Health inspection·September 6, 2024

§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 with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. § 72303. Physician Services--General Requirements. (a) All persons admitted or accepted for care by the skilled nursing facility shall be under the care of a physician selected by the patient or patient's authorized representative. (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: (1) Patient evaluation including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission. (2) An evaluation of the patient and review of orders for care and treatment on change of attending physicians. (3) Patient diagnoses. (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. Orders for restraints shall meet the requirements of Section 72319(b). (6) Health record progress notes and other appropriate entries in the patient's health records. (7) Provision for alternate physician coverage in the event the attending physician is not available. On 7/17/2024 the California Department of Public Health (CDPH) made an unannounced visit to investigate a complaint regarding quality of care received on 7/11/2024. The resident (Resident 1) was not provided her prescribed regular medication by the facility’s physician (Primary Medical Doctor 1 [PMD 1]) upon being admitted to the facility from General Acute Care Hospital 1 (GACH 1). The facility failed to ensure that the primary care physician (PMD 1) for Resident 1, who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth, and metabolism] into the bloodstream), reviewed Resident 1’s GACH 1’s progress notes, including medications essential to Resident 1’s medical treatment. PMD 1 failed to prescribe Resident 1 her routine medication (medication taken regularly) of Levothyroxine (a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy) upon admission to the facility on 5/26/2024. As a result, Resident 1 did not receive 30 doses of Levothyroxine from 5/26/2024 to 6/25/2024. Subsequently, Resident 1 was transferred to GACH 2 where Resident 1 was diagnosed with myxedema coma (severe hypothyroidism leading to decreased mental status [mental capacity], hypothermia [dangerously low body temperature], and other symptoms related to slowing of function in multiple organs) requiring Resident 1 to be admitted into the Intensive Care Unit (ICU- a unit in a hospital providing intensive care for critically ill patients) on 6/25/2024. A review of Resident 1’s Admission Record indicated that Resident 1 was admitted to the facility on 5/26/2024 with diagnoses that included hypothyroidism. A review of Resident 1’s History and Physical (H&P) from GACH 1, completed by PMD 1, dated 5/23/2024, the H&P indicated that Resident 1 was admitted to GACH 1 on 5/23/2024. Listed under Resident 1’s medical history was a diagnosis of hypothyroidism. The H&P further indicated that Resident 1’s routine home medications included Levothyroxine 100 micrograms (mcg-unit of measure), one tablet to be taken by mouth once a day. A review of Resident 1’s H&P completed by PMD 1 (same physician in charge of Resident 1 while at GACH 1 and while in the facility) at the facility, dated 6/13/2024, indicated that Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated that Resident 1’s medical history included a diagnosis of hypothyroidism. A review of Resident 1’s Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 6/1/2024 indicated that Resident 1’s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required set up assistance with eating; supervision with oral hygiene; moderate assistance with personal hygiene; and maximum assistance with toileting hygiene and bathing. During a review of Resident 1’s Physician Orders from 5/26/2024 to 6/25/2024, the Physician Orders for Resident 1 did not indicate an order for Levothyroxine. During a review of Resident 1’s Change of Condition (COC- a sudden deviation from a resident’s health status) dated 6/25/2024, the COC indicated that on 6/25/2024 at 9:52 a.m., Resident 1 passed out in the shower room. The COC further indicated at 9:54 a.m., Resident 1 regained consciousness (the state of being awake and aware of one's surrounding) and was verbally responsive. On 6/25/2024 at 10:07 a.m., emergency services was called via 911 and on 6/25/2024 at 10:22 a.m., paramedics arrived at the facility, took over Resident 1’s care and transferred Resident 1 to GACH 2. A review of Resident 1’s Discharge Summary (DS) from GACH 2, dated 7/5/2024, indicated that Resident 1 was admitted to GACH 2 on 6/25/2024 with diagnoses that included myxedema coma. The DS indicated that Resident 1 had a history of thyroidectomy (surgical removal of all or part of the thyroid gland) and was previously prescribed Levothyroxine, but Levothyroxine was not continued for the past several months. The DS indicated that Resident 1 had severely elevated thyroid stimulating hormone (TSH- a blood test that measures thyroid stimulating hormone [normal TSH level is 0.5 to 5.0 milli-internal units per liter {mIU/L- unit of measure}]) and low thyroxine test (T4- a blood test that measures the level of thyroxine in the blood [normal T4 level is 0.8 to 1.9 nanograms per deciliter {ng/dL-unit of measure}]) dated 6/26/2024. Resident 1 was found to have profound hypothyroidism and myxedema coma with an initial TSH level drawn on 6/26/2024, TSH level greater than 150 mIU/L. Resident 1 was initiated on Levothyroxine intravenous (into the vein). The DS also indicated that Resident 1’s thyroid function was noted to be severely affected. An interview on 7/24/2024 at 11:48 a.m. with PMD 1, PMD 1 stated that he (PMD 1) was the primary care physician for Resident 1 during Resident 1’s stay at GACH 1 and at the skilled nursing facility. PMD 1 stated that Resident 1 had a history of hypothyroidism. When PMD 1 was asked if PMD 1 reviewed Resident 1’s routine home medications that indicated that Resident 1 was taking Levothyroxine, PMD 1 stated that he (PMD 1) did not review Resident 1’s routine home medications list. PMD 1 stated that had he (PMD 1) reviewed Resident 1’s routine home medications list, PMD 1 would have noted that Resident 1 was prescribed Levothyroxine and PMD 1 would have continued Resident 1’s previously prescribed Levothyroxine. PMD 1 further stated “it’s a big problem” Resident 1 ended up with myxedema coma as a result of the lack of Levothyroxine, an essential medication needed for Resident 1’s diagnosis of hypothyroidism. During an interview and concurrent record review on 7/24/2024 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1’s H&P from GACH 1, completed by PMD 1, dated 5/23/2024; Resident 1’s H&P at the facility, completed by PMD 1, dated 6/13/2024, and Resident 1’s Physician Orders from 5/26/2024 to 6/25/2024. The DON verified the Physician Orders for Resident 1 did not indicate an order for Levothyroxine. The DON stated PMD 1 did not prescribe Resident 1 Levothyroxine throughout Resident 1’s stay at the facility. The DON stated PMD 1 should have reviewed Resident 1’s total program of care including the list of medications and treatments upon admission to GACH 1 and upon admission to the facility vital to Resident 1’s health and well-being. During a review of the facility policy and procedure (P&P), titled Physician Services and Orders dated January 2017, last reviewed on 8/17/2023, the P&P indicated that it is the policy of the facility that each resident remain under the care of a physician. Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services…The physician must review the resident’s total care at each visit, write, sign and date progress notes and sign and date all orders. This includes reviewing medications and treatments. The facility failed to ensure that the primary care physician (PMD 1) for Resident 1, who had a history of hypothyroidism reviewed Resident 1’s GACH 1’s progress notes, including medications essential to Resident 1’s medical treatment. PMD 1 failed to prescribe Resident 1 her routine medication of Levothyroxine upon admission to the facility on 5/26/2024. As a result, Resident 1 did not receive 30 doses of Levothyroxine from 5/26/2024 to 6/25/2024. Subsequently, Resident 1 was transferred to GACH 2 where Resident 1 was diagnosed with myxedema coma requiring Resident 1 to be admitted into the ICU on 6/25/2024. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.