Health inspection·October 25, 2021

The following reflects the findings of the California Department of Public Health during the recertification survey of the facility. § 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, including but not limited to the following: §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. On 7/12/21, an unannounced visit was conducted at the facility for the annual recertification survey. An investigation was conducted regarding one patient who was on dialysis (process of purifying blood of a person whose kidneys are not working normally). Resident 14 is a 59-year-old male admitted to the facility with diagnoses of Chronic Kidney Disease, Stage 5 (kidneys are getting very close to failure or have completely failed) and dependence on dialysis. Based on interview and record review, the facility failed to provide dialysis care and services according to the professional standards of care for one sampled dialysis resident (Resident 14) when: 1. Dressing changes were not provided to the CVC (Central Venous Catheter - a small flexible tube that is inserted into a large vein for the purpose of providing dialysis) dialysis site. 2. A care plan (CP) was not revised after Resident 14 refused dialysis treatments. 3. The physician was not notified when Resident 14 refused his dialysis treatments on 6/30/21, 7/5/21, and 7/9/21. These failures resulted in Resident 14 developing an infection to the CVC dialysis site (presence of pus and blood to the dialysis site) which required antibiotic therapy for seven days and had the potential to result in a change in the resident's condition to go untreated by the physician due to the physician being unaware of the resident's refusal to receive life-saving dialysis. 1. During a review of Resident 14's "Order Summary Report" (OSR), dated 5/13/21, the "OSR" indicated, "Dialysis schedule: 3 x/week (three times per week at an offsite dialysis clinic) on M-W-F (Monday, Wednesday, Friday) . . . Rt (Right) Subclavian (a vessel that lies just below the clavicle [collarbone]) . . ." During a concurrent interview and record review, on 7/15/21, at 10:10 AM, with Director of Nursing (DON), Resident 14's "Progress Note" (PN), dated 7/13/21, was reviewed. The "PN" indicated, on 7/13/21, "Resident was noted to have pus and blood to his [CVC] site to right side of chest. . . resident to start on Ceftriaxone [antibiotic used to treat bacterial infections] 1 gm [gram - a unit of measurement] IM [intramuscular injection - used to deliver a medication deep into the muscles] daily x 7 days [for seven days] and Doxycycline [antibiotic used to treat bacterial infections] 100 mg bid [two times a day] x 7 days." DON stated, "[Dialysis Center] is doing the dressing during his dialysis days but that he's refusing to go to dialysis for approximately two weeks now." DON stated the dressing to the CVC dialysis site had not been changed since his last dialysis treatment (6/28/21). During an interview on 7/19/21, at 8:04 AM, with Assistant Director of Nursing (ADON), ADON stated, "We never do the dressing for the dialysis site. We monitor the dressing site to check if it has any drainage." During an interview on 7/19/21, at 8:31 AM, with Nurse Consultant (NC), NC stated, "We don't manipulate the dialysis dressing change. If a dressing change is needed, the resident needs to be transferred to the dialysis center or ER [Emergency Room]. [Facility] should have asked for some directions from the dialysis center and should have documented that they referred the resident for dressing changes on the dialysis site [CVC] when he refused [dialysis] treatment [since 6/28/21]." During an interview on 7/19/21, at 11:20 AM, with DON, DON stated, "We could have sent him to the dialysis center or ER for the dressing changes on the dialysis site when he refused treatments." During a review of the facility's policy and procedure (P&P) titled, "End-Stage Renal Disease (kidney failure), Care of a Resident with," dated 9/10, the P&P indicated, "Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. . . 1. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including. . . 2. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care." During a review of the NCBI Bookshelf (a service of the National Library of Medicine, National Institutes of Health) article titled, "Care of A Central Line (central venous catheter)" indicates "Catheter Site Dressing Regimen . . . Central line dressing should not be changed every day unless they are loose or soiled. Current recommendations are to change gauze dressing every two days and transparent, semi-permeable dressing every seven days unless soiled or loose. . ." 2. During an interview on 7/12/21, at 11:30 AM, with Resident 14, Resident 14 stated, "I'm not on dialysis. I don't feel good. I feel tired and dizzy. I don't want [any] more dialysis." During a concurrent interview and record review, on 7/15/21, at 10:10 AM, with DON, Resident 14's "CP", dated 4/15/21 was reviewed. DON was unable to find a care plan for Resident 14's refusal to do his dialysis treatments. DON stated, the care plan should have been revised to reflect Resident 14's refusal to go to for his dialysis treatment. During a review of the facility's P&P titled, "Care Plans, Comprehensive Person-Centered," dated 12/16, the P&P indicated, under the Policy Statement, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented. . . 7. The care planning process will. . . Include an assessment of the resident's strengths and needs. . . 8. The comprehensive, person-centered care plan will. . . Include measurable objectives and timeframes. . . Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. . . Incorporate identified problem areas . . . Reflect the resident's wishes regarding care and treatment goals. . . Aid in preventing or reducing decline in the resident's functional status and/or functional levels. . . Reflect currently recognized standards of practice for problem areas and conditions. . . 10. Identifying problem areas and their causes, developing interventions that are targeted and meaningful to the resident. . . 14. The Interdisciplinary TEAM [IDT-group of health care professional who meets to plan residents care needs] must review and update the care plan: a. When there has been a significant change in the resident's condition. . . " 3. During a concurrent interview and record review, on 7/19/21, at 8:31 AM, with NC, Resident 14's "Progress Notes" (PN), dated 6/28/21 to 7/15/21 were reviewed. NC was unable to find documented evidence that the physician was notified when the resident refused his dialysis treatments on the following dates: 6/30/21, 7/5/21, and 7/9/21. NC stated, the physician should have been notified consistently on the days when Resident 14 refused his dialysis treatments. During a review of the facility's P&P titled, "Change in a Resident's Condition or Status," dated, 5/17, 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 and/or status. . . 1. The nurse will notify the resident's Attending Physician's or physician on call when there has been a(an): f. refusal of treatment or medications two (2) or more consecutive times) . . . " In violation of the references previously cited, the facility failed to provide dialysis care and services when dressing changes were not provided to the CVC dialysis site. The facility failed to revise and update the care for the resident when the resident refused to go to dialysis. The facility failed to notify the physician of the resident's refusal to go to dialysis. These failures resulted in Resident 14 developing an infection to the CVC dialysis site which required antibiotic therapy for seven days and had the potential to result in the resident's change of condition to go untreated by the physician due to the physician being unaware of the resident's refusal to receive dialysis. This violation presented an imminent danger that death or serious harm would result or a substantial probability that serious physical harm would result and represents a Class "A" citation.