Other·December 14, 2023

F690 42 CFR §483.25 Quality of Care (UTI) §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §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 an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (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. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. 22 CR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (1) Physician services policies and procedures which include: (A) Orientation of new physicians to the facility and changes in physician services and/or policies. (B) Patient evaluation visits by the attending physician and documentation of alternate schedules for such visits. (2) Nursing services policies and procedures which include: (A) A current nursing procedure manual. (B) Provision for the inventory and identification of patients' personal possessions, equipment and valuables. . . . (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. . . . On 11/10/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect and resident death. As a result of the investigation, CDPH determined that the facility failed to: 1. Notify a physician or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of the urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on 5/6/2022 in accordance with the facility's policy and procedures (P&P) titled, "Laboratory -Critical values (laboratory results that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician)," revised 11/2018. 2. Place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection in accordance with the facility's policy and procedures (P&P) titled, "Laboratory -Critical values," revised 11/2018. 3. Provide necessary care and treatment, such as prescribe an antibiotic [medication to treat infection]) for Resident 1 in accordance with the facility's policy and procedures (P&P) titled, "Laboratory -Critical values (laboratory results that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician)," revised 11/2018. As a result, on 5/8/2022 at 10:30 A.M., Resident 1 developed altered mental status (AMS -change in mental function that maybe as a result of illness or injuries) and Resident 1 was transferred to a general acute care hospital (GACH) via 911 (telephone number used to reach emergency medical, fire, and police services). Resident 1 was treated for sepsis (a life-threatening medical emergency and the body's extreme response to an infection which causes organ damage) and UTI. Resident 1 was admitted to telemetry unit (a floor in a hospital where patients undergo continuous heart monitoring). Resident 1 died on 5/15/2023. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on 4/15/2022, with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), acute (sudden onset) kidney failure, chronic (ongoing) kidney failure, acute on chronic heart failure, and generalized muscle weakness. The admission record did not indicate Resident 1 was on dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 1's Minimum Data Set (MDS-a standardized screening tool) dated 4/22/2022, indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required limited assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1's history and physical (H&P) dated 4/18/2022, indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was able to make needs known but could not make medical decisions. A review of Resident 1's complete blood count (CBC -blood test that checks for infection) report collected on 5/4/2022, indicated Resident 1's neutrophil (white blood cells or WBC -body cells that protect against illness and disease) count was high at 80.2 percent (normal range is 45.0 % to 70.0 %). A review of Resident 1's Registered Nurse (RN) Note dated 5/5/2022 at 11:46 A.M., indicated pending urine results for urinalysis and urine C&S for Resident 1. The nurses' notes indicated to inform the NP of the urine results once received. A review of Resident 1's UA report dated 5/6/2022, indicated urine collection time not provided. The UA report indicated that Resident 1's urine sample was slightly cloudy (indicates presence of an infection, blood, pus, protein [normal urine color is pale/light/clear yellow]), white blood cells (WBC - are part of CBC that help fight infections) count was high at 5 per high power field (HPF- diagnostic evaluation such as the quantification), (reference range [RR] is zero to two [0-2]), and protein was 100 milligrams per deciliter (mg/dL-unit of measurement (RR negative or none)). The UA indicated presence of bacteria (RR is none) and moderate mucus (RR is none too few). A review of Resident 1's Change of Condition (COC - a decline in a resident's mental, psychosocial, or physical functioning) dated 5/8/2023 at 2:40 P.M., under abdominal/GI (gastrointestinal - stomach and intestines) Status Evaluation, indicated "not clinically applicable to the change in condition being reported abnormal. ... Available Laboratory Tests/Diagnostic Procedures indicated None to Report". The COC indicated that on 5/8/2023 at around 10:30 A.M., Resident 1's family member 1 (FM 1) approached the charge nurse and said that Resident 1, "seemed like is not herself." Resident 1 was unable to answer simple questions which was not within her baseline. Resident 1 was lying in bed saying "please help me" repeatedly and nonstop while eyes closed. ... 911 called. A review of Resident 1's interfacility transfer form dated 5/8/2022 at 2:40 P.M., indicated at 10:30 A.M., Resident 1's FM 1 approached the charge nurse (not identified) stating Resident 1 had AMS. On assessment, charge nurse found Resident 1 with AMS, unable to answer simple questions which is not within her baseline. Resident 1's blood pressure (BP) was recorded to be low at 98/59 millimeters of mercury (mmHg -unit of measure [normal BP is 120/80 mmHg]) and pulse (heart rate) was 61 beats per minute (bpm -number of times the heart beats per minute). The facility called 911 and Resident 1 was transferred to GACH at 11 A.M. A review of GACH Emergency Provider (a physician who evaluates/manages/treats people with severe injuries or sudden illnesses) Note for Resident 1 dated 5/8/2022 at 11:20 A.M., indicated Resident 1 was brought in by Emergency Medical Services (EMS - a team of medical professionals who respond to 911 calls and treat and transport people in crisis health situations) to the Emergency Department (ED) for evaluation of sudden AMS. Resident 1 was alert, awake and oriented times one (AOx1 - Resident 1's baseline). Resident 1 was last seen normal at 8:30 A.M. Resident 1's blood pressure (BP) was 103/61 mmHg, temperature (Temp) was low at 35.1 degrees Celsius (C - a scale for measuring temperature RR is 36.1 C and 37.2 C). Resident 1 was in acute distress (life threatening) and was moaning. Resident 1's abdomen was distended (enlarged, swollen from internal pressure). The ED notes indicated laboratory test results for Resident 1 indicated the following: 1. Blood culture (blood test to look for germs/bacteria) test was positive for gram positive cocci (bacteria). 2. Urine for UA indicated clarity as hazy, protein one plus (1+) (RR is negative), blood 1+ (RR is negative), leukocyte esterase (a urine test for the presence of white blood cells and other abnormalities associated with infection) 1+ (RR is negative), WBC 6-10, bacteria few, mucus moderate. 3. Blood Urea Nitrogen (BUN - is what forms when protein breaks down and is filtered out by the kidneys and removed from the body in urine) was 110 milligrams per deciliter (mg/dL- (RR 6-23 mg/dL. High BUN indicates that the kidneys are not working well and can lead to kidney failure). 4. Creatinine (breakdown of muscle tissue which is removed from the blood through the kidneys) was 4.99 mg/dL (RR is 0.60- 1.10 mg/dL). High Creatine is a sign of kidney problems, such as kidney damage or failure, infection, or reduced blood flow, loss of body fluid (dehydration), and muscle problems, such as breakdown of muscle fibers. High creatinine can cause chronic (ongoing) kidney failure. 5. Phosphorus was 6.5 mg/dL (RR is 2.5-4.9 mg/dL). High phosphorus is often a sign of kidney damage which may lead to increased risk of heart attack, stroke or death. A review of the Emergency Provider Notes dated 5/8/2022 at 11:20 A.M., indicated Resident 1 on physical exam, was somnolent (experiencing drowsiness or strong desire to fall asleep), groaning constantly, responsive to painful stimuli but not able to localize. Resident 1's BP was ranging between 87/45 mmHg to 98/53 mmHg. Resident 1 was found with UTI and sepsis and was administered lactated ringers (LR- intravenous [IV - into a vein] 1 (one) liter and was started on IV cefepime and vancomycin antibiotics (medications to treat infection). Inpatient palliative care (a specialized medical care for people living with serious illness) consult was placed for Resident 1. A review of the Emergency Provider Notes dated 5/8/2022 at 11:20 A.M., indicated Computerized Tomography (CT- a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) was recommended because Resident 1 had abdominal distention and abdominal pain on exam. Resident 1 "remained in critical condition and required constant monitoring and attendance of care." Resident 1 had a "high probability of imminent deterioration threatening life or limb, required immediate attending physician's attention/intervention ...particularly concerning for hypotension (low BP) ... had a high probability of respiratory compromise (a high likelihood of respiratory insufficiency and failure, respiratory arrest [stop] or death)." The emergency provider note indicated Resident 1 had acute renal (kidney) failure, acute cystitis usually caused by a bladder infection), urinary retention (a condition in which a person is unable to empty all the urine from his/her bladder), ... CT abdomen indicated urinary catheter (a flexible tube inserted in the bladder to drain urine) in place and the bladder was empty for Resident 1. Resident 1's condition was critical (injury or illness is life threatening). A review of the Emergency Provider Notes dated 5/8/2022 at 11:20 A.M., indicated Resident 1's condition was discussed with a family member (FM). FM wanted Resident 1 to be full code (if a person's heart stopped beating and/or the person stopped breathing, all resuscitation [process of correcting physiological disorders such as lack of breathing or heartbeat] procedures will be provided to keep the person alive). Per FM, Resident 1 had been altered for several days. Resident 1 had severe uremia (a dangerous condition that occurs when waste products associated with decreased kidney function build up in your blood). GACH admitted Resident 1 to telemetry unit (a floor in a hospital where patients undergo continuous heart monitoring) for further treatment and management. Resident 1 will be treated for sepsis. A review of the GACH history and physical (H&P) dated 5/8/2022 at 3:31 P.M., under assessment/plan of the H&P indicated ... sepsis. Meets two of four (2/4) criteria (for sepsis - temperature above 38 degrees centigrade [36 degrees Celsius], pulse greater than 90 beats per minute [p/min], respirations greater than 20 breaths p/min, neutrophils count greater than 10%) with hypotension (low blood pressure), hypothermia (a medical emergency that occurs when the body loses heat faster than it can produce, causing dangerously low body temperature). The H&P indicated "will sepsis and then re-evaluate." A review of GACH notes for Resident 1 dated 5/13/2022 at 8:07 P.M., indicated GACH discharged Resident 1 to home on palliative care with FM 1. On 11/10/2023 at 9:30 A.M., during an interview with FM 1, FM 1 stated Resident 1's mind was okay the first week Resident 1 was admitted at the facility. FM 1 stated that on 5/5/2022, she visited Resident 1 and noticed Resident 1's, "mind was off." FM 1 stated she went to nurses' station and informed a head nurse (she does not know the charge nurse's name) and the head nurse told FM 1 that Resident 1 may have UTI and would have laboratory tests done on Resident 1. FM 1 stated she decided to visit Resident 1 daily and followed up daily on the lab results with the nurses seated at the nurses' station (does not know their names). FM 1 stated she never found out the lab results for Resident 1. On 11/10/2023 at 9:30 A.M., during the interview with FM 1, FM 1 stated as she continued to visit Resident 1 at the SNF, she noticed Resident 1's mind continued to decline. FM 1 stated that on 5/8/2022 at 10:30 A.M to 11 A.M., she went to the facility to visit Resident 1 and waited outside the door because Resident 1's door was shut. FM 1 stated that on 5/8/2022 at around 10:30 A.M., and 11 A.M., she entered Resident 1's room after a certified nurse assistant (CNA) came out of Resident 1's room. FM 1 stated that upon entering resident 1's room, she noticed that Resident 1 was not alert (when a person is awake/aware and can respond to the environment around them independently), was groaning and was saying, "please, please, help me." FM 1 stated she went to the nurses' station and told a nurse that Resident 1 "did not seem right". FM 1 stated the nurse told FM 1 that Resident 1 may have UTI and the facility called paramedics (medical professionals who specialize in emergency treatment). On 11/10/2023 at 9:30 A.M., during the interv