Other·March 27, 2024

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 §483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident’s immediate care and needs. §483.30(a) Physician Supervision. The facility must ensure that— §483.30(a)(1) The medical care of each resident is supervised by a physician. 22 CCR § 72303. Physician’s Services – General. (b) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. Physician services shall include but are not limited to: (2) An evaluation of the patient and review of orders for care and treatment on change of attending physicians. (4) Advice, treatment and determination of appropriate level of care needed for each patient. (5) Written and signed orders for diet, care, diagnostic tests and treatment of patients by others. 22 CCR § 72307. Physician Services - Supervision of Care. (a) Each patient admitted to the skilled nursing facility shall be under the continuing supervision of a physician who evaluates the patient as needed and at least every 30 days unless there is an alternate schedule, and who documents the visits in the patient health record. 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: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (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. On 2/6/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to ensure Resident 399, who was a newly admitted patient that required insulin shots for diabetes mellitus (DM – a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood] causing blood sugar (glucose) levels to be abnormally high), was provided quality of care and received nursing services, physician services, and treatment in accordance with the facility’s policies and procedures (P&Ps). The facility failed to: a. Follow its policies and procedures entitled, “Reconciliation of Medications on Admission,” when upon admission of Resident 399 to the facility, on 12/26/2024, MD 1 and Licensed Vocational Nurse 1 (LVN 1) did not perform a complete medication reconciliation (formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders) of the medications listed in the transfer medication orders from General Acute Care Hospital 1 (GACH 1) to be continued at the facility. b. Commence a meaningful initial assessment upon admission when nursing staff did not verify Resident 399’s diagnoses and medication and conduct an admission assessment to identify immediate care needs for Resident 399. c. Provide Physician’s services when MD 1 did not thoroughly review Resident 399’s discharge documents from GACH 1 including diagnoses and did not order medications to meet Resident 399’s diabetic care needs on admission. d. Follow the facility’s policy and procedure on “Diabetes – Clinical Protocol” on admission, including failure to identify Resident 399 as diabetic, assessing, and documenting the dose and time of most recent diabetic medication given at GACH 1, the blood sugar (BS) level history of 48 hours, usual patterns of BS before admission and failure to monitor BS throughout her care at the facility. e. Ensure nursing staff conducted a continuous assessment of Resident 399’s diabetic needs after admission (12/26/2023) and through 1/6/2024. f. Ensure that LVN 1 promptly notified a supervisor and the MD of the lack of physician’s order for a BS level of 475 milligrams per deciliter (mg/dL) which was abnormally high (normal fasting [not eating for at least eight hours] BS level is below 100 mg/dL and normal BS level at random time is below 200 mg/dL) and failed to promptly notify a supervisor and the MD of her elevated BS on 1/4/2024, including for additional communication with the Medical Director if necessary. g. Implement numerous other policies and procedures applicable to providing quality care and treatment to Resident 399. As a result, Resident 399 did not receive the needed insulin in GACH 1 medication orders for a total of 11 consecutive days (12/26/2023 to 1/6/20224). On 1/6/2024, Resident 399 required transfer to GACH 2 Emergency Room (ER) with extremely high BS levels leading to polyuria (frequent urination) and altered mental status (AMS - change in mental function characterized by confusion, disorientation, disordered perceptions) requiring hospitalization. A review of Resident 399’s Admission Record indicated the 95-year-old female resident was admitted to the facility from GACH 1 on 12/26/2023 with diagnoses including DM. A review of Resident 399’s Discharge Summary packet from GACH 1 sent with Resident 399 indicated the following: 1) Diagnosis of DM 2) A1C (a test indicating average BS levels for the last 3 months) level of 6.8% and 7% on 12/22/2023. 3) On insulin at home 4) Diabetic diet 5) Discharge medications included insulin glargine 25 units subcutaneous (SQ, injection under the skin) twice a day. A review of Resident 399’s Physician Orders on admission (12/26/2023) did not include an order for insulin glargine as indicated in GACH 1 discharge medication list. A review of Resident 399’s Care Plan, dated 12/26/2023, indicated the resident had DM and the interventions included giving medications as ordered by doctor and monitoring and documenting side effects and effectiveness. A review of Resident 399’s laboratory test results, with collection date of 1/3/2024, indicated a BS level result of 475 mg/dL on 1/3/2024 and the communication note dated 1/4/2023, by LVN 1 to MD 1 indicated MD 1 did not give any new order (to lower Resident 399’s BS level). A review of Resident 399’s licensed nurses Progress Notes, dated 1/5/2024, indicated Registered Nurse 1 (RN 1) informed MD 1 about Resident 399’s frequent urination. A review of Resident 399’s Physician Discharge Note, dated 1/6/2024 at 11:50 a.m., indicated Resident 399 was discharged to GACH 2 by MD 1 due to AMS. A review of Resident 399’s Situation, Background, Assessment Recommendation (SBAR, communication form between members of the health care team caring for the resident), dated 1/6/2024 and timed at 1 p.m. by LVN 2, indicated Resident 399’s confusion increased and MD 1 and Resident 399’s family were notified. A review of Resident 399’s Physician Orders, dated 1/6/2024 and timed at 3:04 p.m., indicated to administer Resident 399 insulin Humalog (fast-acting insulin) per sliding scale (dosing plan whereby the amount of insulin administered depends on the BS level). A review of Resident 399’s GACH 2 ER admission record indicated the resident was admitted on 1/6/2024 at 4:04 p.m. with extremely high BS levels, AMS and polyuria. On 1/6/2024 at 4:17 p.m., Resident 399’s BS level was greater than 600 mg/dL; at 4:32 p.m., the BS level was 861 mg/dL; at 8:07 p.m., the BS level was 581 mg/dL; at 9:07 p.m., the BS level was 581 mg/dL. At 11:22 p.m., Resident 399’s urine glucose level was greater than 1000 mg/dL and Resident 399 was having seizures (convulsions, burst of abnormal electrical signals in one or more parts of the brain that interrupt normal signals). During a first interview of LVN 1 on 2/7/2024 at 10:44 a.m., LVN 1 stated registered nurses (RNs) are responsible for admitting new residents to the facility and addressing discrepancies between the hospital discharge orders and current orders. LVN 1 stated for residents with DM, diabetic interventions should include BS control through diabetic diet, oral medications and/or insulin injections. LVN 1 stated residents with DM and history of insulin use at home or in the hospital should continue insulin upon admission to the facility. LVN 1 stated not continuing insulin can cause hyperglycemia (elevated BS levels) with symptoms of confusion, shakiness, loss of consciousness, polyuria, and, in severe cases, lead to death. During a second interview of LVN 1 on 2/7/2024 at 11:23 a.m., LVN 1 stated the discharge packet from the hospital is reviewed for new residents admitted to the facility. LVN 1 stated she verified upon admission Resident 399’s medication orders for Resident 399 with MD 1. LVN 1 stated she later noticed insulin was not ordered but did not follow-up with MD 1 or Nurse Practitioner 1 (NP 1) about the insulin orders for Resident 399. During a first interview of MD 1 on 2/7/2024 at 10:34 a.m., MD 1 stated he reviewed and completed Resident 399’s admission medication orders from the hospital discharge summary orders (MD 1 did not indicate the date). MD 1 stated he had reviewed Resident 399’s GACH 1 discharge summary, and no DM diagnosis or order for insulin was included. During a third interview of LVN 1 on 2/7/2024 at 3:22 p.m., LVN 1 stated she contacted MD 1 on 1/4/2024 for Resident 399’s BS level of 475 mg/dL and that Resident 399 has DM. LVN 1 stated MD 1 gave no new orders. During a second interview of MD 1 on 2/7/2024 at 1:30 p.m., MD 1 stated he did not receive communication from the facility on 1/4/2024 for Resident 399’s BS level of 475 mg/dL. MD 1 stated without completing a thorough assessment of a resident or having ruled out factors such as certain medications, urine infections, etc., elevated BS for DM patients may potentially result from not receiving insulin. During a fourth interview on 2/8/2024 at 4:34 p.m., LVN 1 stated that when MD 1 did not give any orders for Resident 399’s BS level of 475 mg/dL on 1/4/2024, she was concerned and flagged the chart for MD 1 to see it on the next visit to the facility. LVN 1 stated she did not know when MD 1 would visit Resident 399. LVN 1 stated she did not notify a supervisor or the DON about Resident 399’s elevated BS level on 1/4/2024 and MD 1’s the lack of orders or interventions. During an interview on 2/7/2024 at 10:50 a.m., RN 1 stated for new resident admissions the facility receives paperwork from the discharging hospital including a medication list. RN 1/ADON stated the admitting nurse calls the MD to review the medication list which the MD would continue. RN 1 stated Resident 399 was admitted to the facility on 12/26/2023 and during the admission process the insulin order for glargine was not read to MD 1. RN 1 stated Resident 399 was diabetic and LVN 1 and MD 1 should have identified the lack of medication for DM. RN 1 stated LVN 1 and MD 1 failed to complete appropriate medication reconciliation when not ordering insulin and BS checks for Resident 399. During an interview on 2/7/2024 at 10:51 a.m., RN 3 stated the admitting nurse, usually an RN, admits new residents to the facility. RN 3 stated new residents arrive to the facility with a packet of paperwork, and the admitting RN reviews the resident’s medication reconciliation list from the discharging hospital with another RN. RN 3 stated the MD reviews the hospital discharge summary orders for diagnosis and medication list to determine which medications to continue or discontinue. During an interview on 2/7/2024 at 1:18 p.m., the Pharmacy Consultant (PC) stated residents with diagnosis of DM and a care plan for DM should have orders for antidiabetic (to treat diabetes) medications. The PC stated missing 11 days of insulin administration for residents with history of insulin use from home or hospital can lead to AMS, polyuria, and BS levels greater than 500 mg/dL requiring hospitalization. During an interview on 2/7/2024 at 2:31 p.m., NP 1 stated that a medication reconciliation review is done with the nurses and MD. NP 1 stated that during interdisciplinary team (IDT) conference with the family, missed medications can be identified. NP 1 stated a DM care plan indicating to monitor for side effects and effectiveness indicates there is an order for antidiabetic medication. NP 1 stated BS level of 475 mg/dL is considered high and can lead to fatigue, loss of vision, weakness, polyuria, and may require hospitalization. During an interview on 2/7/2024 at 5:39 p.m., Med Dir 1 acknowledged the failure of MD 1 and LVN 1 not completing a thorough medication reconciliation for Resident 399 resulting in the resident missing insulin glargine for 11 days and subsequently requiring hospitalization. Med Dir 1 stated missing 11 days of insulin for a resident with DM can lead to hyperglycemia, coma, death, and hospitalization. Resident 399’s incomplete medication reconciliation led to the omission of 11 days of insulin administration resulting in Resident 399 experiencing AMS and polyuria requiring hospitalization. During an interview on 2/8/2024 at 1:07 p.m., Med Dir 2 (GACH 2 ER Medical Director) stated omitting 11 days of insulin glargine administration was a contributing factor for Resident 399’s severe hyperglycemia. During an interview on 2/8/2024 at 1:25 p.m., Doctor of Osteopathy 1 (DO 1) stated he reviewed (after the fact) Resident 399’s discharge summary packet from GACH 1 and stated based on the discharge medication list, he would have continued the insulin glargine, upon admission to the facility since Resident 399 had DM. DO 1 also stated he would have intervened with orders for a BS level of 475 mg/dl. DO 1 stated omitting 11 days of insulin administration was a contributing factor for Resident 399’s hyperglycemia and the continued hyperglycemia from the insulin omissions led to Resident 399’s hospitalization. During an interview and record review on 2/8/2024 at 1:36 p.m., Med Dir 1 stated the discharge summary packet from GACH 1 for Resident 399 and confirmed the packet indicated a diagnosis of DM, diabetic diet, A1C of 6.8 percent (%) and 7%, and an order for insulin glargine 25 units twice a day. Med Dir 1 stated these are indicators that Resident 399 had DM and should have been on antidiabetic medications. Med Dir 1 stated MD 1 should have reviewed the discharge summary packet from GACH 1 for Resident 399 and continued the insulin glargine upon admission to the facility. Med Dir 1 also stated the DM care plan developed on 12/26/2023 for Resident 399 included “Diabetes medications as ordered by doctor. Monitor/document for side effects (unwanted effects from medications) and effectiveness.” Med Dir 1 stated the facility did not follow or modify Resident 399’s care plan if it was not applicable. Med Dir 1 stated several syst