Other·March 14, 2024

Health & Safety Code 1424 (d) (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. Title 22, Division 5, Chapter 3, Article 3, Section 72311 Nursing Services- 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, § 72353, Pharmaceutical Service – General: (a) Arrangements shall be made to assure that pharmaceutical services are available to provide patients with prescribed drugs and biologicals. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, §72355, Pharmaceutical Service- Requirements: (a) Pharmaceutical service shall include, but is not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on prompt and timely basis as follows: (C) Except as indicated above, all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day. Title 22, Division 5, Chapter 3, Article 3, Section 72313 Nursing Services- Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (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. (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. 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 Residents’ choices, including but not limited to the following. On December 3, 2020, at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. It was determined that the facility failed to provide physician ordered diabetes medications and care for Patient A in accordance with professional standards of practice, policies and procedures, and regulatory requirements. Specifically, these failures include, but are not limited to: 1. Failure to administer the physician ordered insulin medications (medication that lowers the level of glucose [sugar] in the blood) for Patient A on 10/12/2020, at 4:45 pm and 9:38 pm, and on 10/13/2020, at 6:45 am and 10:03 am. 2. Failure to perform blood sugar monitoring of Patient A who had type 1 diabetes. These failures resulted in the unmonitored and uncontrolled blood sugar levels of Patient A to rise, which necessitated the facility to call 911 and have Patient A admitted to the acute care hospital where she expired shortly after arrival at the hospital's emergency room (ER). A review of Patient A’s "Physician Discharge Summary," from the acute care hospital, dated October 12, 2020, indicated: • “Insulin glargine 100 unit/mL (milliliter) injection, commonly known as “LANTUS” o Instructions: inject 0.17 mLs (17 Units total) into the skin 2 (two) times daily. o Dose: 17 Units…” • “Insulin lispro 100 unit/mL injection, commonly known as “HumaLOG” o Instructions: Inject 8 units subcutaneously (under the skin) TIDAC (Three times a day before meals) after (sic) meals if eating > (greater than) 25% of meal.” • “Insulin lispro 100 unit/mL injection, commonly known as: “HumaLOG” o Instructions: Inject 0-5 units three times daily before meals as needed per sliding scale: BG (blood glucose) <70 = hold rapid-acting insulin and see hypoglycemia (low blood sugar) measures. 70-150 = No correction 151-200 = 1 unit, 201-250 = 2 units, 251-300 = 3 units, 301-350 = 4 units, > 350 = 5 units and notify provider on call.” A review of Lexicomp, a nationally recognized drug reference indicated, "Insulin glargine (Lantus) is used to lower blood sugar in patients with high blood sugar (diabetes) and is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Insulin glargine must be used concomitantly (in combination) with rapid or short- acting insulins i.e., multiple daily injection regimen." A review of Patient A's "Admission Summary," from the skilled nursing facility dated, October 12, 2020, at 6:40 p.m., indicated, "Admitted to (initials of facility) at 2pm 10/12/2020, this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name) ...Patient is alert, able to make needs known, not in respiratory distress...Patient ate 25% for supper... (name of doctor) made aware of this admission..." Further review of Patient A’s facility electronic record indicated, Patient A was admitted to the facility with diagnoses that included pyelonephritis (inflammation of the kidney due to a bacterial infection), and insulin dependent type 1 diabetes (disease in which the body does not make enough insulin to control blood sugar levels). A review of Patient A's facility record included a document titled, "Order Summary Report," dated October 12, 2020; indicated the following: - "Admit to (initials of facility) 10/12/2020 under the services of (name of doctor) with the following Dx (diagnosis)...Insulin dependent Type 1 DM (diabetes mellitus) ...", - "HumaLOG solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals.” - "HumaLOG Solution 100 Unit/ML (Insulin Lispro) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals."; and - "Lantus Solution 100 Unit/ML (insulin glargine) Inject 17 unit subcutaneously two times a day for diabetes mellitus." The “Order Summary Report,” dated October 12, 2020, did not indicate an order to monitor blood sugar levels. On December 30, 2020, at 2:04 p.m., during a phone interview, Registered Nurse (RN 1), stated the following: • She was the admitting nurse for Patient A on October 12, 2020; • She had input Patient A's facility orders received from the discharging hospital; • There should have been an order for blood sugar checks and a sliding scale for Patient A; • She had spoken with the nurses at the facility on October 13, 2020, the day after Patient A’s admission and informed them that if a patient had a diagnosis of diabetes and there was no order for blood sugar monitoring, they must call the physician and get an order to check the blood sugar. A review of Patient A's facility care plan dated October 12, 2020, indicated the following, "Focus- The patient has Diabetes Mellitus Type 1(insulin dependent)...Goal - The patient will be free from any s/s (signs or symptoms) of hyperglycemia (high blood sugar levels) through the review date (no review date provided) ...The patient will have no complications related to diabetes through the review date. Interventions...Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness...Educate regarding medications and importance of compliance..." A review of the facility record, for Patient A titled, “Medication Administration Record,” (MAR) dated October 1 to 30, 2020, did not indicate whether the insulins such as: Humalog (before meals) or the Lantus ordered for 9:00 p.m., were administered as ordered by the physician on October 12, 2020. A review of the facility progress note documented by a license vocation nurse (LVN 1) dated October 12, 2020, at 9:38 p.m., indicated, “Orders- Administration Note: Lantus Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse.” On December 28, 2020, at 3:09 p.m., during a phone interview, LVN 2 stated the following: • He had provided care for Patient A on October 13, 2020. • He could not remember exactly which insulin he had given to Patient A on October 13, 2020. However, he believed he had given Lantus. • There was no order to check the patient’s blood sugar prior to the RN supervisor calling the doctor to get an order on the morning of October 13, 2020. • The glucose monitor, kept reading “high,” once the order was received to check the blood sugar on the October 13, 2020, at approximately 10:00 a.m. In addition, when asked if there had been an order to monitor Patient A’s blood sugar or an order for a sliding scale (a progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges), LVN 2 responded with “I guess not.” On December 29, 2020, at 4:07 p.m., during a phone interview with Patient A's attending physician (AP) for the facility, the following were discussed: • The AP was asked if she had been notified when Patient A did not receive her ordered insulins on October 12 and October 13, 2020. The AP stated that she was not notified when the patient failed to receive her medications. • The AP continued that she does not "always get notified for things like that." • The AP was then asked if it would be expected to have an order to check blood sugars for a patient with diabetes and have a sliding scale for insulin. The AP stated, "Yes, of course," there should have been an order. No explanation was given why there was no order given. On December 30, 2020, at 10:30 a.m., during a phone interview, LVN 1 stated the following: • She had provided care for Patient A on October 12, 2020, and she worked a double shift that day from 6:30 a.m. to 11:00 p.m. • She did not administer Patient A's insulins, and that the medications had not been delivered from the pharmacy to the facility during her shift. • She did not call the physician to inform her that the medications were not available to give. • She was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. • It is expected for the physician to be notified if a medication was not available to be given at the ordered time. • “There was not an order for blood sugar checks.” A review of a facility progress notes for Patient A dated October 13, 2020, at 6:33 a.m., indicated, "Heath Status Note...patient remains alert, oriented and verbally responsive. Able to make needs known...No adverse drug reactions noted at this time. No n/v (nausea and vomiting) ..." A review of the facility MAR dated October 1 to 30, 2020, indicated for Humalog to be administered at 6:45 a.m. on October 13, 2020; 15 minutes before breakfast. The MAR did not indicate that Humalog was administered. Further review of Patient A's facility medical record identified no documentation that indicated the patient's physician was notified when Humalog ordered for 4:45 p.m., and the Lantus for 9:00 p.m., were not administered on October 12, 2020. There was no documentation that the physician was notified when the Humalog ordered to be administered for 6:45 a.m., on October 13, 2020, was not given. A review of Patient A's facility "Health Status Note," dated October 13, 2020, at 11:30 a.m., indicated, "At 10:17 this morning patient was noted to be sweating and breathing fast. She was able to respond to her husband who was on the phone at the time. Blood sugar was checked and showed "HI". (A review of the leading provider of blood sugar monitoring systems, "Accu-Chek" indicated, "If the letters HI are displayed on the screen, the blood glucose may be higher than the measuring range of the system. The meter is designed to provide a numerical value for blood glucose in the range of 20-600 mg/dL (milligram/deciliter)." CNA (certified nursing assistant) reported to this writer earlier that patient vomited breakfast food (sic)... (name of doctor) and husband informed...Husband was updated of patients' (sic) condition and at 10:54am (sic) agreed that patient be transferred to hospital preferably to (name of discharged hospital). Call to 911 was placed and they arrived about 11:15. This writer went to check on the patient at about this time and found her to be unresponsive (unconscious, possibly dead or dying) ...patient was transferred out of the facility around 11:25am (sic)." Further review of Patient A's facility medical record identified no documentation that any blood sugar check had been done prior to 10:00 a.m., on October 13, 2020, 20 hours after admission to the facility. A review of an article for “The American Diabetes Association,” titled, “Blood Glucose Testing and Management,” undated, indicated, “Blood sugar (blood glucose) monitoring is the primary tool to find out if blood glucose levels are within target range…It’s important for blood glucose levels to stay in a healthy range. If glucose levels get too low, one may lose the ability to think and function normally. If they get too high and stay high, it can cause damage or complications to the body…” A review of Patient A's emergency transport's, "Patient Care Report," dated, October 13, 2020, at 10:56 a.m., indicated the facility called paramedics who arrived at the facility and were with Patient A by 11:12 a.m. The record further indicated that the paramedics arrived at the facility for