Health inspection·March 13, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Complaint CA00815317. Representing the Department, HFEN 37409 State Citation A was written. F684 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility Patients. Based on the comprehensive assessment of a Patient, the facility must ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patients' choices. § 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 12/8/22, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure finger stick blood sugar (FSBS, a blood sugar test performed by piercing the skin via fingerstick to draw blood onto a chemically active disposable test-strip) levels were checked for Patient 1 when the order from the General Acute Care Hospital (GACH) for Patient 1 to have FSBS two times a day was not carried out after Patient 1 was transferred to the facility. 2. Properly transcribe GACH's order to have Patient 1 checked twice a day for FSBS. This failure resulted in Patient 1 expeirencing severe low blood sugar (below 54 mg/dL (milligrams per deciliter, a unit of measure for concentration of substance in a specific amount of fluid)), which led to his admission to an intensive care unit (ICU, a GACH unit for patients with life-threatening injuries and illnesses) for treatment. Review of Patient 1's Admission Record indicated he was admitted to the facility from a General Acute Care Hospital, on 10/26/2022, with diagnoses of dementia (a condition characterized by loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes (a disease of which the body is not able to take up sugar into its cells and use it for energy). Review of Patient 1's Minimum Data Set (MDS, a clinical assessment tool), dated 11/2/2022, indicated his cognition was moderately impaired. Review of Patient 1's Skilled Nursing Facility (SNF) Orders that the General Acute Care Hospital sent to the facility, dated 10/26/2022, indicated Patient 1 had orders for Glucagon (an emergency medicine used to treat hypoglycemia, a condition in which your blood sugar (glucose) level is lower than the standard range of 70 to 100 mg/dL) 1 mg reconstituted solution inject subcutaneously (under the skin) as needed for hypoglycemia and FSBS two times a day. Review of Patient 1's physician order at the facility lacked indication for FSBS two times a day for Patient 1. During an interview with the director of rehabilitation (DOR) on 1/27/2023 at 3:50 p.m., she stated, on 11/2/2022, when she provided care to Patient 1 that day, Patient 1 complained of feeling cold. The DOR stated she provided blankets to Patient 1, but Patient 1 still complained of being cold, and he looked cold. So, she checked Patient 1's SpO2 (SpO2, the percentage amount of oxygen in the blood, of which the normal range would be 92% to 100%) and it was below 90%. She reported it to the licensed nurse. Review of Patient 1's Change in Condition Evaluation, dated 11/2/2022 at 2:51 p.m., indicated Patient 1 had fluctuating blood pressure, his hands were cold, his left fingers were purple and his SpO2 could not be obtained. Extra blankets were provided to Patient 1, and the physician ordered oxygen 2 LPM (liters per minute, a measure of air flow velocity) via nasal cannula (NC, a medical device to provide supplemental oxygen to people who have lower oxygen levels) as needed for comfort. Review of Patient 1's Health Status Note, dated 11/2/2022 at 10:06 p.m., indicated Patient 1 still had cold hands, and his SpO2 could not be obtained. Review of Patient 1's Health Status Note, dated 11/3/2022 at 5:23 p.m., indicated Patient 1 became lethargic, and the physician ordered to send Patient 1 to the Emergency Room (ER) via 911 emergency medical service ambulance. Review of Patient 1's Health Status Note, dated 11/3/2022 at 10:05 p.m., indicated at approximately 5:30 p.m., Patient 1's fingers were too cold, and SpO2 still could not be obtained. Paramedics (healthcare professionals who respond to emergency calls for medical help outside of a hospital) came to pick up Patient 1 and stated Patient 1's FSBS was below normal level. Review of Patient 1's Ambulance Record, dated 11/3/2022, indicated Patient 1 presented with hypoglycemia, altered mental status, somnolence (abnormal drowsiness), and shortness of breath. His skin was dry and cold. Patient 1's respiratory rate was slow and shallow, and his lung sounds were diminished bilaterally (both sides). Patient 1's blood pressure was 182/100 mmHG (millimeters of mercury, a measure pressure), which increased to 216/113 mmHG, and his pupils were non-reactive to light (an abnormal condition, because the pupils of a person's eyes normally change in size when exposed to light). A SpO2 sensor placed on Patient 1's ear showed his SpO2 was 78% while he was on 1- 6 LPM of oxygen, and his blood sugar was 24 mg/dL. After 250 milliliters (ml, a metric unit of volume) of dextrose 10% (a medicine used to elevate blood sugar level) was intravenously (IV, by way of a person's vein) administered to Patient 1, his blood sugar was 32 mg/dL, and there was no improvement in Patient 1's mental status and breathing. So, bag-valve-mask (BVM, an airway apparatus used to cover the patient's nose and mouth and begin ventilating the lungs mechanically by squeezing a reservoir of oxygen or air) ventilations with 10-25 LPM of oxygen were started. Review of Patient 1's Emergency Department Provider Note, dated 11/3/2022, indicated Patient 1 presented with altered mental status, respiratory depression, and hypoglycemia. Patient 1 was ill- appearing and somnolent. His blood pressure was 224/164 mmHG. After one dose of dextrose 50% (used in emergency care to treat hypoglycemia) was administered to Patient 1, his blood sugar level still ranged from below 15 to 31 mg/dL, so two more doses of dextrose 50% were given. After three doses of dextrose 50% were administered, Patient 1 was able to open his eyes, but he was obtunded (a lethargic state, in which the patient has a lessened interest in the environment, slowed responses to stimulation and tends to sleep more than normal with drowsiness in between sleep states), had difficulty breathing and needed bagging. Patient 1 was intubated (to insert a tube into a person or a body part, especially the windpipe for ventilation), put on a ventilator (a machine that helps a person breathe), and admitted to the ICU. During an interview with licensed vocational nurse A (LVN A) on 1/24/2023 at 5:45 p.m., she stated she admitted Patient 1 and transcribed Patient 1's physician orders. LVN A reviewed Patient 1's Skilled Nursing Facility (SNF) Orders that the General Acute Care Hospital sent to the facility and confirmed Patient 1 had an order for FSBS two times a day. LVN A stated she did not see the order and did not carry it out. During an interview with Patient 1's physician on 1/27/2023 at 3:30 p.m., she reviewed Patient 1's Skilled Nursing Facility (SNF) orders and confirmed Patient 1 had the order for FSBS two times a day, but the order was missed; therefore, it was not carried out. Patient 1's physician agreed that, since Patient 1 had a Glucagon order, he should have the FSBS checked; otherwise, the staff would not know if Patient 1 had hypoglycemia. During an interview with the director of nursing (DON) on 1/27/2023 at 5 p.m., she reviewed Patient 1's Skilled Nursing Facility (SNF) Orders and confirmed Patient 1 had the order for FSBS two times a day, but the order was missed and not carried out. The DON also agreed that since Patient 1 had a Glucagon order, he should have the FSBS checked; otherwise, the staff would not know if Patient 1 had hypoglycemia. Review of the facility's undated job description, "LVN Staff Nurse," indicated "General Duties and Responsibilities: ... Clinical: ... Receives and transcribes orders accurately from attending/alternate physician." Review of the facility's Handbook for Long Term Care Medical Directors and Providers, "Attending Physician Role and Responsibilities," dated 12/2021, indicated "Roles and Responsibilities of the Nursing Home Attending Physician: 1. Provide competent, safe medical care to Patients under their care with relevant age-appropriate medical and/or geriatric principles. 2. Orders are related to medically necessary items and services." In violation of the above cited standards, the facility failed to ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patients' choices, including but not limited to: the facility failed to ensure FSBS levels were checked for Patient 1 when the order from the GACH for Patient 1 to have FSBS two times a day was not carried out after Patient 1 was transferred to the facility. This failure resulted in Patient 1 to experience severe low blood sugar (below 54 mg/dL), which led to his admission to an ICU for treatment. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.