Other·September 30, 2022

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 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 42 CFR §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. 22 CCR § 72511. Use of Outside Resources. (a) If a facility does not employ qualified personnel to render a specific service to be provided by the facility, there shall be arrangements through a written agreement with outside resources which shall meet the standards and requirements of these regulations. 22 CCR §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 8/3/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident about quality of care and a resident’s death. The facility failed to ensure Resident 1, who was in a vegetative state (a coma-like state characterized by open eyes and the appearance of wakefulness), was totally dependent on staff for all activities of daily living (ADLs – include activities such as moving in bed, dressing, and personal hygiene), and required hemodialysis (HD or dialysis - a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleaned blood back to the body) treatment, was kept free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) and received care in accordance with standards of practice when on 8/1/2022, Resident 1 was left with no supervision and monitoring while undergoing HD treatment. The facility failed to: 1. Ensure Resident 1 was monitored and supervised with visual observation of the resident’s arterio-venous fistula (AV fistula - connection between an artery [blood vessel that carries blood from the heart to tissues and organs] and a vein [blood vessel that carries blood to the heart] used as an access point for HD) on the left upper arm while having an on-going HD treatment. On 8/1/2022, Dialysis Technician 1 (DT 1) left Resident 1, who was in Bed A at 5:05 p.m., with no supervision and monitoring. DT 1 went to Resident 2 in Bed C (same room) to clean and disinfect Resident 2's HD machine as the resident had completed their treatment at approximately 5:05 p.m. On 8/1/2022 at 5:22 p.m., DT 1 returned to Resident 1's beside after cleaning Resident 2's HD machine and observed Resident 1 with a dislodged venous needle (when the needle slips out and returning blood drains from the body onto the bed or floor instead of back to the patient's bloodstream) with a pool of Resident 1's blood on the mattress and on the floor. 2. Ensure HD staff knew to call out for help and inform facility staff regarding Resident 1’s condition after DT 1 saw Resident 1’s DT 1 called out for help and informed facility staff regarding Resident 1's condition after DT 1 saw Resident 1's venous needle dislodgment. On 8/1/2022 at 5:22 p.m., DT 1, after seeing Resident 1's blood dripping on the mattress and on the floor, did not call or use the call light button to ask for help or inform any facility staff. Instead, DT 1 texted the Dialysis Registered Nurse 1 (Dialysis RN 1), who was at the Dialysis Storage Room doing his documentation, to come because there was an emergency. On 8/1/2022 at 5:25 p.m., the Dialysis RN 1 came and infused 500 milliliters (ml - unit of measurement for fluids) of Normal Saline (NS - fluid infused into a vein to increase fluid volume inside the body). Dialysis RN 1 then went out of the room to the nurses' station and informed RN 3 (facility's RN) on 8/1/2022 at 5:30 p.m. RN 3 went to Resident 1's room and upon seeing the large amount of blood, called the paramedics (a person trained to give emergency care to individuals who are injured or ill) through 911 on 8/1/2022 at 5:30 p.m. The paramedics arrived on 8/1/2022 at 5:35 p.m. 3. Ensure a communication system was in place between the dialysis and the facility staff when Resident 1 had a venous needle dislodgement so that immediate actions could be undertaken to save Resident 1's life. 4. Ensure the facility's contracted dialysis provider (CDP 1) conducted in-service trainings to the facility staff regarding HD as required in the facility's contract agreement with CDP 1. In an interview, on 8/15/2022 at 2:07 p.m., RN 3 stated that this incident was horrifying, and he was never given an in-service training on how to handle this kind of situation. 5. Ensure the facility’s contract terms with CDP 1 regarding in-service trainings to DTs with the facility's emergency protocols were met. As a result, there was delay in care and interventions as Resident 1 continued to lose a large amount of blood leading to Resident 1's death on 8/1/2022 at 5:59 p.m. A review of Resident 1's Admission Record indicated the facility admitted the resident on 12/17/2020 and readmitted the resident on 11/23/2021. Resident 1 had diagnoses that included hypoxic ischemic encephalopathy (a lack of oxygen and damage to cells within the brain as a result of restricted blood flow), dependence on respirator (ventilator - a mechanical breathing machine), and end-stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), dated 6/22/2022, indicated the resident was in a persistent vegetative state and was totally dependent on staff for all ADLs. A review of the Physician’s Order for Resident 1 dated 11/23/2021 indicated HD by CDP 1 every Monday, Wednesday, and Friday. A review of Resident 1's Dialysis Order dated 7/18/2022, indicated the following: - Order type: Home HD (HHD). - Dialyzer (artificial kidney): F200NR (a type of dialyzer used for HD) - Duration: 3 hours and fifteen minutes - Blood flow rate: 400 milliliters per minute (ml/min- unit of measure) - Dialysate flow rate: 500 ml/min - Access: primary AV fistula (left upper arm) - Needle gauge (refers to the inner measurement or opening of the needle) arterial (removes blood from the body to the machine): 15 - Needle gauge venous (returns blood from the machine to the body): 15 - Code status: Full Code (if a person's heart stopped beating and/or they stopped breathing, all procedures will be provided to keep them alive). A review of Resident 1's HHD Treatment Flowsheet, dated 8/1/2022, indicated the following: - Dialysis treatment started on 8/1/2022 at 2:01 p.m. with blood pressure (BP - normal BP is 120/70 mmHg) reading of 173/91 milliliter of mercury (mmHg - a unit of pressure used in measuring blood pressure) and pulse rate (PR - normal PR 60-100 beats per minute [bpm]) of 89 bpm. - Dialysis treatment ended on 8/1/2022 at 5:25 p.m. with BP reading of 71/33 mmHg and PR of 41 bpm with notes indicating Dialysis RN 1 documented that venous needle was noticed out (venous needle dislodgment) with no alarms triggered, blood was noted on bed, and blood was reinfused (returned) with 500 ml of normal saline (NS - a mixture of salt and water; it is called normal because its salt concentration is similar to tears, blood and other body fluids). - On 8/1/2022 at 5:29 p.m., a code (code blue - there is a medical emergency occurring) was called and the paramedics were called through 911. - On 8/1/2022 at 5:29 p.m., the treatment note indicated there was venous needle dislodgment, blood noted on the bed and floor. The note further indicated that staff was unable to give NS because the arterial needle dislodged. Paramedics arrived and took over the CPR, and Resident 1 expired on 8/1/2022 at 5:29 p.m. - On 8/1/2022 at 5:30 p.m., Dialysis RN 1 approached RN 3 and relayed that Resident 1 was bleeding and there was a need to call the paramedics through 911. The Charge Nurse and Medical Doctor 1 (MD 1) immediately went and assessed Resident 1, who was noted to have significant bleeding and hypotension (low blood pressure) BP was 71/40 mmHg and heart rate greater than 120 bpm. MD 1 immediately gave an order to call 911. The Charge Nurse called 911 right away. A review of Resident 1's Nursing Progress Notes (Evaluation), dated 8/1/2022, indicated the following: - On 8/1/2022 at 5:30 p.m., Dialysis RN 1 approached RN 3 and relayed that Resident 1 was bleeding and there was a need to call the paramedics through 911. The Charge Nurse and Medical Doctor 1 (MD 1) immediately went and assessed Resident 1, who was noted with significant bleeding and hypotension (low blood pressure). BP was 71/40 mmHg and heart rate greater than 120 bpm. MD 1 immediately gave an order to call 911. Charge Nurse called 911 right away. - On 8/1/2022 at 5:31p.m., a code (code blue) was called on Resident 1, vital signs (clinical measurements, specifically blood pressure, pulse rate, respiration rate, and temperature, that indicate the state of a patient's essential body functions) were not appreciated (measured), Primary Nurse and Respiratory Therapist 1 (RT 1) began chest compressions and manually bagging (giving ventilations to the patient during CPR) while waiting for the paramedics to arrive. - On 8/1/2022 at 5:35 p.m., the paramedics arrived and took over the care of Resident 1. - On 8/1/2022 at 5:59 p.m., the paramedics pronounced Resident 1 had expired (died). Time of death was 5:59 p.m. A review of Resident 2's Admission Record indicated the facility admitted the resident on 5/1/2020 and readmitted on 5/6/2022, with diagnoses that included diabetes mellitus (uncontrolled sugar in the blood), chronic respiratory failure (the airways that carry air to your lungs become narrow and damaged) and end- stage renal disease. A review of Resident 2's MDS, dated 11/30/2021, indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding for daily decision-making) were moderately impaired and the resident was totally dependent on staff for ADLs. A review of the physician’s order for Resident 2 dated 5/6/2022 indicated an order for HD by CDP 1 every Monday and Friday. A review of Resident 2's HHD Treatment Flowsheet, dated 8/1/2022, indicated the following: - Dialysis treatment started on 8/1/2022 at 2:35 p.m. - Dialysis treatment ended on 8/1/2022 at 5:05 p.m. On 8/5/2022 at 1:58 p.m., during an interview, DT 1 stated there were four DT and one dialysis RN on 8/1/2022 for the entire building. DT 1 stated her job description included preparing the dialysis machine, testing if the alarms were working, staying in the room with the residents the whole time while dialysis is on-going, and monitoring their BP and PR. DT 1 stated she was assigned to dialyze Resident 1 in Bed A and Resident 2 in Bed C in the same room, with an empty Bed B (no resident). DT 1 stated Resident 1 had an AV Fistula on the left upper arm and was positioned next to the door while the machine was on the other side of the bed, and the dialysis machine lines placed on top of the resident’s body. DT 1 stated she was cleaning and disinfecting the machine of Resident 2 in Bed C, took out the dialyzer and discarded them into the biohazard trash, and cleaned the blood pressure cuff. DT 1 stated that after cleaning the machine in Bed C, she went back to check on Resident 1, and that is when she saw Resident 1 bleeding. DT 1 stated she first texted Dialysis RN 1, then applied pressure on the venous access after removing the venous needle because a small part was still inside the venous access. DT 1 stated Dialysis RN 1 came into the room and gave 500 ml of NS to Resident 1. DT 1 stated she should have monitored Resident 1 throughout the treatment time and should not have left Resident 1 to clean the dialysis machine of Resident 2. DT 1 stated she could have alerted Dialysis RN 1 sooner upon the dislodgement of the HD access site for Resident 1, before the resident had lost significant amount of blood, if she had only focused on Resident 1. On 8/5/22 at 2:50 p.m., during an interview, RN 3 stated that on 8/1/2022, around 5:30 p.m., Dialysis RN 1 told him to call 911 immediately. RN 3 stated he and MD 1 went to Resident 1's room to assess the resident and observed blood on Resident 1's gown. RN 3 stated that Resident 1 was noted with a BP reading of 72/40 mmHg. RN 3 stated that he immediately went back to the nursing station to call 911 per MD 1 order. RN 3 stated there was no call light activated during this emergency. On 8/5/2022 at 3:14 p.m., during an interview, Dialysis RN 1 stated he was in the dialysis storage room (approximately 245 feet from Resident 1's room) charting when DT 1 texted him at 5:22 p.m. saying "emergency come" (meaning there was an emergency and to come to the room). Dialysis RN 1 stated that he got to Resident 1's room in around two minutes, and that he observed the resident's dialysis machine alarming. Resident 1's blood was observed on the bed and on the floor. DT 1 was applying pressure on Resident 1's left upper arm AV fistula site with a gauze (a thin translucent fabric of silk, linen or cotton). On 8/9/2022 at 11:21 a.m., during an interview, RT 1 stated that on 8/1/2022, sometime around 5:20 p.m. she entered Resident 1's room and she observed Resident 1 in Bed A with dialysis staff (Dialysis RN 1 and DT 1) working on the left side of Resident 1. RT 1 stated she saw blood on the side where the dialysis staff were working. RT 1 stated she then called "RT" (the facility's version of code blue), visually assessed Resident 1, grabbed gloves, and started CPR until the paramedics arrived. On 8/15/2022 at 8:17 a.m., during an interview, Dialysis RN 1 stated the last time he was in Resident 1's room was at 5:05 p.m. Dialysis RN 1 stated that he remembered the time specifically because that was the time Resident 1's roommate (Resident 2) finished his HD treatment. Dialysis RN 1 stated he then went to check on four other residents with ongoing dialysis at that time, however, was unable to identify the residents he checked on. Dialysis RN 1 stated that after checking on the other residents, he returned to the dialysis storage room to complete his documentation. Dialysis RN 1 stated he did not know what time Resident 1's venous needle dislodgment occurred. Dialysis RN 1 stated that Resident 1 was okay when he left the room at 5:05 p.m. Dialysis RN 1 stated that when he was called into Resident 1's room due to an emergency, he was able to infuse 500 ml of NS to Resident 1 using the arterial needle. Dialysis RN 1 then stated that he went out of Resident 1's room to inform facility staff to call 911. Dialysis RN 1 stated that he then went back and tried giving one liter of NS to Resident 1 but could not infuse anymore NS because the arterial line had clotted (when blood turns from a liquid form to a thickened mass not allowing flow of NS to the body). Dialysis RN 1 stated that at 5:59 p.m. (on 8/1/2022), he told DT 1 to stop holding pressure on Resident 1's left upper arm AV fistula access, which was no longer taped, because there was no more blood coming out. On 8/15/2022 at 2