Health inspection·June 13, 2024

22 CCR § 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 22 CCR 72311. Nursing Service – 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility’s inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. 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. 42 CFR F698 Dialysis §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. On 4/30/24, the California Department of Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to ensure patient’s dialysis treatments were followed for Patient 1, who was to receive scheduled dialysis treatments on Tuesdays, Thursdays, and Saturdays, as ordered by the physician. The facility failed to arrange services to transport Patient 1 to and from the off-site certified dialysis facility (an entity that provides outpatient maintenance dialysis services) for dialysis treatments on 4/13/2024 and 4/16/2024. As a result, Patient 1 missed two dialysis treatments scheduled on 4/13/24 and 4/16/2024. In addition, Patient 1 was transferred to the General Acute Care Hospital (GACH) Emergency Department (ED) for weakness and lethargy. GACH 1 ED report dated 4/17/24 indicated Patient 1 was at risk for central nervous system [brain and spinal cord (a long, tube-like band of tissue that connects the brain to the lower back), cardiopulmonary (heart and lungs), metabolic (chemical changes that take place in a cell or an organism to produce energy and basic materials needed for important life processes), renal demise (dying of kidney) and required aggressive intervention. A review of the facility’s “Preadmission Report – Patient Analysis” for Patient 1 dated 4/11/2024, indicated Patient 1 ’s diagnosis included being “dialysis dependent.” The Preadmission Report indicated Patient 1 ’s dialysis days were scheduled on Tuesdays, Thursdays, and Saturdays. The Preadmission Report indicated “blank” under transportation. A review of Patient 1 ’s Admission Record indicated the facility admitted a 51 year old male patient on 4/11/2024, with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) Stage 3, Type 2 diabetes mellitus (a disease that occurs when the body’s blood sugar is too high), dependence on renal dialysis, hypertension (high blood pressure). The Admission Record indicated Patient 1 as self-responsible and listed Family Member (FAM) 1 in the contact information as the first contact for Patient 1. A review of Patient 1 ’s “History and Physical (H&P),” dated 4/11/2024, indicated Patient 1 had the capacity to make decisions or make needs known. The H&P indicated Patient 1 had generalized weakness that needed maximal assist (helper does more than half the effort) for transfers, unable to balance sitting, standing and unable to ambulate. A review of Patient 1 ’s “Clinical Physician Orders,” dated 4/12/2024 (Friday), indicated Patient 1 ’s physician order to have dialysis with chair time at 3:45 am to 7:30 am, scheduled every Tuesdays, Thursdays, and Saturdays. A review of the facility’s internal communication record, titled “Care Communication,” dated 4/13/2024 (Saturday) timed at 6:56 am, indicated a communication entry for Patient 1 that indicated, “Scheduled dialysis T-Th-S (Tuesday-Thursday-Saturday) with 3:45 am chair time (dialysis appointment time). No one showed up to pick up patient this morning. Please arrange transportation.” A review of an email communication from the facility’s Admission Specialist (AS) dated 4/13/2024 timed at 9:56 am, addressed to the facility’s corporate office and courtesy copies sent to the interim DON, Administrator (ADM), and the Admission Coordinator (ADC) indicated, “We have an issue with transportation... The patient does not qualify for routine transportation, including dialysis, only for emergency to hospital...The courtesy ride did not show up to pick up patient today for dialysis per nursing notes.” A review of Patient 1 ’s “Nursing Progress Note,” for April 2024 indicated the following documented information: 1. On 4/11/2024 timed at 2:29 PM, the progress notes indicated Patient 1 was admitted to the facility via ambulance, with all orders verified with attending physician. The progress note indicated Patient 1 had a right chest Perma catheter intact and with dry dressing. The progress note indicated Patient 1 ’s last dialysis was performed on 4/10/2024. The progress notes indicated “continue to monitor pt. (patient), endorsed.” The Nursing Progress Notes from 4/13/2024 to 4/15/2024, did not indicate an entry indicating any missed scheduled dialysis treatment to Patient 1 on 4/13/2024 or if a dialysis treatment was rescheduled, and/or if attending physician was notified. 2. On 4/16/2024 timed at 6 am, the progress note authored by Licensed Vocational Nurse (LVN) 1 (11 pm to 7 am shift), indicated “No transportation showed up to pick up patient for dialysis treatment. RN (registered nurse) made aware and followed up with dialysis. New schedule received for chair time (dialysis treatment] today at [1:30 pm]. Patient [1] made aware.” 3. On 4/16/2024 timed at 7:20 am, another progress note entry authored by LVN 1 (11 pm to 7 am shift), indicated “Endorsed to morning shift LVN and SSD (social services designee) to follow up transportation.” 4. On 4/17/2024 timed at 1:17 am, a progress note authored by LVN 1 (11 pm to 7 am shift), indicated “Patient [1] missed dialysis. No signs of distress noted.” Another note indicated, “Transfer patient to [GACH1].” 5. On 4/17/2024 timed at 5:59 am, another progress note entry authored by LVN 1 (11 pm to 7 am shift), indicated “Patient [1] in bed slept in long intervals... Currently being monitored due to missed dialysis... No signs of fluid overload... Also, on monitoring for poor PO intake.” 6. On 4/17/2024 timed at 2:41 pm (7 am to 3 pm shift), the progress note authored by RN Supervisor (RNS) 2 indicated, Patient 1 was picked up by the ambulance to transfer to GACH 1 in stable condition. The progress note indicated FAM 1 was informed of the GACH 1 transfer due to missed dialysis treatment. A review of Patient 1 ’s “Clinical Physician Orders,” dated 4/17/2024, indicated to transfer the patient to the acute hospital (GACH 1) related to two missed dialysis treatments, poor intake, for treatment and further evaluation. A review of Patient 1 ’s GACH 1 ED record, dated 4/17/2024 timed at 3:16 am, indicated Patient 1 was seen by the GACH 1 physician for dizziness and syncope with chief complaint indicating “dialysis patient refusing dialysis” and presented with weakness, malaise (discomfort, illness or lack of well-being)/fatigue (extreme tiredness and lack of energy). The record also indicated “the patient was at risk for central nervous system, cardiopulmonary, metabolic, renal demise and required aggressive intervention.” A review of Patient 1 ’s GACH 1 record titled “Physician History and Physical,” dated 4/18/2024 timed at 2:09 pm, indicated Patient 1 was admitted to GACH 1 with weakness lethargy (lack of energy). The record also indicated “patient is extremely lethargic, somnolent (drowsy) and difficult to verbalize complaints.” During a concurrent interview and record review of the facility’s internal communication record, titled “Care Communication,” dated 4/13/2024 (Saturday) timed at 6:56 am, on 4/30/2024 at 3:30 pm, RNS 1 stated, the communication record indicated Patient 1 had missed a dialysis treatment on 4/13/2024, but was not documented in the resident’s records. RNS 1 stated the missed dialysis treatment on 4/13/2024 should be documented in Patient 1 ’s medical records to make sure everyone who took care Patient 1 be aware of the situation. RNS 1 further stated the physician should be informed on the same day for recommendations and monitoring. After reviewing Patient 1 ’s “Change of Condition,” “Nurses Progress Notes,” “Orders Summary” and “Care Plan” since admission (4/11/2024), RNS 1 stated, he could not find any documents in Patient 1 ’s record to indicate that Patient 1 had missed a dialysis treatment and if it was reported to the physician on 4/13/2024. During an interview on 4/30/2024 at 4:21 pm, with the Admission Specialist (AS), the AS stated, Patient 1 was admitted to the facility on 4/11/2024 and had a scheduled dialysis treatment on 4/13/2024. The AS stated, the transportation did not come to pick up Patient 1 on 4/13/2024, so the AS was informed by the facility’s staff nurse (unable to recall nurse). The AS stated, he contacted Patient 1 ’s insurance company and was informed that Patient 1 did not have transportation benefits. The AS stated, he emailed the facility’s department heads, including the Admission Coordinator (ADC), the Administrator, and the interim DON to inform them about Patient 1 ’s transportation benefit issues on 4/13/2024. During an interview on 4/30/2024 at 4:44 pm with the ADC, the ADC stated, the Social Service Worker (SSW) usually takes care of dialysis transportation. The ADC stated, she did not inform the SSW when she was informed by the AS on 4/13/2024 that Patient 1 had missed his scheduled dialysis treatment on 4/13/2024, due to no transportation benefit because it was a Saturday. During an interview on 4/30/2024 at 5 pm with the SSW, the SSW stated, she did not know that Patient 1 had missed his scheduled dialysis treatment on 4/13/24, due to transportation benefit issue. The SSW stated, she was made aware of Patient 1’s missing dialysis treatment on 4/16/2024 but did not know that it was the second time Patient 1 missed his dialysis treatment. The SSW stated, if she was made aware on 4/13/2024 and was sure that it was because of the transportation benefit issue, she would provide other solutions so that Patient 1 would not miss his second dialysis treatment on 4/16/2024. The SSW stated, the second missed dialysis treatment should had been prevented if SSW was notified by facility staff (AS, ADC, ADM, DON) on 4/13/2024. During an interview on 5/1/24 at 11 am with Patient 1 ’s FAM 1, FAM 1 stated, she told the facility’s staff nurse (could not recall the staff’s name) when Patient 1 was admitted on 4/11/2024 that Patient 1 was dependent on dialysis and that it was very important that he should not miss any dialysis treatment. FAM 1 stated, she was not informed that Patient 1 had missed a dialysis treatment on 4/13/2024. FAM 1 stated, when she called the facility for an update on Patient 1 (4/17/2024), she was informed that Patient 1 was already transferred to the acute hospital because “he was getting very sick.” During an interview on 5/1/2024 at 1:12 pm, with the interim Director of Nurses (DON), the DON stated, he received the email from the AS on 4/13/2024, but did not check the situation so he was not aware of the resident’s transportation issue. The DON stated, if he was aware of the transportation issue on 4/13/2024, he would follow up with the physician and the SSW to resolve it timely, which could prevent the second missed dialysis treatment on 4/16/2024. During an interview on 5/1/2024 at 2:39 pm with LVN 1, LVN 1 stated, he worked night shift on 4/15/2024 from 11 pm to 7 am up to the morning on 4/16/2024. LVN 1 stated, Patient 1 was scheduled for dialysis treatment and was supposed to be picked up around 4 am on 4/16/2024 but the transportation did not show up. LVN 1 stated he informed the RNS in charge so she could reschedule the dialysis for another time. LVN 1 stated, Patient 1 did not refuse any dialysis treatment. A review of the facility’s policy and procedure titled, “End Stage Renal Disease, Care of a Resident With,” dated September 2010, indicated “Residents with End Stage Renal Disease will be cared for according to currently recognized standards of care.” The policy indicated “The resident’s comprehensive care plan will reflect the resident’s needs related to ESRD/dialysis care.” The facility failed to ensure the patient’s needs related to dialysis treatments for Patient 1, who was to receive scheduled dialysis treatments on Tuesdays, Thursdays, and Saturdays, as ordered by the physician. The facility failed to arrange services to transport Patient 1 to and from the off-site certified dialysis facility for dialysis treatments on 4/13/2024 and 4/16/2024. As a result, Patient 1 missed two dialysis treatments scheduled on 4/13/24 and 4/16/2024. In addition, Patient 1 was transferred to the GACH ED for weakness and lethargy. GACH 1 ED report dated 4/17/24 indicated Patient 1 was at risk for central nervous system, cardiopulmonary, metabolic, renal demise and required aggressive intervention. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1 and other residents receiving dialysis treatment.