Health inspection·October 3, 2023

F710 Physician Services 483.30 A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. California Code of Regulations, Title 22, Section 72523 Administrative 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 5/31/23, at 9 a.m., the California Department of Public Health (CDPH) made an unannounced visit at the facility to investigate two anonymous complaints regarding the lack of care Resident 1 received while at the facility. Resident 1's anticoagulant medication was not reordered after Resident 1's surgery was cancelled and rescheduled for a later date, leading to Resident 1 missing four doses of his medication and developing a DVT (deep vein thrombosis [blood clot]). As a result, Resident 1 was hospitalized and underwent an invasive procedure, placement of an inferior vena cava (IVC) filter (to prevent movement of blood clot into lungs). Based on interview and record review, the facility failed to provide orders for 1 of 3 sampled residents (Resident 1) to meet Resident 1's immediate care and needs. During a review of Resident 1's "Admission Record," dated 5/31/23, the Admission Record indicated that Resident 1 was a 24-year-old male admitted to the facility on 5/5/23, with diagnoses which included unspecified fracture (broken bone) of upper end of left tibia (shin bone), encounter for other specified surgical aftercare and encounter for prophylactic (preventative) measures. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/12/23, indicated Resident 1 was able to think and reason. During a review of Resident 1's Order Recap Report (ORR) dated 5/6/23, the ORR indicated, "[Name of first anticoagulant medication] Injection Solution Prefilled Syringe 30MG [milligrams, a unit of measure]/0.3ML [milliliter, a unit of measure] Inject 30 mg. subcutaneously [beneath the skin] two times a day for DVT prophylaxis until 5/12/23 OK to give the dose on the day of surgery." Resident 1's anticoagulant medication was written to be given up on the original date of his surgery, 5/12/23. During a review of Resident 1's Nursing Progress Note (NPN), dated 5/12/23, 4:54 a.m., the NPN indicated, "Resident went to Orthopedic [branch of medicine dealing with bone deformities] surgery appt. via gurney at around 4:14 a.m. in stable condition." Resident 1's NPN dated 5/12/23, 6:14 a.m., indicated, "Resident returned from Ortho [orthopedic] Surgery appt. Per patient and transport the pre-op center said that surgery was rescheduled to 5/22/23." No re-order of Resident 1's anticoagulant medication was given after his surgery was rescheduled. During an interview on 5/31/23 at 3:00 p.m., via phone, Resident 1 stated, "My surgery for 5/12/23 at [hospital name] was cancelled but they sent me anyway. The hospital sent me back and said my surgery would be 5/22/23. When I got back, they stopped my blood thinner, and I developed pain in my leg." Resident 1 signed out of the facility AMA (against medical advice) on 5/17/23 and his family took him to (hospital name). "I had an infection in my leg and a blood clot in my leg." Resident 1 remained in the hospital and had the re-scheduled surgery performed on 5/22/23 and was discharged home 5/28/23. During an interview and record review on 6/1/23, at 12:30 p.m., with Nurse Practitioner (NP), NP stated the (name of first anticoagulant medication) should have been renewed on 5/12/23 after the cancelled surgery but there was no order from the surgeon to do so. NP acknowledged she was responsible for writing medication orders for residents in the facility. During a review of Resident 1's ED (emergency department) Provider Notes (EDPN), dated 5/17/23, the EDPN indicated, "Exam for warmth and mild tenderness over left lower extremity [leg]. CT [computerized x-ray] of the lower extremity with contrast notable for DVT and surrounding cellulitis. [Name of second anticoagulant medication] drip ordered." During a review of Resident 1's Internal Medicine Daily Progress Note (IMPN) dated 5/19/23, the IMPN indicated, "status post [meaning after] IVC filter placement with IR [interventional radiology] today, as he has LLE [left lower extremity] DVT and want to prevent embolization [movement] of clot during surgery." During a review of Resident 1's Discharge Summary (DS), dated 5/28/23, the DS indicated, "...initially treated with [name of second anticoagulant medication] then switched to [name of third anticoagulant medication]. Discharged with [name of third anticoagulant medication] ensure that is taken for at least 6 months, prior to discontinuing, consider re-imaging...IVC filter retrieval when indicated." A review of the facility's policy titled, "Physician Services," dated February 2021, indicated, "once a resident is admitted, orders for the resident's immediate care and needs can be provided by a physician...nurse practitioner...Supervising the medical care of residents includes [but is not limited to]: participating in the resident's assessment and care planning...prescribing medications and therapy." Based on interview and record review, the facility failed to provide orders for 1 of 3 sampled residents (Resident 1) to meet Resident 1's immediate care and needs. Resident 1's anticoagulant medication was not reordered after it was given up on Resident 1's original surgery date, yet his surgery was cancelled and rescheduled for a later date, leading to Resident 1 missing four doses of his medication and developing a DVT. As a result, Resident 1 was hospitalized and underwent an unnecessary invasive procedure (placement of an IVC filter). This violation presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1.