Health inspection·August 23, 2021

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the Patient’s clinical condition demonstrates that this is not possible or Patient preferences indicate otherwise. Title 22, Division 5, Chapter 3, Article 5, Section 72315 Nursing Services- Patient Care. (g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. On August 21, 2020, at 12:45 p.m., an unannounced visit was made to the facility for the investigation of a complaint. It was determined that the facility failed to ensure that Patient A maintained acceptable electrolyte balances (minerals in the body) and maintained proper hydration and health. Patient A required transfer to the general acute care hospital for evaluation and treatment for acute change in mental status and was diagnosed with severe dehydration (body does not have enough water or fluids to carry out normal function). This failure resulted in the overall decline in the patient's physical well-being that led to Patient A’s death. Patient A’s facility medical record was reviewed and indicated the patient was 62 years old. The patient was admitted to the facility on June 4, 2020, with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis (partial weakness on one side of the body) following cerebral infarction affecting the right dominant side, aphasia (inability to comprehend or formulate language because of damage to specific brain regions), encephalopathy (damage or disease that affects the brain), dementia (group of thinking and social symptoms that interfere with daily functioning), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Patient A's facility "History and Physical" (H&P), dated June 6, 2020, indicated, "This patient has the capacity to understand and make decisions." Review of a document for Patient A titled, "Dehydration Risk Assessment," dated June 4, 2020, indicated the patient’s risk level was zero (no risk) on the assessment document. A laboratory report located in Patient A’s facility record indicated that a blood sample was collected in the facility on June 15, 2020, at 5:10 a.m. The laboratory report indicated the following "High" results: - BUN (Blood Urea Nitrogen) results of 37. BUN is measurement of the chemical urea (waste product that is excreted by the kidneys and measured in the blood). The report's normal reference range was documented as 7-25. - creatinine results of 2.26. Creatinine is a waste product produced by muscles removed from the body by the kidneys. The normal reference range was documented as 0.60 to 1.2. - sodium results of 149. Sodium is a chemical that helps with the function of nerves and muscles and helps to keep the right balance of fluids in the body. The normal reference range was documented as 136-145. Review of a physician's order for Patient A dated for June 28, 2020, at 7:00 p.m., indicated that the patient was to receive infusion (IV) therapy. The order read, "Primary continuous infusion: D5NS (dextrose 5% in normal saline), rate 60 ml/hr (milliliters/hour), duration: X (times) 4 days." Review of Patient A's "Certified Nursing Assistant ADL (activities of daily living) Sheet," for the month of June, indicated in the section titled, "Meal (chart % taken)," that the patient had been documented as refusing his breakfast on June 28th, 29th and 30th, his lunch June 25th, 27th, 28th and 29th. The document further indicated that the patient had refused dinner on June 27th, 28th and 29th. Review of a progress note for Patient A, dated June 30, 2020, at midnight indicated, “While making rounds, patient resting comfortably in bed. No c/o (complaint of) pain/acute distress noted…” A second progress note for Patient A, dated June 30, 2020, at 2:25 a.m., indicated, “While doing rounds and checking on patient’s I.V., patient noted with audible congestion. Upon assessment, resident unresponsive to verbal & tactile stimuli. Unable to open eyes…911 called…” Review of Patient A's document titled "COC (change of condition)/Interact Assessment Form," dated June 30, 2020, at 2:25 a.m., indicated "VS (vital signs) BP: (blood pressure) 90/54, pulse: 86, RR (respiratory rate) 27." The document further indicated, “Situation identified: Unresponsive to verbal & tactile stimuli, low 02 (oxygen) sat (saturation) 70%.” (The Mayo Clinic documents normal oxygen measured in the blood usually ranges from 95 to 100% with levels below 90% considered low). The document further indicated, “Acute change in mental status or function decline…Management/Plan…Transfer to hospital ER (Emergency Room) for evaluation, 911 via Paramedics…” A physician order for Patient A dated, June 30, 2020, at 2:30 a.m., indicated, "May transfer to hospital for further eval (evaluation) and TX (treatment)." Patient A's hospital (Hospital 1) records were reviewed on September 1, 2020. The record located a paramedic report, dated June 30, 2020, that indicated, "911 (emergency) response." The report further indicated, "...IV access initiated by (name of paramedic company)..." Review of Patient A's Hospital 1 "Emergency Nursing Record," indicated the patient arrived in the ER at 3:07 a.m. on June 30, 2020. The record further indicated that the patient was intubated (placement of a plastic tube passed through the mouth into the windpipe when a person cannot breathe on their own.) at 3:13 a.m., six minutes after Patient A’s arrival in the ER. Patient A's "Emergency Nursing Record" further indicated the patient had an internal jugular central line (an intravenous catheter placed into the jugular vein in the neck to access blood draws and infuse large amounts of fluids or medicines) inserted at 6:30 a.m. on June 30, 2020. The ER physician documented that "Patient (Patient A) was not responsive to noxious (very unpleasant) stimuli" on arrival to ER The patient's vital signs were documented, as blood pressure 110/60, heart rate 96, and respiratory rate was 40. The patient's skin was documented as warm and dry. The ER records further indicated a diagnosis of renal (kidney) failure with hyperkalemia (high potassium level in the blood). Further Review of Patient A's ER records indicated that blood was drawn on admission (June 30, 2020) for testing. The laboratory results indicated: - Sodium level of 183 (normal range 135-145). The record indicated that this was a critical level. - potassium level of 6.5 (range 3.3-5.3). and indicated that the result was high. - BUN was 295 (normal range 5-25). The record indicated that this was a critical level. - creatinine result was 14.0 (0.5-1.4). The record indicated that this result was high. - chloride result was 153 (98-107). The record indicated that this result was high. Review of a critical care physician's note for Patient A indicated that a decision was made to transfer the patient to another hospital (Hospital 2) because the patient required a higher level of care. Patient A was transferred to Hospital 2 at 7:30 a.m., on June 30, 2020. Review of Patient A's Hospital 2 document titled, "ED (emergency department) Provider Notes," dated June 30, 2020, indicated, "Pt (patient) presented to OSH (outside hospital) in respiratory distress and was intubated...Pt also in severe renal failure with hyperkalemia, hypernatremia (high sodium level in the blood) and renal failure..." Further review of Patient A's Hospital 2 ED record indicated that blood was drawn on admission (6/30/2020) and indicated: - sodium level of 190, - potassium level of 5.6, - BUN results on admission was 226, - creatinine result was 11.8 (0.5-1.4), - chloride result was 146 (98-107). Review of Patient A's Hospital 2 ED record indicated that on June 30, 2020, at noon a "Hemodialysis Catheter (hemodialysis is a procedure where a dialysis machine and a special filter are used to clean the blood of waste products)" had been inserted. The record indicated, "Consent: The procedure was performed in an emergent situation. Reason for central line (hemodialysis catheter) insertion: New indication for central line. Indications: vascular access (Dialysis)." Further review of Patient A’s Hospital 2 record indicated that the patient was admitted to the Medical Intensive Care Unit of Hospital 2 on June 30, 2020. Patient A's Hospital 2 document titled, "Adult Critical Care Center Admission Note," further indicated, "For AKI (Acute Kidney Injury) and hypernatremia nephrology (a specialty of medicine that deals with diseases of the kidney) was consulted and planned to start CRRT (Continuous Renal Replacement Therapy. CRRT is dialysis treatments that are provided as a continuous 24-hour per day therapy. Blood is removed from the patient, pumped through a dialysis filter and returned to the patient following removal of surplus water and wastes. CRRT is a slower type of dialysis that puts less stress on the heart)." Patient A's Hospital 2 document titled, "Discharge Summary," indicated "July 9: Patient transitioned to comfort care with palliative extubation (removal of the endotracheal tube from a patient who is not expected to sustain independent respirations while easing the patient's suffering) and ultimately passed away at 23:55 (11:55 p.m.) on 7/9/2020," nine days after Patient A's admission to Hospital 2. On September 1, 2020, at 11:58 a.m., an interview was conducted with a certified nursing assistant (CNA 1). CNA 1 confirmed that she had provided care for Patient A. CNA 1 stated that the Patient would drink the fluids on his meal tray but would not drink water. The CNA continued that she would encourage the patient to drink. On September 1, 2020, at 12:13 p.m., an interview was conducted with CNA 2. CNA 2 confirmed that he had provided care for Patient A. CNA 2 stated he had observed that Patient A had exhibited signs of dehydration. CNA 2 stated, "You could just tell." CNA 2 continued that Patient A had a, "change in mentation." CNA 2 stated he had informed the charge nurse, and the charge nurse had notified the physician. On September 1, 2020, at 12:31 p.m., an interview was conducted with the facility's Director of Staff Development (DSD). The DSD was asked the expectation for monitoring patients for signs/symptoms (S/S) of dehydration. The DSD stated that the staff were expected to observe the patients daily for S/S of dehydration. The DSD stated that if a CNA identified S/S of dehydration, they were expected to report the S/S to the charge nurse. The DSD further stated if a patient had eaten less than 50% of a meal, the CNA staff were expected to notify the charge nurse. The DSD said that the charge nurse would then be expected to contact the physician for a change in condition. On September 1, 2020, at 12:40 p.m., an interview was conducted with the facility's Director of Nursing (DON). The DON was asked the expectation of staff in monitoring for S/S of dehydration. The DON stated that the staff were expected to look at the patient's skin turgor (elasticity), weakness, dry lips and mucous membranes. The DON continued that if S/S (of dehydration) were identified, staff were expected to notify the physician to get orders to either draw labs or get an order for IV hydration. Review of a facility policy titled, "Dehydration- Measures to Prevent," undated, indicated, "This facility will implement measures to prevent dehydration." The policy further indicated, "c. Monitoring of BUN & Creatinine as per physician's orders, to ensure that BUN is within normal limits (7-25)...d. Assess patients for signs/symptoms of delirium (confused thinking) that may indicate impending dehydration...i. Decreased skin turgor, ii. Dry mucous membranes, iii. Orthostatic hypotension (blood pressure reading decreases with change of position from lying to sitting to standing). iv. Delirium M/B (manifested by) disorientation, confusion, anxiety impaired attention, etc. 2. Identification of need to implement measures to prevent dehydration and notification of attending physician for orders..." Therefore, it was determined that the facility failed to ensure that Patient A maintained acceptable electrolyte balances (minerals in the body) and maintained proper hydration and health. Patient A required transfer to the general acute care hospital for evaluation and treatment for acute change in mental status and was diagnosed with severe dehydration (body does not have enough water or fluids to carry out normal function). This failure resulted in the overall decline in the patient's physical well-being that led to Patient A’s death. The above violation presented either an imminent danger of death or serious harm or substantial probability of death or serious physical harm to the patient.