Health inspection·June 21, 2024

F635 42 CFR §483.20(a) Admission orders At the time each resident is admitted, the facility must have physician orders for the resident's immediate care. To ensure each resident receives necessary care and services upon admission.

F684 42 CFR § 483.25 Quality of Care 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:

F711 42 CFR § 483.30 Physician Visits? Review Care/Notes/Order §483.30(b) Physician Visits-The physician must §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders except for influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. On 5/1/24 at 10:33 am, California Department of Public Health (CDPH) conducted an unannounced visit to investigate a complaint regarding a patient's death. During the investigation, CDPH determined that the facility failed to ensure Patient 1 received treatment and care in accordance with professional standards of practice, Patient 1's care plan and the facility's policy and procedures for treatment and management of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar [glucose] levels because the body does not produce or use insulin [a type of hormone] normally and required blood sugar monitoring and/or medications to lower blood sugar levels) by failing to ensure: 1. Upon admission of Patient 1 to the skilled nursing facility on 4/12/23 the attending physician/Medical Doctor (MD) 1 or designee reviewed all appropriate General Acute Care Hospital (GACH) discharge orders for management of Patient 1's DM. 2. The Director of Nursing (DON) or designee thoroughly reviewed Patient 1's medical history of DM and discharge orders from the GACH, identified Patient 1's care needs which indicated patient was receiving Novolog Insulin (medication given by injection to lower blood sugar level) prior to admission to the facility, and verified with the physician if blood sugar monitoring and/or confirmed whether Insulin should be continued to be administered to the patient while residing in the facility. 3. To provide physician services because there were no orders to monitor Patient 1's blood sugar while receiving Januvia (a medication that lowers blood sugar level), or needed to continue insulin to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) for Patient 1 with diagnosis of DM. 4. To implemented Patient 1's care plan to monitor the patient for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) from the date of admission to the facility on 4/12/23 and discharged from the facility on 4/19/24 (a total of six days). 5. Follow facility's policies and procedures, on "Admission and Orientation of Patients", "Progress Notes, Physician's Orders", "Diabetic Care", and "Director of Nursing Services responsibilities." As a result of this deficient practices Patient 1 was transferred to the GACH via 911 (an emergency number for medical assistance) on 4/19/23 due to altered level of consciousness and was admitted to the Emergency Department (ED) and with blood sugar of 823 (normal blood sugar level is between 70 to 100) mg/dL (milligrams per deciliter, a unit of measurement). The patient was transferred to ICU (intensive Care Unit- a unit in the hospital for patients with life threatening condition) where patient received Aspersing (medications given into the vein to increase blood pressure which then increases the blood flow to the body) and continuous insulin drip (a hormone therapy continuously given directly into vein and enters the bloodstream to lower and/or control high blood sugar level) was started due to critical high blood sugar and was diagnosed with Diabetic Ketoacidosis (DKA, a serious complication of diabetes and occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Patient 1 required ICU care from 4/19/23 until Patient 1 expired on 4/25/23 at 8:07 PM (a total of 6 days after Patient 1 was admitted to the GACH) due to cardiac arrest (sudden, unexpected loss of heart function). A review of Patient 1's Admission Record indicated Patient 1 was a 78 year old female originally admitted to the facility on 4/12/23 with diagnoses that included DM, cerebral infarction (stoke or interruption of oxygen and blood flow to the brain resulting in brain cell death), hypertension (high blood pressure) and muscle wasting (decrease size and muscle tissue that cause body weakness and strength). A review of Patient 1's "Clinical Admission Evaluation" indicated Patient 1 was admitted to the facility on 4/12/23 at 8:20 PM. The Clinical Evaluation indicated Patient 1 had a diagnosis of DM. During a review of Patient 1's clinical record titled, Hospital Discharge Instructions, indicated Patient 1 was admitted to the GACH on 3/29/23 with diagnosis that included DM and was discharged to the facility on 4/12/24. The GACH record indicated Patient 1 received 6 units of Novolog on 4/12/23 at 12 PM for the blood sugar level of 241 mg/dL (eight hours prior to admission of the patient in the facility). A review of Patient 1's History and Physical (H&P), dated 4/13/23, indicated Patient 1 had fluctuating capacity to understand and make decisions. A review of Patient 1's Order Summary Report for April 2023, included to administer "Sitagliptin Phosphate (also known as Januvia- brand-name of an oral medication that control the blood sugar) an oral tablet 100 mg and give 1 tablet by mouth in the morning for DM with meal." A review of Patient 1's Medication Administration Record (MAR) for April 2023 indicated Patient 1 was administered Sitagliptin daily from 4/13/23 to 4/19/23. The MAR had no documented evidence that Patient 1's blood sugar was monitored. The MAR also did not show documented evidence that staff monitored Patient 1 for signs and symptoms of hypoglycemia or hyperglycemia, as indicated in the patient's care plan. A review of Patient 1's care plan for "Potential for injury related to hypoglycemia secondary to the use of oral hypoglycemic agents or insulin therapy", initiated on 4/13/23, created by Registered Nurse (RN) 1, indicated the facility staff are to "monitor for [signs and symptoms] of hypoglycemia and hyperglycemia such as changes on [level of consciousness], skin [temperature], change in mood, thirst and notify MD." A review of Patient 1's Skilled Evaluation form for the dates of 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, and 4/17/23 (a total of six days) did not have documented evidence that the licensed nurse verified with the Nurse Practitioner (NP) or MD 1 if the patient needed an order to check the blood sugar or to administer insulin based on the patient's history of diabetes and receiving insulin while in the GACH prior to admission to the facility. A review of Patient 1's Change in Condition Evaluation (CIC), dated 4/19/23, timed at 6:45 PM, indicated Patient 1 was found unresponsive on 4/19/23 at 6:30 P.M. The CIC report indicated Patient 1 had a pertinent diagnosis of diabetes. The CIC had no documented evidence Patient 1's blood sugar was checked when Patient 1 had a change of condition. The CIC indicated Patient 1's physician and family was notified. The CIC indicated Patient 1 was transferred via 911 to GACH. A review of Patient 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 4/19/23, indicated the patient had severely impaired cognition (ability to remember and process information). The MDS also indicated Patient 1 had a diagnosis of DM. A review of the paramedic run report indicated the paramedics arrived at the facility on 4/19/23 at 7:03 PM, and Patient 1's chief complaint was weakness and hyperglycemia. A review of Patient 1's Transfer Form, dated 4/19/23, timed at 7:15 PM, indicated Patient 1 was transferred back to GACH for the "loss of consciousness." The Transfer Form also indicated DM as a relevant diagnosis. The Transfer Form indicated 911 was called on 4/19/23 at 7 P.M. A review of Patient 1's Emergency Documentation Notes from GACH, dated 4/19/23, indicated the patient was admitted to the ED on 4/19/23 at 7:54 PM with chief complaint of hyperglycemia, family stated patient had not eaten for five days and had not been coherent. The notes indicated the blood sugar was "400+ on scene (in the facility from the 911 call)." The notes indicated Patient 1 "will need ICU admit" and was started on insulin drip at 6 units/h (units per hour). Additionally, the laboratory blood test results indicated the following: 1. High Potassium level 5.4 (normal range 3.5 to 5.0 Potassium is a mineral that helps the nerves, muscles to contract and helps the heartbeat to stay regular. A high potassium level can result in the heart to stop beating). 2. High White Blood Cells 20.6 (normal WBCs in the blood is 4,500 to 11,000 per microliter (4.5 to 11.0 × 109/L, high WBC level may indicate infection and inflammation). 3. High Lactate acid level 2.6 (normal range less than 1.0 millimoles per liter, a medical condition such as severe infection and uncontrolled blood sugar can cause a harmful buildup of lactate. This can lead to serious health problems and a life-threatening condition called lactic acidosis). A review of Patient 1's Critical Care In Patient (IP) Progress Notes from GACH, dated 4/19/23, timed at 10:57 PM, indicated Patient 1 was admitted to the Emergency Department (ED) with a blood sugar of 823 mg/dL and the patient's condition was "critical." A review of Patient 1's Progress Notes from GACH, dated 4/20/23, indicated Patient 1 was admitted back to GACH due to altered mental status, elevated blood sugar levels and was diagnosed with DKA. A review of Patient 1's Progress Note from the GACH, dated 4/21/23, timed at 12:06 PM, indicated Patient 1's overall condition was worsening in respiratory and neurological (brain function) status overnight and Patient 1 remained obtunded (less responsive to touch and pain stimuli) needing 100% Non-rebreathing mask (a type of respiratory mask that delivers high level of oxygen) and remained febrile (high body temperature) and the patient will be placed on mechanical ventilation (a machine that provides artificial breathing support to a person who is not able to meet their body's oxygen demand). A review of Patient 1's Procedure Note from GACH, dated 4/21/23, timed at 12:16 PM an endotracheal intubation (a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth to provide artificial breathing and life support) procedure was performed and Patient 1 was placed on mechanical ventilation on 4/21/23 at 12:16 PM. A review of Patient 1's Physician Orders of Medication from GACH indicated Patient 1 received the following medications between 4/19/23 to 4/25/23: a. Insulin drip: "Insulin regular IV (intravenous-given into the vein) additive 100 Unit(s) + NS [Normal Saline] 0.9% (base) 100 mL (milliliter-a unit of measurement)". The order was started on 4/19/23 at 11:12 PM and was discontinued on 4/20/23 at 12:15 PM and physician order for insulin was changed to ISS (insulin sliding scale-insulin dose given based on the blood sugar level) on 4/20/23. b. Vasopressin "Vasopressin IV additive 40 Unit(s) + NS 0.9% 100 mL". The physician order indicated to start on 4/21/23 at 8:30 PM. A review of Patient 1's Critical Care IP Progress Notes from GACH, dated 4/25/23, indicated Patient 1 was pronounced brain dead (when a person no longer has any brain functions) on 4/25/23 at 6 PM (five days after admitted back in GACH). A review of Patient 1's Certificate of Death, indicated Patient 1 died on 4/25/23 at 8:07 PM due to cardiac arrest (when the heart stops beating suddenly) as the primary cause of death. During a concurrent interview and record review of Patient 1's clinical records that included the physician orders, Order Summary report, Nursing Progress notes and MAR on 5/1/24 at 11:41 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Patient 1 had no physicians' order to receive insulin or to monitor for blood sugar. LVN 1 stated there was no evidence that Patient 1 was administered any insulin or had her blood sugars monitored during the patient's stay in the facility. LVN 1 stated Patient 1 had a diagnosis of DM and included insulin as one of the medications Patient 1 was ordered to receive in GACH. During an interview on 5/3/24 at 11:08 AM, MD 1 stated most oral diabetic medications like Sitagliptin do not drastically lower the blood sugar. MD 1 stated "putting an order to monitor the patient's blood sugar would depend on the orders sent by the transferring hospital." MD 1 stated "continuation of insulin and blood sugar monitor would depend on the discharge paperwork provided by the hospital to the facility and