Other·December 20, 2023

California Code Regulations, Title 22, section 72311 Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at the least the following: (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (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. California Code Regulations, Title 22, section 72301 Required Services (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, section 72313 Nursing Service- Administration of Medications and Treatments. (a) Medications and treatment 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 not 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. California Code of Regulations, Title 22, section 72523 Patient Care Policies and Procedures (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulation, Title 42, 483.25 (e) Incontinence. 483.25 (e) (2) For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. On October 5, 2023, at 10:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care. As a result of the investigation, CDPH determined that the facility failed to: a. Ensure a urinalysis was completed for Patient A on April 14, 2023, in accordance with the physician order dated April 14, 2023.; b. Ensure a care plan addressing the newly inserted indwelling catheter due to urinary retention for Patient A was developed on April 17, 2023, in accordance with the facility's policy and procedure titled," Change of Condition Notification," revised July 01, 2015. ; c. Ensure Patient A consulted with a urologist for a scheduled appointment on April 27, 2023, in accordance with the physician order dated April 25, 2023.; d. Notify promptly and timely report an abnormal urinalysis result completed on May 10, 2023, in accordance with the facility's policy and procedure titled, " Laboratory, Diagnostic and Radiology Services," dated January 1, 2017.; e. Administer Macrobid [medication used to treat bladder infections] to Patient A, for urinary tract infection (UTI) in accordance with the physician order dated August 26, 2023.; and f. Re-assess the clinical need for continuous use of an indwelling catheter [IC- a flexible tube inserted in the bladder to drain urine into a bag outside your body]. Patient A was admitted with no indwelling catheter and an indwelling catheter was inserted while at the facility due to urinary retention from April 17 to August 26, 2023. As a results of these failures, Patient A had recurrent episodes of UTI on April 15, May 18, June 2, August 4, and August 25, 2023. On August 26, 2023, Patient A was transferred to the general acute care hospital (GACH), due to a change of condition secondary to UTI and Patient A expired after three days at the GACH due bacteremia and UTI. On October 5, 2023, Patient A's record was reviewed. Patient A was admitted to the facility on January 12, 2023, with diagnoses which included dementia [memory loss/cognitive impairment] and benign prostatic hyperplasia [enlarged prostate]. A review of Patient A's "History and Physical," dated January 13, 2023, indicated Patient A did not have an indwelling catheter upon admission. A review of Patient A's "Minimum Data Set [MDS - an assessment tool]," dated January 19, 2023, indicated Patient A had periods of continence [able to control urge to urinate] and incontinence [unable to control urge to urinate] and did not have an indwelling catheter. A review of Patient A's "Progress Notes," dated April 13, 2023, at 5:03 p.m., indicated, "...Patient has swollen testes [testicles]...more confused...abdominal distention bladder scan [a device used to measure volume of urine in the bladder] is at 434 cc [cc/ml - milliliter; unit of measurement]...Per (name of physician), obtain urine sample, CBC [Complete Blood Count - laboratory test to measure blood counts], CMP [Complete Metabolic Panel - laboratory test to check electrolyte levels]...repeat bladder scan at 7-8 pm (7 p.m. to 8 p.m.) If more than 500 cc retention, will need foley [a thin, flexible catheter used to drain urine from the bladder by way of the urethra.] ..." A review of Patient A's "Order Summary Report," included a physician's order, dated April 14, 2023, which indicated, "... (name of doctor) wants patient to consult with Urologist [a doctor who specializes with diseases of the male and female urinary tract system] Asap [as soon as possible] for swollen testes, urinary retention [difficulty urinating and completely emptying the bladder], and thick, cloudy, and odorous urine..." A review of Patient A's laboratory result, dated April 14, 2023, indicated the test results of the completed CBC, and CMP, as ordered by the physician on April 13, 2023. However, the laboratory document indicated urinalysis was not performed and that a urine specimen required recollection and new order for a test should be placed if urinalysis result is needed. Further review of Patient A's record did not indicate whether a urine specimen was collected for urinalysis nor if the physician was notified that the urinalysis ordered on April 13, 2023, was not completed. A review of Patient A's physician order dated April 15, 2023, indicated, "...Cipro [antibiotic medication used to treat bacterial infection] Oral Tablet 500 mg [milligram- unit of measurement] give by mouth every 24 hours for UTI infection until 4/18/2023 (April 18, 2023) ..." A review of Patient A's physician order, dated April 17, 2023, indicated, "...Indwelling catheter...to drainage bag due to diagnosis of retention..." There was no documented evidence care plans were developed to address Patient A's UTI and the use of an indwelling catheter due to urinary retention on April 17, 2023. A review of Patient A's physician order, dated April 25, 2023, indicated a urology consult was scheduled on April 27, 2023, at 2:50 p.m. Further review of Patient A's clinical record, did not indicate documented evidence Patient A was taken to the urology appointment scheduled on April 27, 2023, as ordered by the physician. A review of Patient A's "SBAR [Situation-Background-Assessment-Recommendation -a documentation of communication about condition of a patient amongst healthcare professionals]: Change of Condition," dated May 10, 2023, indicated Patient A was noted with increased lethargy [tiredness], cloudy and concentrated urine, and poor food intake. A review of Patient A's physician order, dated May 10, 2023, indicated a request for laboratory tests including urinalysis with culture and sensitivity [UA w/ C & S] stat [immediately] due to increased lethargy and abnormal changes in urine status. A review of Patient A's laboratory results, dated May 10, 2023, indicated a urinalysis was completed, with the following abnormal results: - Color: dark yellow. - Character: turbid - WBCs [White Blood Cell)]: >200 [normal: none] In further review of Patient A's clinical record, there was no documented evidence the UA w/ C & S laboratory result dated May 10, 2023, was reported to the physician for appropriate treatment. A review of Patient A's physician order, dated May 12, 2023, indicated, "...Urology consult appt (appointment): (name of doctor). Date of appointment 5/18/2023 (34 days after the order for stat urology consult order on April 14, 2023) ..." A review of Patient A's clinical records on October 05, 2023, did not include documentation reflecting the result of the urology consult on May 18, 2023. A review of Patient A's urology consults notes, dated May 18, 2023, provided by the facility on November 10, 2023, indicated, "...being seen for a chief complaint of Swollen Testicles...He is in poor physical condition and his clothes are quite stained. He is with a caregiver has no understanding of why the patient has a catheter how often the catheter is changed. The patient has an odor indicating clear infection with very turbid urine draining his catheter..." Further review of the consult notes indicated the following urologist's recommendation for Patient A: - Bactrim DS [antibiotic for UTI] twice daily for seven days; - Change indwelling catheter every four weeks; and - Renal and bladder ultrasound. Refer to the facility physician and report any abnormalities to the urologist. A review of Patient A's physician order, dated May 18, 2023, indicated, "Bactrim DS Oral Tablet 800-160 mg...give 1 (one) tablet by mouth two times a day for UTI for 7 (seven) days..." The physician's order for antibiotic was started on May 18, 2023 [8 days after the onset of Patient A's change of condition on May 10, 2023]. Further review of Patient A's clinical record, did not indicate documented evidence that the urology consult report completed on May 18, 2023, was obtained while Patient A was still at the facility. Furthermore, there was no documentation indicating whether Patient A's physician was aware of the renal and bladder ultrasound recommended by the urologist on May 18, 2023. A review of Patient A's care plan, dated May 22, 2023, indicated, "...The patient has an indwelling catheter...At risk of UTI Urinary Retention...Goals...The Patient will have minimized risk for complications from indwelling catheter with interventions...Notify physician/responsible party, as needed, regarding urinary status changes...Observe Patient for changes in mental or functional status...Observe urine odor, color, clarity and amount as needed..." A review of Patient A's physician order dated June 2, 2023, indicated, "...Macrobid [medication used to treat UTI] Oral Capsule 100 mg...Give by mouth two times a day for UTI for 10 days..." A review of Patient A's physician order, dated July 30, 2023, indicated, "UA with culture...to r/o (rule out) UTI..." A review of Patient A's laboratory result, dated July 31, 2023, indicated, "...Urinalysis w/ C&S...Urine culture result: ESBL [Extended Spectrum Beta-Lactamase - bacteria usually resistance to many antibiotics] POSITIVE Escherichia coli [a type of bacteria that normally lives in your intestines] isolated. Colony count > 100,000..." A review of Patient A's physician order, dated August 4, 2023, indicated, "...Ertapenem Sodium [medication to treat bacterial infection] ...use 1 gm [gram- unit of measurement] intravenously [medication via the veins] at bedtime for ESBL for seven days. A review of Patient A's "Progress Notes," indicated the following: - August 20, 2023, at 6:14 a.m., "...Patient pulled out his f/c (foley catheter) and noted with redness to his...penis and scrotum...re-inserted f/c...;" - August 21, 2023, at 2:50 p.m., "...Most of the time Patient appeared to be restless and confused...;" - August 23, 2023, at 2:24 a.m., "...Patient received alert and noted to be restless in bed, trying to get out of bed...agitated and aggressive when trying to make him comfortable...";" - August 25, 2023, at 3:08 a.m., "...Patient receiving bladder scans for F/C removal...MD (physician) was messaged for 450 cc bladder retention, awaiting response...:" - August 25, 12:13 p.m., "...Patient has abdominal distention and scanned with 600 ml of cloudy, foul smelling, deep concentrated urine. Foley catheter is reinsertion (sic), and PCP (physician) is notified of findings. Urine sample is collected...;" and - August 25, 2023, at 3:11 p.m., "...Patient with increased confusion, fatigue, cloudy urine with increased sediment. Foul smelling urine, low grade fever of 100.2, HR (heart rate) of 104, (BP) blood pressure of 112/68...did not eaten (sic) breakfast or lunch...UA (urinalysis) order carried out STAT (immediately)...;" A review of Patient A's urinalysis results, dated August 25, 2023, indicated, "...URINALYSIS W/ (with) C&S (Culture and sensitivity) IF INDICATED/URINE CULTURE...Collected: 8/25/2023 (August 25, 2023) 1141 (11:41 a.m.) ...Received: 8/25/2023 1915 (7:15 p.m.) ...urine screen...color...yellow...character...turbid...WBCs...>200 (normal - none) ...RBCs (red blood cells) ...10-30 (normal - none) ...bacteria...1+ (normal - none) ..." In further review of Patient A's clinical record, there was no documented evidence the urinalysis result was reported to the physician when it was received on August 25, 2023, at 7:15 p.m. A review of Patient A's "Progress Notes," dated August 26, 2023, at 1:14 p.m., indicated, "...Macrobid Oral Capsule 100 mg...give one capsule by mouth two times a day for UTI for 10 days..." The physician order was documented as obtained 18 hours after the urinalysis result was reported to the facility on August 25, 2023, at 7:15 p.m. There was no documented evidence Macrobid was administered to Patient A after it was ordered by the physician on August 26, 2023. A review of Patient A's "Progress Notes," dated August 26, 2023, at 10:36 p.m., indicated, "...Patient not responsive, increase in HR (heart rate)...coughing without able to expectorate...vital signs were as follows BP (blood pressure) 148/78, P (pulse) 128 (normal rate 60 - 100), Resp (respiratory - breathing) rate 22...Dr (doctor) called and recommended to transport to (name of hospital)..." Further review of Patient A's clinical record, indicated the following: a. The patient had an indwelling catheter from April 17, 2023, to August 26, 2023. There was no documented evidence the facility implemented interventions for Patient A to restore or improve normal bladder function and there was no reassessment of the need for continued use of indwelling catheter. b. There was no documented evidence the facility conducted an IDT [Interdisciplinary Team - a group of healthcare professionals] meeting to address Patient A's recurrent episodes of UTI on April 14, Ma