Health inspection·September 8, 2021

Health and Safety Code Section 1424 (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. A physical condition or one or more practices, means, methods, or operations in use in a long-term health care facility may constitute a class "A" violation. The condition or practice constituting a class "A" violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the state department, is required for correction. Except as provided in Section 1424.5, a class "A" citation is subject to a civil penalty in an amount not less than one thousand dollars ($1,000) and not exceeding ten thousand dollars ($10,000) for each and every citation. Title 42, Code of Federal Regulations, Section 483.25(h) Parenteral Fluids Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Title 22, California Code of Regulations, Division, 5, Chapter 3, Article 3, Section 73211 (c)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, Section 72313 (a)(2) and (3), Nursing Service, Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (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. The facility failed to safely monitor the administration of 5% dextrose in water (D5W) intravenous (IV, tube inserted into a vein) fluid for one of 12 sampled residents (Resident 49) when physician order was not followed regarding daily basic metabolic panel (BMP, a blood test that measures your glucose (sugar) level, kidney function, electrolyte and fluid imbalance), failed to monitor the amount of D5W IV fluids administered to Resident 49, and failed to implement the fluid imbalance care plan intervention to monitor for signs of fluid imbalance such as mentation changes (loss of alertness), and edema (swelling caused by excess fluid trapped in your body's tissues).These failures resulted in Resident 49's fluid overload (too much fluid in the body) and presented imminent danger of death or serious harm, or substantial probability of death or serious physical harm. On 5/3/21, an annual recertification survey was conducted at the facility. The team entered the facility and informed the facility regarding the recertification survey. During onsite recertification survey Resident 49's closed clinical record was reviewed. According to Resident 49's undated face sheet, Resident 49 was admitted on 3/18/20, with diagnoses including hypertension (increased blood pressure), muscle weakness, dysphagia (difficulty in swallowing), and dementia (memory problem). Residents 49's minimum data set, (MDS, an assessment tool) dated 2/10/21, noted a brief interview occurred for mental status (BIMS, cognitive status) code of 99 (a code of 99 if the resident was unable to complete the interview or the resident did not participate) with short term and long term memory problems were recorded. Resident 49's functional status in bed mobility, transfer, dressing, eating, toileting, and personal hygiene were noted to require staff assistance. The MDS also indicated Resident 49 had no weight loss and no weight gain. Resident 49's fluid imbalance care plan, dated 3/19/20, noted that Resident 49 had a risk for fluid imbalance related to cognitive problem, extensive assistance with feeding, and drinking fluids. The intervention listed was to monitor for signs of fluid imbalance such as mentation changes and edema. However, review of Resident 49's facility medical records revealed no documentation that the facility monitored Resident 49 since admission and when she had fluid overload on 2/23/21 for any signs of mentation changes, and edema as required by the fluid imbalance care plan. Resident 49's nutritional assessment dated 2/10/21, indicated the normal total fluid requirement was 1600 milliliters (ml, unit of measurement) per day for Resident 49's age and weight. During an interview with the facility's registered dietician (RD) on 5/6/21 at 3:36 p.m. she confirmed Resident 49's total fluid requirement was 1600 ml per day. Review of Resident 49's BMP collected on 2/21/21, indicated the sodium (NA, electrolyte and minerals in the body) level was 180 milliequivalent per liter (NA normal level 136-145). Resident 49's nursing note, dated 2/22/21, indicated Resident 49's sodium level was critical (180 mEq per liter), the physician was notified regarding the critical sodium level, the physician ordered to check BMP daily, and licensed nurses administered D5W IV fluids at 75 cubic centimeter (cc, unit of measurement) per hour with no stop date (75 cc per hour= 1800 cc per day). However, further review of Resident 49's medical records, revealed no documentation that Resident 49's BMP was checked daily on 2/23/21, 2/24/21, and 2/25/21. Resident 49's nursing note, indicated on 2/23/2021 at 6:00 a.m., Resident 49 had a shortness of breath, received 4 liters per minute of oxygen, and continued to receive D5W IV fluids at 75 cc per hour. Resident 49's physician order, dated 2/23/21, ordered 2-5 liters of oxygen to be administered for shortness of breath, chest pain, wheezing, as needed. The physician also ordered on 2/23/21 Furosemide was prescribed for diagnoses of fluid overload, 20 milligrams (mg, unit of measurement) per 2 ml vial to give IV push, then 10 mg IV push after 1 hour. Furosemide is used to treat edema and fluid overload. Resident 49's progress note, dated 2/23/21 at 6:23 a.m., indicated at 6:00 a.m., Resident 49 had shortness of breath with oxygen level at 78 percent and started the oxygen at 4 liters per minute. Resident 49's electronic medication administration record (eMAR), dated 2/23/21 at 9:00 a.m., Furosemide 20 mg was administered when Resident 49's blood pressure (pressure of blood within arteries) was 99/49 (normal blood pressure 120/80) milliliters of mercury (mmHg). The eMar also indicated on 2/23/21 at 10:00 a.m., indicated the Director of Nursing (DON) administered furosemide 10 mg via IV push and then gave another furosemide 10 mg via IV after 1 hour for the diagnosis of fluid overload. Resident 49's nursing notes, dated 2/24/21, indicated on 2/24/21at 1:41p.m., Resident 49 had shallow and labored breathing with 5 liters of oxygen, mottled skin, and that was why administration of D5 IV fluids was discontinued. Resident 49's nursing notes, dated 2/25/21 at 9:19 pm, indicated at 8:25 p.m., Resident 49 was unresponsive, stopped breathing, and that two RNs (identify their acronyms i.e.- RN A, RN B) confirmed death. During an interview and record review with licensed vocational nurse C (LVN C) on 5/6/2021 at 10:55 a.m., LVN C was the assigned nurse and she confirmed Resident 49's sodium level was high at 180 mEq per liters collected 2/21/21 at 3:25 p.m. LVN C stated she called the physician regarding the critical sodium level, the physician ordered to check the BMP daily, and administered D5W IV at 75 cc per hour with no stop date. LVN C also stated there was no monitoring on the medical records regarding the amount D5W IV fluids administered to Resident 49 on 2/22/21, 2/23/21, and 2/24/21. During an interview and clinical record review with registered nurse D (RN D) on 5/7/21 at 7:01 a.m., RN D was the assigned charge nurse and she confirmed Resident 49 had D5W IV on 2/22/21, 2/23/21, and 2/24/21 according to medical records. She also stated physician ordered BMP daily, however, BMP was not checked daily to monitor the electrolyte treatment given to Resident 49. RN D stated Resident 49 had a fluid imbalance care plan but there was no monitoring on the medical record related to fluid imbalance. RN D also stated Resident 49 had fluid overload or fluid imbalance related to D5W IV fluids which could cause weakness, deterioration, and death. During an interview with medical doctor (MD) on 5/7/21 at 8:15 a.m., MD confirmed she ordered BMP daily on 2/22/21 and D5W IV with no stop date. MD stated she ordered D5W IV to remove the sodium in the body and she was not sure if BMP was checked daily in the facility. MD also stated she ordered Furosemide 20 mg via IV to remove the fluids in the lungs, crackles, and shortness of breath. MD stated Resident 49 should have been monitored by a licensed nurse for fluid imbalance and daily BMP level. During an interview with the DON on 5/7/21 at 9:33 a.m., she stated the daily BMP should have been checked daily and the physician's order should have been followed to prevent fluid imbalance for Resident 49. The DON also stated the care plan for fluid imbalance was not implemented related to monitoring for signs of fluid imbalance. During an interview with the facility's pharmacy consultant (PC) on 5/7/21 at 2:22 p.m., he stated Resident 49 should have been monitored for IV fluid infused related to D5W IV. PC stated the treatment could cause electrolytes imbalance such as decrease in potassium, NA, and sugar in the body. PC stated the daily BMP was important to check how the resident's body responds to D5W IV fluids which could cause fluid overload of cardiovascular system or heart problem. Review of the facility's 2008 policy, "Intravenous Fluid and Drug Administration General Practices", indicated the nurse should monitor the resident's therapeutic response, recognize indications of untoward reactions, and implement nursing interventions. Monitoring the residents should be ongoing. Review of the facility's undated policy, "Peripheral IV Catheter Insertion", indicated to provide safe peripheral IV for the administration of fluids, or medications, the following information should be recorded in resident's medical record: the amount of solution or medication to be infused, and the resident's response to treatment. Review of the facility's 4/2019 policy, "Administering Medications", indicated medications are administered in a safe, timely manner, and as prescribed. The facility failed to safely monitor the administration of 5% dextrose in water (D5W) intravenous (IV, tube inserted into a vein) fluid for one of 12 sampled residents (Resident 49) when physician order was not followed regarding daily basic metabolic panel (BMP, a blood test that measures your glucose (sugar) level, kidney function, electrolyte and fluid imbalance), failed to monitor the amount of D5W IV fluids administered to Resident 49, and failed to implement the fluid imbalance care plan intervention to monitor for signs of fluid imbalance such as mentation changes (loss of alertness), and edema (swelling caused by excess fluid trapped in your body's tissues).These failures resulted in Resident 49's fluid overload (too much fluid in the body) and presented imminent danger of death or serious harm, or substantial probability of death or serious physical harm.