Other·August 22, 2022

California Code of Regulations, Title 22, section 72311 (a) (3) (B) - Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, section 72523 (a) Patient Care 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. Title 42 CFR 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 resident's choices. The facility failed to notify the physician when Patient A, who had diabetes (disease that occurs when the blood sugar is too high), and was taking multiple diabetic medications, consumed 40% of breakfast, and had refused to eat lunch on October 21, 2019. In addition, the facility failed to follow their policy and procedure for diabetes management, when the staff did not monitor the patient's vital signs, and blood sugar levels after the patient had a change in condition on October 21, 2019. These failures resulted in Patient A's blood sugar dropping dangerously low, and Patient A required transfer to the acute care hospital. The patient expired on October 22, 2019, one day after the patient was admitted at the acute care hospital. On November 6, 2019, at 10:26 a.m., the Department conducted an unannounced visit to the facility to investigate a complaint related to a quality of care issues. A review of Patient A's record indicated that the patient was admitted to the facility on April 7, 2019. The patient had diagnoses which included Type 2 Diabetes Mellitus and Alzheimer's disease (a brain disorder that caused memory loss and cognitive impairment). A review of Patient A's Medication Administration Record (MAR) dated October 1 to 31, 2019, indicated that on October 21, 2019, at 9 a.m., the patient received the following medications: a. "...Liraglutide Solution (medication used to control high blood sugar) Pen-injector 18 MG/3 ML (milligrams per milliliter) Inject 1.2 milligram subcutaneously (under the skin) one time a day for diabetes..." A review of Lexicomp, a nationally recognized drug reference, indicated Liraglutide's peak time (highest concentration of a drug in the bloodstream) is at 8 to 12 hours after the medication is administered. (If the medication was given at 9 am, peak will be at 4 pm - 8 pm) b. "...SitaGLIPtine Phosphate (medication to lower blood sugar) tablet 100 MG (milligrams) Give 1 tablet by mouth one time a day for diabetes..." A review of Lexicomp, indicated Sitagliptine's effect peaks at 1 to 4 hours after the medication is administered. (If medication was given at 9 am, peak will be at 12 noon). c. "...Metformin Hcl (medication to lower blood sugar) Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetic give with food..." A review of Lexicomp, indicated Metformin's effect peaks at 2 to 3 hours after the medication is administered. (If the medication was given at 9 am, peak will be at 12 noon). A review of the facility record titled, "ADL (Activities of Daily Living) Flow Record," for October 21, 2019, indicated the following: a. Patient A ate 40% of her breakfast meal, and had refused the food substitute; and b. Patient A refused lunch, and food substitute. A review of the ADL record dated October 21, 2019, indicated the charge nurse was not notified of the patient's food intake. A review of the facility document titled, "...SBAR (Situation Background Assessment Recommendation - a communication tool for changes of condition between the nurses and the physician) dated October 21, 2019, at 11:30 a.m., indicated, "...Resident appears pale, cold, and clammy...Nursing Notes...New orders STAT (to be done immediately) CBC (Complete Blood Count - test that screens for certain disorders that can affect health), CMP (Comprehensive metabolic panel - blood test that helps evaluate kidney and liver function) d/t (due to) resident appears pale cold and clammy...Blood sugar at 96 (normal range 70 - 110) ..." There was no documented evidence the physician was notified of either Patient A's poor intake during breakfast or Patient A's refusing lunch on October 21, 2019. On November 6, 2019, at 2:37 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that on October 21, 2019, at 11:30 a.m., while conducting medication pass, she noticed Patient A was cold and clammy; however, the patient's blood sugar was at 96. She stated she did not check the patient's blood sugar again after 11:30 a.m. There was no documented evidence indicating licensed staff conducted a reassessment of the patient after the change of condition at 11:30 a.m., on October 21, 2019. On November 6, 2019, at 3:21 p.m., during an interview, LVN 2 stated that on October 21, 2019, at the start of the evening shift (3 p.m.-11 p.m.), she received a report regarding the patient's change of condition during the a.m. shift (7 a.m.-3 p.m.). LVN 2 stated she started passing medication to the other patients and when she got to Patient A's room, the patient was unresponsive. During a concurrent review of the patient's progress notes dated October 21, 2019, with LVN 2 she verified that at 4:54 p.m., the patient was found unresponsive, with a low BP (Blood Pressure- pressure of blood pushing against the walls of the arteries) 80/50 (normal is 120/80). The record indicated that the patient was cold, clammy, and with a weak pulse. In addition, the progress notes indicated the physician gave an order to send the patient to the acute care hospital for evaluation. On November 12, 2019, at 12:03 p.m., during an interview with Certified Nursing Assistant (CNA) 1, she stated the CNA would provide a substitute, if a patient refused to eat her meals. In addition, she stated the CNA should inform the charge nurse and document the food refusal in the ADL flow record, especially when a patient continues to refuse the meal and the substitute. On November 12, 2019, at 1 p.m., during an interview, the Assistant Director of Nursing (ADON) stated that for a patient with a blood sugar of 96, the licensed nurse was expected to check the patient at least every 30 minutes and to obtain a physician order for an additional blood sugar check. She stated the licensed nurse was expected to keep monitoring the patient, keep offering food and fluids, and keep the physician updated that the patient had refused meals, especially if the patient had been given multiple blood sugar medications. The ADON stated when Patient A was found unresponsive at 4:54 p.m., the licensed nurse should have checked the patient's blood sugar and document the result in the MAR. In a concurrent record review of records with the ADON, she verified that there was no documentation indicating that Patient A's vital signs, blood sugar level, and change of condition were monitored from 11:30 a.m., to the time Patient A was found unresponsive at 4:54 p.m. A review of the STAT (to be done immediately) CMP (Comprehensive metabolic panel - blood test that helps evaluate kidney and liver function) dated October 21, 2019, and collected at 4 p.m., prior to the patient being found unresponsive, indicated that the patient's blood glucose (sugar) level was CL (critically low) at 26. This STAT laboratory was ordered at 11 a.m. but not collected until 4 p.m. (5 hours later). A review of the EMS (emergency medical services) notes titled, "...Patient Care Report..." dated October 21, 2019, indicated EMS arrived at the facility at 5:20 p.m. The narrative report indicated, "...on scene assessing an 82-year-old female lying in bed in an altered state...upon their arrival the patient had a BGL (blood glucose level) of 26, GCS of 9 (Glasgow Coma Scale - score of 9-12 means moderate brain injury) ...established a 20G IV (intravenous - into the vein) in the RAC (right antecubital - forearm) and administered Dextrose 10%... Prior to transport the patient daughter arrived on scene and stated that this is not a normal presentation of the patient..." A review of the acute care hospital ED (Emergency Department) provider notes dated October 21, 2019 at 1851 (6:51 p.m.) indicated, "...Given the patient's history and physical exam findings...SUSPECT: Encephalopathy (brain damage) 2/2 (secondary to) hypoglycemia (low blood sugar) vs (versus)...cardiac (heart) etiology...lmpression: 1. Acute encephalopathy 2. Hypoglycemia 3. Hyperkalemia (high potassium) 4. Lactic acidosis (lactic acid build up in the blood stream) ..." A review of the acute care hospital record titled, "Physician Discharge Summary," written on October 23, 2019, indicated, "...Admit date: October 21, 2019...Discharge Date: October 22, 2019...Principal Diagnosis: acute encephalopathy...code status was discussed with family, and they decided for DNR (Do not resuscitate)/ DNI (Do not intubate), comfort care measures. Patient passed away at 8:56 a.m..." A review of Lexicomp, indicated Metformin had the following US (United States) boxed warning: "Post marketing cases of metformin-associated lactic acidosis have resulted in death...The onset is often subtle, accompanied by nonspecific symptoms (e.g. malaise...respiratory distress...abdominal pain)...Temporarily discontinue therapy in patients with restricted food and fluid intake..." A review of the facility's policy and procedure titled, "Food Intakes: Recording Percentage/Nutritional Assessment," revised January 2012, indicated, "Any resident meal percentage less than 75% will be reported to the licensed nurse...lf more than 75% of the entire meal is refused by the resident on a consistent basis, the licensed charge nurse will interview the resident to try to determine ways to improve meal intake. If follow through is required, the charge nurse will request a dietary evaluation and/or notify the physician, if appropriate..." A review of the facility's undated policy and procedure titled, "Diabetes Management," indicated, "Management of Hypoglycemia (low blood sugar) ...Severity of hypoglycemia is determined by a combination of blood sugar results and clinical symptoms... Symptoms of hypoglycemia may include...drowsiness, weakness...tachycardia (increased heart rate)...pale/cool/moist skin...unconsciousness...For symptomatic but responsive (conscious) residents with hypoglycemia: If he/she is able to swallow...give resident 4 ounces of orange juice...Recheck blood sugar in approx. 15 minutes...repeat juice if indicated and recheck blood sugar in approx. 15 minutes...lf no improvement, call the doctor...Stay with the resident...Monitor vital signs...Hold all diabetic medications..." Based upon interview and record review, the facility failed to notify the physician when Patient A, who had diabetes and who was taking multiple diabetic medications, consumed 40% of breakfast, and then refused to eat lunch on October 21, 2019. In addition, the facility failed to follow their policy and procedure in diabetes management, when the staff did not monitor the patient's vital signs, and blood sugar levels after the patient had a change in condition on October 21, 2019. The facility failed to follow their policy and procedure in food intake recording and assessment, when the staff did not notify the charge nurse of Patient A's lunch and food substitute refusals. Based upon Patient A's change of condition at 11:30 a.m., and the policy and procedures quoted above, the facility should have monitored the patient for hypoglycemia. These failures resulted in Patient A's blood sugar dropping dangerously low without prompt intervention, thereby causing the patient to be transferred to the acute care hospital, where the patient expired on October 22, 2019, one day after the patient being admitted to the acute care hospital. This violation either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or substantial probability that death or serious physical harm would result for Patient A.