nursing progress notes and MAR was conducted during an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/20/24 at 2:21pm. and indicated the following: * On 1/11/24 at 9:51 P.M., Resident 51's blood sugar was 56. The nurse initiated the facility's hypoglycemia protocol (interventions to reverse low blood sugar). The DON stated there was no documented evidence that Resident 51's M.D. was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. * On 1/20/24 at 8:10 P.M., Resident 51's blood sugar was 60. The nurse initiated the facility's hypoglycemia protocol. The DON stated there was no documented evidence that Resident 51's M.D. was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. * On 1/21/24 at 8:45 P.M., Resident 51's blood sugar was 65. The nurse initiated the facility's hypoglycemia protocol. The DON stated there was no documented evidence that Resident 51's M.D. was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. * On 1/22/24 at 10 P.M., the DON stated Resident 51's blood sugar result was not documented on the MAR. According to the progress notes, "Insulin glargine 10 units at bedtime held d/t (due to) BS results outside of normal of BS parameter less than 60. The DON stated there was no documented evidence that Resident 51's M.D., was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. * On 1/24/24, the DON stated there was no documentation on the MAR and progress notes to show that Resident 51's blood sugar was checked. * On 1/29/24 at 9:48 P.M., Resident 51's blood sugar was 41. The DON stated there was no documented evidence that Resident 51's MD was notified regarding the resident's low blood sugar. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. * On 1/30/24 at 9:44 P.M., Resident 51's blood sugar was 48. The DON stated there was no documented evidence that Resident 51's MD was notified regarding the resident's low blood sugar. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. On 1/31/24 at 5:29 P.M., Resident 51's son came to the facility and found Resident 51 unresponsive. Resident 51's blood sugar result was 43. The nurse called 911 and transferred Resident 51 to the hospital. The DON stated when caring for a resident experiencing a hypoglycemia episode, the nurses should monitor the residents blood sugar, conduct a pre and post assessment of the residents condition, follow the facility's hypoglycemia protocol (give half (1/2) cup of orange juice , 1/2 cup of soft drinks, 1 cup of milk, 1/2 cup of apple juice, or other item with 15-30 grams of carbohydrates- calories and to continue offering the resident carbohydrates until blood sugar is above 70), notify the MD and document the incident in the resident's medical record. The DON stated all the above were important to ensure that the resident care needs were addressed. The ADON stated she should have communicated Resident 51's multiple diabetic medications when the resident was first admitted to the facility. The ADON stated medication review should have been done due to Resident 51's multiple diabetic medications to avoid hypoglycemia episodes. A record review of Resident 51's hospital history and physical, written by a physician, dated 2/8/24, indicated, "... Upon review of the patient's chart, the patient had a lot of medications for diabetes. She has insulin on board... I believe that polypharmacy is playing a significant role in the patient becoming hypoglycemic...". Per the same history and physical, Resident 51 was diagnosed with sulfonylurea induced hypoglycemia and polypharmacy. An interview on 2/15/24 at 7:25 A.M., with licensed nurse (LN) LN 35 was conducted. LN 35 stated Resident 51's blood sugar needed to be monitored at least twice a day or more frequently due to the resident's history of low blood sugar. An interview with the facility's medical doctor (MD) 1 for Resident 51 was conducted on 2/15/24 at 7:45 A.M. MD 1 stated the use of multiple diabetic medications without monitoring the resident's blood sugar could lead to hypoglycemia. MD 1 stated that residents diagnosed with DM should have their blood sugar monitored more than twice daily. MD 1 stated the nurses should have notified him of Resident 51's low blood sugar. An interview with LN 31 was conducted on 2/15/24 at 7:52 A.M. LN 31 stated Resident 51 was sent out to the hospital early this morning for a low blood sugar. An interview with the facility's Pharmacy Consultant (PC) was conducted on 2/15/24 at 8:06 A.M. The PC stated that Resident 51's blood sugar should have been checked twice daily or more since Resident 51 was on multiple diabetic medications. An interview with LN 34 was conducted on 2/20/24 at 11:24 A.M., LN 34 stated that Resident 51's MD should have been notified of Resident 51's low blood sugars and documented in the progress notes. LN 34 stated if the care was not documented, then the care was not done. A review of the facility's undated policy and procedure titled, "Hypoglycemia" was conducted. The policy indicated that when the resident's blood sugar is less than 70mg/ml the attending physician must be notified. If there are repeated episodes of hypoglycemia on sequential days, the nursing staff needs to ensure that the physician is aware for possible change in treatment. It also states that for "Severe Hypoglycemia" the nursing staff need to notify the attending physician immediately, monitor the resident closely, checking fingerstick and vitals every 15 minutes until stable or transferred, and document all interventions as ordered and implemented. A review of the facility's undated policy and procedure titled, "Diabetic Care" was conducted. The policy states that an attending physician will write parameters for notification when blood sugar is out of control and that the attending physician must be notified when a resident's blood sugar is less than 70. A Licensed Nurse must also monitor the resident's blood glucose per the attending physician's order and administer medication as indicated. The facility failed to provide quality of care for Resident 51 when: * Resident 51's physician was not notified of at least six hypoglycemic episodes, which were sudden and/or marked adverse change in her signs, symptoms, or behaviors. * Resident 51 received multiple oral diabetic medications without continuous assessment of the patient's need for the medication with input (as necessary) from health professionals, such as physicians and pharmacists, involved in the care of the resident. * On 1/22/2024 and 1/24/2024 the facility did not check Resident 51's blood sugar, which is necessary prior to the administration of insulin, and failed to administer insulin as prescribed. * Resident 51's blood sugar was not monitored at least twice daily in accordance with the standard of practice as stated by facility staff, such as Resident 51's physician, the pharmacy, director of nursing and licensed nurses. * Nursing staff did not notify the physician of Resident 51's repeated episodes of blood sugar that was less than 70, as required by the facility's policies and procedures entitled "Diabetic Care" and "Hypoglycemia" and the physician's orders. As a result, Resident 51 became unresponsive, was sent to the hospital, and was diagnosed with sulfonylurea induced hypoglycemia and polypharmacy. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 51.