Other·October 6, 2023

42 CFR §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident's written plan of care. 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, including but not limited to the following: 42 CFR §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that a 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. 42 CFR §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph [(e)] of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 22 CCR § 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 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. 22 CCR 72329.1 - Nursing Service - Staff (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirements required by this section are minimum standards only. Skilled nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g). On 7/28/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate two complaints about quality of care. The facility failed to provide treatment and care in accordance with the comprehensive plan of care and professional standards of practice to Resident 1, who was dependent on staff for care and was at risk of bleeding, hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), and urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine). The failures included: 1. Not monitoring and accurately documenting Resident 1’s urine characteristics (such as color, odor, pain or discomfort and presence of blood [hematuria - blood in the urine]) as indicated in the plans of care, to promptly identify UTI to mitigate (to alleviate) the infection and prevent complications, such as repeated UTIs (two or more UTIs within six months or three or more within a year) and sepsis (a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death). 2. Having a form Treatment Administration Record (TAR) that documented signs (objective findings that can be seen or measured) and symptoms (subjective and can be perceived only by the person affected) of UTI in a binary (system represented only by two symbols or digits), fashion where a plus (+) indicated all signs and symptoms (S/S) of UTI were present, and a zero (0) indicated no S/S of UTI were present, which resulted in staff documenting that no S/S of UTI were present whenever some, but not all, S/S of UTI, were present. 3. Not having policies and procedures (P&P) for documenting individual S/S of UTI in residents, rather than a binary all-or-nothing rubric (guidelines). 4. Documenting Resident 1 had zero (0) S/S of UTI throughout the resident's stays from 3/7/2023 to 4/14/2023 and from 4/27/2023 to 7/5/2023 when both times Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with UTI and sepsis. 5. Not implementing Physician 1’s order to monitor Resident 1’s urinary drainage bag (collects urine) and document the presence of S/S of UTI every shift. 6. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) not identifying and not documenting Resident 1's S/S of UTI. 7. LVN 1 not taking Resident 1's vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the blood vessel walls]) and not measuring the oxygen saturation (O2 Sat, the amount of oxygen circulating in the blood) and blood sugar level to promptly identify Resident 1’s change of condition (COC) on 7/5/2025, starting at 3:55 p.m. when Resident 1 was found with hematuria (presence of blood in the urine) to 9:20 p.m. to determine Resident 1's need of prompt medical interventions and provide Physician 1 with the overall Resident 1’s condition. LVN 1 did not seek guidance from a Registered Nurse (RN) throughout this time to allow RN management of Resident 1’s COC from 4:06 p.m. to 8:50 p.m. at total of four hours and 44 minutes. 8. LVN 1 and LVN 2 not promptly informing an RN on 7/5/2023 at 9:20 p.m., when Resident 1 had blood pressure (BP) of 82/54 millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between 90/60 mmHg and 120/80 mmHg), heart rate of 119 beats per minute (bpm; ideal range is between 60 bpm and 100 bpm), O2 Sat of 94% (ideal range is between 95% and 100%), and blood sugar of 67 milligrams (mg) per deciliters ([dL] mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). 9. LVN 1 not administering orange juice via gastrostomy tube (GT – a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications) to Resident 1 on 7/5/2023 at 9:20 p.m., when Resident 1’s blood sugar was 67 mg/dL as ordered and as indicated in the plan of care. 10. LVN 1 improperly administering Eliquis (apixaban – anticoagulant medicine that helps prevent blood clots forming in the heart and reduce the risk of stroke [disrupted blood flow to the brain] but is dangerous when administered to a patient that is bleeding) to Resident 1 at 5:00 p.m., where Resident 1 showed signs of hematuria as of 3:55 p.m. that day. 11. LVN 1 not seeking guidance from an RN on 7/5/2023 before administering Eliquis to a resident (Resident 1) that had signs of hematuria just 1 hour prior to Eliquis administration. 12. Failing to ensure implementation of the facility’s P&P on Catheter Care, Urinary; Catheterizations (procedures used to drain the bladder and collect urine through a flexible tube); COC; Vital Signs, Weights, Height; and Documentation Principles. 13. Failing to take adequate steps to ensure Resident 1 received prompt transportation to GACH 1 when so ordered by Physician 1, which resulted in inordinate (unwarranted) delay when no regular ambulance was available for transport and paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] health personnel trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) were not called. 14. LVN 1 not clarifying with Physician 1 whether the order dated 7/5/2023 at 9:20 p.m., to transfer Resident 1 to GACH 1 referred to paramedics, regular ambulance, or first available; not seeking further guidance from an RN to clarify the order; and not taking further action when regular ambulance services indicated they were unavailable. 15. The LVNs Job Description indicating LVNs were to perform continuous assessment of residents’ condition instead of data gathering (basic assessment). 16. LVNs performing comprehensive assessment of residents outside their scope of practice. 17. An RN and not an LVN accurately and continuously assessed Resident 1 for S/S of UTI to prevent complications such as repeated UTIs and sepsis. 18. There was an RN available to supervise LVNs, to provide consultations and guidance to LVNs, and to perform residents’ assessments. 19. There were P&P on RN oversight (supervision), and LVNs’ training on effective and accurate identification and documentation of S/S of UTI including the urine characteristics every shift. As a result, Resident 1 suffered recurrent unidentified UTI and sepsis on 4/14/2023 and 7/5/2023. On 7/5/2023 there was a delay of six hours and 38 minutes in transferring Resident 1 to GACH 1 to receive the needed medical interventions. Resident 1’s condition deteriorated, and the resident subsequently died at GACH 1 on 7/19/2023. A review of Resident 1’s Admission Record (face sheet) indicated the facility admitted the resident, an 87-year-ol female, on 3/7/2023 and readmitted the resident on 4/27/2023. Resident 1’s new diagnoses upon readmission included sepsis, UTI, and encephalopathy (brain disease that alters brain function or structure). Resident 1’s other diagnoses included essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and dysphagia (difficulty swallowing) following cerebral infarction (stroke). Other diagnoses included type 2 diabetes mellitus (body does not make enough insulin [a hormone that lowers the level of sugar in the blood] or cannot use it as well as it should), sacral (triangular shaped bone at the base of the spine) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and dehydration (a harmful reduction in the amount of water in the body). A review of the Physician's Orders for Resident 1, dated 3/7/2023, indicated: - Admit to hospice care (special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness). - Change the Foley (type of an indwelling urinary catheter) catheter as needed when clogged, soiled, or pulled out. - Change the Foley catheter starting on the 15th and ending on the 15th every month. - Monitor the Foley catheter urinary drainage bag (collects urine) and document a plus (+) sign for presence of S/S of UTI and zero (0) for absence of S/S of UTI every shift. A review of Resident 1’s Care Plan, developed on 3/7/2023, for the resident’s impaired elimination (movement of urine or feces from the body) indicated the use of indwelling catheter due to wound management. The Care Plan indicated a goal for Resident 1 to have reduced risk of UTI daily. The interventions included to monitor S/S of UTI, to provide frequent incontinent care (care addressing loss of bowel and/or bladder control), and to change the Foley catheter and drainage bag according to policy. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/20/2023, indicated the resident rarely/never communicated. The MDS indicated Resident 1 was totally dependent on bed mobility, transfer, dressing, eating (via enteral feeding - way of delivering nutrition directly to the stomach through tube feeding), toilet use, and personal hygiene. The MDS further indicated Resident 1 had an indwelling catheter and a GT. A review of Resident 1’s Care Plan, developed on 3/26/2023, for the resident’s risk for bleeding and bruising due to the use of apixaban, included the intervention to assess the resident for signs and symptoms of bleeding such as blood in urine or stool and notify the physician. A review of Resident 1’s Care Plan, developed on 3/26/2023, for Resident 1’s risk of hypoglycemia due to diabetes, included the interventions to administer medications as ordered and to initiate nursing measures for hypoglycemia immediately. A review of Resident 1’s Care Plan, developed on 3/26/2023, for the resident’s risk of unavoidable UTI due to history of UTI and catheter use, had a goal to reduce the risk of recurrence through interventions daily. The interventions included to notify the physician of any S/S of UTI (such as changes in urine characteristic). A review of Resident 1's Licensed Nursing Note, dated 4/14/2023, indicated Family Member 1 (FM 1) asked about the care Resident 1 received and then proceeded to call the paramedics to "get my mom out of here." The note also indicated the facility notified the hospice agency that FM 1 withdrew the resident from hospice care. Resident 1 left the facility accompanied by the paramedics, on 4/14/2023 at 1:03 p.m. to GACH 1. A review of Resident 1's Licensed Nursing Note and TARs from 3/7/2023 to 4/14/2023 indicated no documentation that the resident manifested S/S of UTI. The TAR indicated zero (0) for absence of S/S of UTI in the urine every shift. On 4/14/2023, there was no documentation of Resident 1 having a COC or being uncomfortable and moaning as identified by FM 1 and as reported to the staff of GACH 1. A review of Resident 1’s GACH 1 History and Physical (H & P), dated 4/14/2023, indicated the resident presented to the emergency department after the family requested the transfer, and requested to break (cancel) hospice if admission to the hospital was needed. The H & P indicated the resident was reportedly very uncomfortable and moaning at the facility and the facility was not ac