Health inspection·September 11, 2024

§483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident. § 72523. 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. On 7/9/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was neglected by the facility due to Resident 1's hospitalization with fulminant (something that occurs suddenly and with great intensity or severity) Clostridoides Difficile Colitis ([C. Diff] results from the disruption of normal healthy bacteria in the colon that can lead to severe damage to the colon and can be fatal), multi system organ failure requiring an emergent colectomy (a surgical procedure to remove the entire colon) and gastric wedge resection (a surgical procedure in which a wedge shaped portion of the stomach is removed). On 7/23/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint. Upon investigation, CDPH determined, Resident 1's physician was not notified when Resident 1 had multiple episodes of large/loose diarrhea (loose watery stools) between 7/1/2024 and 7/5/2024. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days in accordance with the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition or Status." 2. Ensure LVN 1 and LVN 2 implemented Resident 1's Care Plan titled, "Resident at Risk for Constipation," by monitoring the amount, consistency, and frequency of Resident 1's bowel movements. 3. Ensure Certified Nursing Assistant 1 (CNA 1) and other unidentified CNAs reported their findings of Resident 1's loose/water stools to licensed nurses. As a result, Resident 1 had a delay in care and treatment leading to her transfer to a General Acute Care Hospital (GACH) on 7/6/2024, where she underwent an emergent total colectomy, a gastric wedge resection, a partial omentectomy (a surgical procedure to remove a portion of the omentum [a fold of tissue that surrounds the stomach and other organs]), and a temporary abdominal (stomach) closure in the setting of (two conditions that co-exist but are not linked) fulminant C. diff. A review of Resident 1's Admission Record (Face Sheet) indicated, Resident 1, a 71 year-old male, was originally admitted to the facility on 1/26/2018 and readmitted on 5/29/2023, with diagnoses including hypernatremia (high sodium levels in the blood), hypertensive heart disease (a condition in which the blood vessels have persistently raised pressure), chronic kidney disease ([CKD] kidney damage lasting three months or more) heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following a cerebral infarction ([stroke] lack of oxygen to tissues in the brain). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2024, indicated Resident 1's cognitive (thinking) skills for daily decision making were moderately impaired. A review of Resident 1's History and Physical (H&P), dated 11/17/2023, indicated, Resident 1 had a fluctuating capacity (situations where a person's decision-making ability varies) to understand and make decisions. A review of Resident 1's Physician's Order Summary Report dated 6/14/2024, indicated Resident 1 was to receive Cefuroxime Axetil (an antibiotic used to treat a wide variety of bacterial infections) 250 milligrams (mg) two times a day for a urinary tract infection ([UTI] a bacterial infection in any part of the urinary tract) caused by Escherichia coli ([E. coli] a type of bacteria that can cause severe bloody diarrhea) for seven days. A review of Resident 1's Medication Administration Record (MAR), dated 6/2024, indicated Resident 1 received Cefuroxime Axetil from 6/14/2024 through 6/20/2024. A review of the article Cefuroximine "What side Effects can this Medication Cause" from the nationally recognized National Library of Medicine, indicated Cefuroxime Axetil can cause serious side effects such as watery or bloody stool, stomach cramps or fever during treatment or for up to two or more months after stopping treatment. Medlineplus.gov https://medlineplus.gov/druginfo/meds.a601206.html A review of Resident 1's Care Plan, titled "Resident at Risk for Constipation," dated 6/18/2024, indicated Resident 1's goal was to maintain passage of soft formed stools at a frequency perceived as normal through 9/16/2024. The Care Plan's intervention included to monitor the amount, consistency, and frequency of Resident 1's bowel movements. A review of Resident 1's Bowel and Elimination form, dated 7/1/2024 through 7/5/2024, indicated the following: 1. On 7/1/2024 at 2:59 p.m. and 10:59 p.m., Resident 1 had two episodes of large loose/diarrhea. 2. On 7/2/2024 at 2:30 p.m., Resident 1 had one episode of a large loose/diarrhea. 3. On 7/3/2024 at 11:14 a.m. and 9:14 p.m., Resident 1 had two episodes of large loose/diarrhea. 4. On 7/4/2024 at 6:09 a.m., 1:29 p.m., and 9:46 p.m., Resident 1 had three episodes of large loose/diarrhea. 5. On 7/5/2024 at 9:31 p.m., Resident 1 had one episode of a large loose/diarrhea. A review of Resident 1's Clinical Record, indicated there was no documentation to indicate licensed nurses monitored Resident 1's stool, care planned or that Resident 1's physician was notified of Resident 1's loose/diarrhea. A review of Resident 1's General Laboratory Work, dated 7/5/2024, indicated Resident 1's Comprehensive Metabolic Panel ([CMP] a blood test that gives doctors information about the body's chemical fluid balance) illustrated Resident 1 had a critically high Creatinine (a waste product that comes from the breakdown of muscle tissue and the digestion of protein in food, [reference range = 0.55 mg/dl- 1.02 mg/deciliter (dl)]) level of 7.6 mg/dl, a critical high blood urea nitrogen ([BUN] a waste product that the kidneys remove from the blood) [reference range = 9.0 mg/dl 23.0 mg/dl) level of 108 mg/dl, and a high sodium (a mineral needed by the body to keep the body fluids in balance, [reference range= 135 milliequivalents per liter (mEq/L - 145 mEq/L]) level of 155 mEq/L. A review of Resident 1's Progress Notes, dated 7/6/2024, indicated at 7:15 a.m. on 7/6/2024, Resident 1 was awake and refused breakfast and medications. At 12:30 p.m., Resident 1's vital signs ([v/s] measurements of the body's most basic functions such as breathing, heart rate [HR], temperature, and blood pressure [B/P]) were taken. Resident 1's B/P was unobtainable, HR was 51 beats per minute ([bpm], reference range 60-100 bpm), respiratory rate (RR) was 48 breaths per minute (reference range 12-20 breaths per minute), and the resident's Oxygen Saturation level ([O2 Sat] a measure of how much oxygen is circulating in the blood, reference range 95% - 100%) was 91%. The Progress Notes indicated Resident 1 was lethargic (a condition marked by drowsiness) and unresponsive to verbal commands. The Progress Notes indicated 911 was called and Resident 1 was taken by paramedics to a GACH. A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured framework that provides communication between members of the health care team about a patient's condition), dated 7/6/2024, indicated Resident 1 was lethargic, her B/P could not be obtained, and she was short of breath (SOB) with shallow breathing (when you only draw small amounts of air into your lungs, not using full capacity). A review of the GACH's Emergency Department (ED) Documentation, dated 7/6/2024, indicated upon admission to the GACH on 7/6/2024, Resident 1 was not alert, her skin was dry, cool, and pale, and her oral mucous membranes (the moist inner lining of some organs and body cavities such as the nose, mouth, lungs, and stomach) were dry. The ED's Documentation indicated Resident 1's B/P was 64/30 millimeters of mercury ([mmHg]the reference range is 120/ 80 mmHg), and her HR was 150 bpm. The ED's Documentation indicated Resident 1 was admitted to the Medical Intensive Care Unit ([MICU] a hospital ward that provides intensive continuous 24-hour care for patients who are critically ill or injured) with a diagnosis of septic shock (a life-threatening condition that happens when your blood pressure drops to dangerously low levels after an infection). The ED's Documentation indicated while in MICU Resident 1's laboratory tests results on 7/6/2024 indicated the resident had metabolic acidosis (a condition in which the body's fluids have too much acid, resulting in an abnormally low pH [describes the acidity or basicity of a solution]). Resident 1's laboratory results dated 7/6/2024 indicated the following: 1. pH level 7.30 (reference range 7.35- 7.45). 2. Arterial blood carbon dioxide level (indicates how well the lungs remove carbon dioxide [a clear, odorless, and colorless gas] from the blood, reference range 35-45) 20. 3. Bicarbonate level (a form of carbon dioxide, a low level indicates metabolic acidosis) reference range 22-27) 10. 4. White blood cell count ([WBC] part of the body's immune system that helps the body fight infections and other diseases [reference range is 4,000- 11,000 per microliter [cells/ul of blood) 33.4 ul. 5. Creatinine level 9.14 mg/dl. 6. Sodium 153 milliequivalents per liter (mEq/L). 7. Lactate level (a byproduct caused by any type of severe viral or bacterial infection) [reference range= 0.5 mg/dl- 2.2 mg/dl]) 6.9 mg/dl. The GACH's ED Documentation indicated on 7/7/2024, Resident 1 underwent an emergent total colectomy, gastric wedge resection, partial omentectomy, and temporary abdominal closure in the setting of fulminant C. Diff. During a concurrent interview and record review on 7/26/2024, at 3:02 p.m., with a certified nursing assistant (CNA 1), Resident 1's Bowel and Elimination documentation was reviewed. CNA 1 stated on 7/2/2024, she notified the charge nurse (CN 1), whose name she does not recall, that Resident 1 had two episodes of watery stools on 7/4/2024. During an interview on 7/29/2024, at 9:59 a.m., LVN 1 stated, no one reported to him that Resident 1 had loose watery stool during the time he worked from 7/1/2024 through 7/4/2024. LVN 1 stated, if he had been notified that Resident 1 had loose watery stool, he would have notified Resident 1's physician, reported this in the staff's morning huddle (a short stand-up meeting 10 minutes or less that is typically conducted at the start of each shift), and completed a Change of Condition (COC) form. During an interview on 7/29/2024, at 1:31 p.m., LVN 2 stated, she was not notified by anyone that Resident 1 had loose watery stools, if this was reported to her, she would have notified Resident 1's physician. During an interview on 7/29/2024, at 2:19 p.m., Resident 1's Physician stated, no one notified him that Resident 1 had loose watery stools, had he known that Resident 1 had loose watery stools for five days, was not eating or drinking, he would have ordered laboratory tests to rule out C. Diff, colitis (a swelling of the large intestine or colon), or diverticulitis (inflammation or infection of small pouches or sacs called diverticula that form in the wall of a hollow organ such as the colon), and would have given instructions to transfer Resident 1 to the GACH sooner than 7/6/2024. During an interview on 7/29/2024, at 2:45 p.m., the Director of Nursing (DON) stated, that CNAs should have reported to the charge nurse (CN) when Resident 1 had loose/watery stools, so the CN could have called the physician for treatment orders. The DON stated, "loose/watery stools could lead to dehydration and trigger other medical conditions." A review of the facility's P&P titled, "Change in a Resident's Condition or Status," dated 12/2016, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The facility failed to: 1. Ensure LVN 1 and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days in accordance with the facility's P&P titled, "Change in a Resident's Condition or Status." 2. Ensure LVN 1 and LVN 2 implemented Resident 1's Care Plan titled, "Resident at Risk for Constipation," by monitoring the amount, consistency, and frequency of Resident 1's bowel movements. 3. Ensure CNA 1 and other unidentified CNAs reported their findings of Resident 1's loose/water stools to the LVNs. As a result, Resident 1 had a delay in care and treatment leading to her transfer to a GACH on 7/6/2024, where she underwent an emergent total colectomy, a gastric wedge resection, a partial omentectomy and a temporary abdominal closure in the setting of fulminant C. diff. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.