Health inspection·September 20, 2024

F635- Admission Physician Orders for Immediate Care §483.20(a) Admission orders- At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care.

F656 – Comprehensive Care Plans §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. (2) A comprehensive care plan must be— (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to— (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

F684- Quality of Care § 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 patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices[.] On 8/8/2024 at 9:30 AM, the California Department of Public Health [CDPH] conducted an unannounced visit to the facility, to investigate a complaint regarding patient neglect and quality of care. Patient 1 was admitted to the facility with a diagnosis of Diabetes Mellitus ([DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body). For 61 days, the facility did not monitor Patient 1’s blood sugar and did not provide Patient 1 with DM medication (insulin). CDPH determined that the facility did not provide quality of care in accordance with professional standards of practice. This resulted in Patient 1’s hospitalization and subsequent death. The facility failed to: 1. Identify Patient 1’s care needs and failed to develop and update a care plan to adequately address Patient 1’s DM diagnosis when the facility’s licensed staff did not review and address Patient 1’s discharge orders from General Acute Care Hospital (GACH) 1 that indicated Patient 1 required DM management, that Patient 1 received insulin in GACH 1, and would need follow up with a physician for DM care, and an appointment with a Neurologist (a doctor that specializes in the treatment of diseases that affect the brain). The facility also failed to provide nursing services and care planning when the nursing staff did not request physician’s orders for medication and blood sugar monitoring of Patient 1. 2. Implement Patient 1’s care plan (dated 2/8/2024 revised on 2/17/2024) interventions to monitor, document, and report on the patient for signs and symptoms of hypoglycemia and hyperglycemia. There was no documented evidence of diabetes management that included blood sugar monitoring, insulin administration, and no monitoring to prevent hyperglycemia (high blood sugar level) and hypoglycemia (low blood sugar level) while the patient resided in the facility from 2/8/2024 to 4/9/2024. 3. Provide physician’s services when the facility’s physician did not give orders for blood sugar monitoring. The physician did not follow pharmaceutical and physician service requirements when MD 1 gave an order on 2/8/2024 to administer insulin, but did not follow up to sign their medication orders to treat Patient 1’s diagnosis of DM. The facility did not provide documentation that a physician evaluated Patient 1 for DM care and treatment. 4. Arrange for pharmaceutical services for Patient 1 and ensure that the facility's Pharmacist Consultant (PH) 1 provided consultation, development, coordination, and supervision of pharmaceutical services for Patient 1’s diagnosis of DM. The Medication Regimen Review (MRR, a process conducted by a pharmacist, to review a patient’s medications) did not indicate PH 1’s recommendations for blood sugar monitoring or insulin regimen to manage Patient 1’s DM. 5. Ensure the facility's Interdisciplinary Team (IDT- a group of professionals with different areas of expertise who work together to achieve a common goal) assessed Patient 1’s needs and developed a care plan for DM, including a review of the patient's records to ensure the care plan was being followed. 6. Implement the facility's policy and procedure titled, "Admission Assessment," when another licensed nurse did not complete a drug regimen review on or after Patient 1’s admission in the facility to identify any potential or actual clinically significant medication issues. The facility failed to implement the facility's policies and procedures titled "Diabetic Care", “Drug Regimen Review”, “Care Planning” and “Admission and Orientation of Patients.” The facility also failed to implement various job descriptions. As a result of these failures, Patient 1 had a change in condition on 4/9/2024, manifested by altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), oxygen desaturation (blood oxygen levels drop below a normal range [normal levels are 96 to100 %]) of 77% and a blood sugar of 500 (normal blood sugar levels are between 70 to 100). Patient 1 was transferred to GACH 2 via 911 emergency services. Patient 1’s blood sugar result from the GACH 2 indicated a blood sugar of 810 on 4/9/2024. Patient 1 died at the GACH 2 due to Diabetic Ketoacidosis (DKA - a life-threatening complication of diabetes when the body does not have enough of a hormone called insulin) on 4/11/24. Patient 1’s immediate cause of death was Diabetic Ketoacidosis with an underlying cause of death from DM Type 2. A review of Patient 1’s GACH 1 record, titled, "Inpatient Progress Notes," dated 2/6/2024, indicated Patient 1 had a diagnosis of DM... The GACH 1 record indicated a plan to continue Patient 1’s insulin medication to maintain a blood sugar goal of less than 180. A review of Patient 1’s GACH 1 record titled "Discharge Documentation" dated 2/8/2024, timed at 11:07 AM, indicated "Issues to Address on Outpatient Follow Up/Discharge Action Plan" to have continued diabetes management in the facility. The record indicated Patient 1 received insulin in GACH 1 and will need a physician to "[follow up] for DM care." Further review of the Discharge Documentation indicated Patient 1’s last blood sugar result in GACH 1 on 2/8/2024 was 157. The record also indicated under, “Appointments Pending to Be Scheduled,” that Patient 1 required a follow up appointment with a neurologist within two weeks of the GACH 1 discharge. A review of Patient 1’s Admission Record, dated 8/8/2024, indicated the patient was admitted to the facility on 2/8/2024, with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process]) abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure). A review of Patient 1’s "Nursing Admission Assessment," dated 2/8/2024, timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the patient was admitted to the facility on 2/8/2024 at around 5:10 P.M. The "Nursing Admission Assessment" indicated Patient 1 had a diagnosis of DM Type 2. A review of Patient 1’s nursing care plan titled, "The patient [Patient 1] has DM," initiated on 2/8/2024 and revised on 2/17/2024, indicated a goal for the patient to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia. The care plan interventions indicated “Diabetes Medication as ordered by the Doctor. Monitor/document for side effects and effectiveness.” A review of Patient 1’s Order Summary Report (OSR) for all orders during Patient 1’s stay at the facility from 2/8/2024 to 4/9/2024, included MD1’s order on 2/8/2024 to administer "Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar)." The OSR indicated the order for Insulin Lispro sliding scale was discontinued by MD 1 on the same date, 2/8/2024. A review of Patient 1’s facility records titled, "Discontinue Order," dated 2/8/2024, timed at 11:17 PM, authored by LVN 1, indicated a telephone order from MD 1, for Insulin Lispro Sliding Scale to discontinue on 2/8/2024, timed at 11:16 PM. The record indicated the reason for discontinuing was "Clarification of Order." A review of Patient 1's History and Physical (H&P), dated 2/12/2024, signed by MD 1, indicated the patient did not have the capacity to understand and make decisions. The H&P indicated Patient 1 had a diagnosis of DM. A review of Patient 1’s IDT Conference Record, dated 2/13/2024, signed by different members of the facility’s IDT from the Nursing Department, Activities Department, and Social Services, participated by Patient 1’s family member (FM 1), indicated Patient 1 had a diagnosis that included dementia and DM Type 2. The IDT Record indicated Patient 1’s plan of care to receive physical therapy (a healthcare profession that helps an individual’s body improve and perform physical movements) and occupational therapy (therapy based on engagement in meaningful activities of daily life) while residing at the facility and the discharge goals to go home with FM 1. The IDT Conference Record did not indicate information that IDT addressed Patient 1’s plan of care for management of DM. A review of Patient 1’s Admission MDS, dated 2/15/2024, indicated the patient had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The Admission MDS does not mention Patient 1 had an order for insulin and did not include patient's diagnosis of DM. A review of Patient 1’s Change in Condition Evaluation (CIC), dated 4/9/2024, timed at 7:04 PM, indicated Patient 1 was found to have labored breathing and with a blood sugar level of 500. The CIC indicated Patient 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Patient 1’s family were notified. The CIC indicated Patient 1 was transferred via 911 emergency services to GACH 2 on 4/9/2024. A review of Patient 1’s Transfer Form, dated 4/9/2024, indicated Patient 1 was transferred to GACH 2 on 4/9/2024. The Transfer Form indicated the reason for the transfer was due to "altered mental status." A review of Patient 1’s GACH 2 "Emergency Department [ED] Reports" dated 4/9/2024, indicated the patient was admitted to the ED on 4/9/2024 at 6:48 PM with a chief complaint of altered mental status and having a blood sugar of "High [a glucometer (a portable device used to measure blood sugar levels) reading that means a very high blood sugar level above 600]." The GACH 2 ED Report indicated "At around 5:50 PM, [Patient 1] refused her dinner and threw her juice on the floor and refused to eat. When [Patient 1] was reevaluated they [GACH 2 staff], noted that she [Patient 1] was breathing heavily [difficulty breathing] and not speaking." The GACH 2 ED Report indicated their staff "tried to measure [Patient 1’s] [blood] sugar, and the glucometer read as high." Th