Health inspection·December 4, 2024

The following reflects the findings of the California Department of Public Health during a Recertification Survey and the investigation of one complaint, Incident # CA00922445. Survey Event ID: EEGB11. State Citation B was written. Code of Federal Regulations, Title 42, Section§ 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. California Code of Regulations, Title 22, Section 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 indicates the care to be given, the objectives to be accomplished and the professional discipline 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 10/1/24 at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to complete a recertification survey and to investigate one complaint regarding resident care. The Department determined the facility failed to ensure Resident 596 received quality care when, Resident 596, who was diabetic (inability for the body to regulate blood sugar/glucose levels) and received insulin (injectable medication used to control/regulate blood sugar/glucose levels) and oral anti-diabetic medications, 1. Experienced injuries from an unwitnessed fall resulting from low blood sugar levels on 9/20/24; 2. Exhibited signs of confusion and altered level of consciousness (a change in a person's state of awareness) and a licensed nurse did not implement emergent nursing interventions to assess Resident 596's blood glucose (BG) level on 9/20/24; 3. A licensed nurse did not inform Emergency Medical Services (EMS, ambulance/fire/police) of Resident 596's diabetic diagnosis or when she had her last dose of Lantus (Insulin) on 9/20/24; and, 4. Resident 596's Attending Physician (AP) did not ensure she had orders for BG monitoring and testing. These failures led to Resident 596 being treated by EMS for a critically low blood sugar level of 20 (normal blood sugar range is 70-100), being admitted into the intensive care unit (ICU, a special care unit within a hospital for the critically ill), and resulted in Resident 596 having two seizures (a temporary, abnormal burst of electrical activity in the brain that can cause physical changes in behavior). Review of Resident 596's "ADMISSION RECORD," indicated Resident 596 was initially admitted to the facility on 9/12/24, with diagnoses including but not limited to diabetes. Review of Resident 596's "Admission Readmission Screen and Baseline Care Plan 4.2," dated 9/12/24, indicated Resident 596 was admitted from Hospital B and was alert, orientated, and verbally appropriate. Review of Resident 596's physician orders from Hospital B, dated 9/12/24, indicated "...continue all attached orders for 30 days...or until reviewed by SNF [Skilled Nursing Facility] Attending Physician...Diabetes Orders...Finger stick blood glucose [BG-blood test used to determine blood sugar level] qAC [before meals] and qHS [before bedtime]...Notify Physician for Change in Condition...Fingerstick Blood Sugar: Notify provider if two BG results are <70 [less than] or > 400 [greater than] in a 24-hour timeframe and/or change in condition; if no condition change, notify provider on the next business day. Notify provider of...any hypoglycemic [low blood sugar] event..." During a telephone interview on 10/4/24, at 1:31 p.m., LN 4 stated she was the admitting nurse for Resident 596 when she first came to the facility on 9/12/24. LN 4 stated she did not put in the portion of the orders which outlined the BG testing/parameters when she entered Resident 596's anti-diabetic medication orders. Further review of Resident 596's SNF physician orders from Hospital B, dated 9/12/24, indicated Resident 596 was ordered routine intermediate acting insulin (Humulin-an injectable anti-diabetic medication which is between a short acting and long-acting insulin) twice per day (morning and evening), and two oral anti-diabetic medications (Glipizide and Metformin). Attached to the Humulin insulin orders were orders to check Resident 596's BG level. During a concurrent interview and record review on 10/3/24, at 4:16 p.m., LN 3 stated she remembered rounding (looking at residents) with Resident 596's Attending Physician (AP) on 9/13/24. LN 3 stated she remembered the AP changed Resident 596's insulin orders and oral anti-diabetic orders verbally. A review of Resident 596's medication administration record (MAR) for September 2024, with LN 3 indicated Humulin insulin (injectable medication used to control/regulate blood sugar/glucose levels) was changed to Lantus insulin (long acting injectable medication used to control/regulate blood sugar/glucose levels) and when the Humulin insulin order was changed on 9/13/24, there were no more orders for Resident 596's BG to be checked. Further review of the MAR with LN 3 indicated the AP discontinued Resident 596's order for oral Glipizide (oral medication that directs your body to store blood sugar) and doubled the order for oral Metformin (oral medication used to help lower blood sugar levels). LN 3 confirmed the last time Resident 596 had her BG tested was on 9/13/24, one day after admission and no new orders to check Resident 596's BG were written by the AP. LN 3 confirmed she changed Resident 596's orders based on the verbal orders of the AP during rounding. Review of Resident 596's "Baseline Care Plan Summary," (a plan of care developed within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 9/13/24, did not indicate a diabetic diagnosis nor mention any of Resident 596's anti-diabetic medications used to treat Resident 596's diagnosis of diabetes. During a concurrent interview and record review on 10/4/24, at 9:41 a.m., the AP stated Resident 596 was admitted to the facility on 9/12/24 and she came into the facility to evaluate Resident 596 on 9/13/24. The AP stated Resident 596 was on a very high dose of insulin twice per day and she recalled telling Family Member (FM) 1 that Resident 596 could not handle the high doses of insulin, including Humulin. The AP stated her BG was controlled when she was at the hospital, so she decided to change the Humulin to Lantus, and then doubled her dose of Metformin. The AP confirmed she did not write orders for BG monitoring or write orders for a sliding scale (the amount of insulin a person would receive depending on their BG result using a scale ordered by the physician). The AP stated it was a system failure. The AP stated Resident 596 was underweight and continued to receive insulin without BG monitoring and this led to the resident having a fall and a change of condition in the facility. The AP confirmed she should have written orders for Resident 596 regarding hypoglycemia (blood sugar level drops too low) and hyperglycemia (blood sugar levels are too high) management, and parameters including a sliding scale (indicates how much insulin to take before each meal dependent on the blood sugar level), and when to inform the physician as part of diabetic management. The AP stated it might have been an oversight on her part. The AP stated she should have gone over Resident 596's orders more carefully. When asked what the risk to Resident 596 was, the AP stated the risk would be death, seizures, or a hypoglycemic event. Review of Resident 596's clinical progress note titled, "Change of Condition," dated 9/20/24, indicated Resident 596 was found lying on the floor with blood coming from her mouth and was transferred to Hospital A via ambulance. Further review of the progress note did not indicate emergent nursing interventions were implemented to assess Resident 596's BG level after the fall. Review of Resident 596's Hospital A's emergency department note, dated 9/20/24, indicated, "...presents from nursing home for found down on ground with concerns of hypoglycemia found to have glucose of less than 20 [normal BG is 70-100] by EMS [can include police/fire/ambulance] given D10 [sugar water given through a vein for treatment of hypoglycemia]...Patient had facial trauma with some blood noticed on her oropharynx [the middle section of the throat, located behind the mouth]...Became more awake and alert, however remains non-verbal on route after glucose given...diabetes on Lantus as well as metformin...unclear if she has been having recent episodes of hypoglycemia...Patient herself is nonverbal unable to get history from patient...Unable to perform ROS [review of symptoms]: Mental status change..." Review of Resident 596's Hospital A transfer summary, dated 9/21/24, indicated, "...presents with severe hypoglycemia in 20's noted at nursing home with patient found on ground seizing [seizure] per report and oral trauma and abrasion to right knee and left foot..." Resident 596 was initially transferred to Hospital A after her fall and was then transferred to Hospital B for further care and treatment. Review of Resident 596's Hospital B transfer summary, dated 9/26/24, indicated, "...presented to [Hospital A] on 9/20 due to a ground-level fall at nursing facility. Patient was noticed to be hypoglycemic by EMS with a glucose less than 20...Patient reportedly had seizure episode twice and was started on Keppra [medication used to treat seizures]...MRI [Magnetic resonance imaging, medical imaging test that produces detailed images of almost every internal structure in the human body] of brain was suggestive of signal abnormality [abnormal electrical activity in the brain]...new onset seizures and involuntary movements...jerks of the right upper extremity...Per neurology [medical specialty that focuses on the diagnosis and treatment of disorders of the brain, spinal cord, and nerves] who evaluated the patient...seizures were triggered by severe hypoglycemia...Reason for Hospital Admission...seizures due to hypoglycemia..." During an interview on 10/4/24, at 12:24 p.m., Licensed Nurse (LN) 1 stated she was Resident 596's LN on 9/20/24 and stated around 2 a.m. the certified nurse assistant (CNA) called for her and she found Resident 596 on the floor, next to her bed and there was blood coming from her mouth. LN 1 stated Resident 596 was alert but not acting normal. LN 1 stated Resident 596 was very lethargic (tired/weak). LN 1 stated she checked Resident 596's blood pressure, oxygen level, and immediately called 911 for EMS. LN 1 confirmed she was aware Resident 596 was diabetic but did not take Resident 596's BG level after the fall. LN 1 stated she did not inform the EMS team who arrived that Resident 596 was diabetic or taking insulin. LN 1 stated it would have been important to inform EMS of Resident 596's diabetic status as they would have been able to treat her more immediately. LN 1 stated when she had a new resident, she would review their orders, but she did not get a chance to look at Resident 596's medical history or her orders during her shift on 9/20/24. LN 1 explained it was important to review the clinical record of the resident she was providing nursing care to, so she knew about the patient to provide appropriate care. LN 1 stated she could have given Resident 596 glucagon IM (intramuscular; an emergency medicine used to treat severe hypoglycemia administered into a muscle) to treat her hypoglycemia if her BG level was known. LN 1 stated it was important to follow hypoglycemia protocol because this would have helped to treat Resident 596's low BG level and would have prevented further decline of the resident. During an interview on 10/2/24, at 10:41 a.m., FM 1 stated Resident 596 came into the facility following a Urinary Tract Infection (UTI, an infection of the urinary system) and was receiving physical therapy to help her with her strength and was set to be released from the facility on 9/24/24. FM 1 stated she received a phone call on 9/20/24 around 2:30 a.m. from Resident 596's nurse who told her Resident 596 had a seizure and was being rushed to the hospital. FM 1 stated the hospital told her Resident 596's blood glucose was below 20. FM 1 stated Resident 596 had never experienced that low of a BG level. FM 1 stated she spoke with LN 4 on 9/23/24 and she told her Resident 569 had a seizure at the facility, and facility staff had not been checking her blood sugars. FM 1 stated Resident 596 had never experienced low blood sugar and had never experienced a seizure prior to this. FM 1 stated Resident 596 still had slight tremors to her right arm and hand and could not open her mouth completely. Review of a facility Policy & Procedure (P&P) titled, "Admission Criteria," dated 3/2019, indicated, "...Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least...medication orders, including (as necessary) a medical condition or problem associated with each medication; and ...routine care orders to maintain or improve the resident's function until the physician and care planning team conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan...Residents are admitted to this facility as long as their needs can be treated adequately by the facility. Examples of condition that can be treated adequately in this facility include...diabetes..." Review of a facility P&P titled, "Specific Medication Administration Procedures," dated 4/2008, indicated a goal of, "...to administer medications in a safe and effective manner..." Review of a facility P&P titled "Nursing Care of the Resident with Diabetes Mellitus," revised 12/29/18, indicated, "...The purposes of this guideline are [sic] to: 1. Review the most common and serious conditions and complications associated with diabetes ...3. Prevent recurrent hyperglycemia/hypoglycemia ...4. Recognize, manage, and document the treatment of complications commonly associated with diabetes...Hypoglycemia...Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following...weakness, dizziness, or faintness ...irritability or bizarre changes in behavior ...numbness of the tongue and lips/thick speech ...(More severe) stupor [unable to act or think normally], unconsciousness and/or convulsions [rapid, involuntary muscle contractions that cause uncontrollable shaking and arm/leg movement]...(More severe) coma [ a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound]...Glucose Monitoring...1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines...2. The physician will order the frequency of glucose monitoring...Management of HYPOGLYCEMIA...For unresponsive residents with hypoglycemia (Blood glucose...70...or less than the physician ordered parameter)...Immediately administer 1 mg [milligram; a unit of measurement] glucagon IM [intramuscular]...and notify MD [Medical Doctor] for further orders. If pt