Health inspection·May 2, 2024

42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(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. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). 42 CFR §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2) For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that— (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 22 CCR §72311 (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 3/21/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1, who was at risk for urinary tract infection (UTI - infection that happens when germs infect the urinary tract), received care and services to prevent UTI. Resident 1 has an indwelling urinary catheter (also known as Foley catheter, a hollow flexible tube inserted in the bladder through the urethra to drain urine) and the facility failed to: 1. Accurately and continuously monitor Resident 1 for signs and symptoms of UTI to prevent complications. 2. Monitor and accurately document Resident 1’s urine characteristics (color, transparency, amount, odor, pain or discomfort, presence of blood [hematuria], etc.) to promptly identify UTI and intervene to mitigate the infection and prevent complications as indicated in the plan of care. As a result, on 3/4/2024 at 7:54 p.m., Resident 1 required emergency transfer by paramedics who, upon arrival to the facility, found Resident 1’s indwelling catheter tube (connects the indwelling catheter to the urine drainage bag) dark brown and murky in appearance. At the General Acute Care Hospital 1 (GACH 1), Resident 1 was diagnosed with severe sepsis (a life-threatening emergency that happens when the body's response to an infection damages vital organs often causing death) and UTI. A review of Resident 1’s Admission Record indicated the facility admitted the 76-year-old male resident on 10/13/2023 and was last readmitted on 2/21/2024. Resident 1 diagnoses included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar [glucose] and using it for energy), UTI, and urinary retention. A review of the Physician’s Orders for Resident 1’s re-admission dated 2/21/2024, indicated to provide indwelling catheter care every shift, change bedside drainage bag every Friday and as needed, and change catheter as needed when clogged, soiled, or pulled out. A review of Resident 1’s nursing re-admission dated 2/21/2024, assessment indicated Resident 1 was unable to understand and make decisions and required extensive to total care with activities of daily living (ADLs, such as transfers, hygiene, toilet use, and personal hygiene). A review of Resident 1’s Change of Condition (COC)/Interactive Assessment form, dated 2/29/2024, indicated Resident 1 pulled out the indwelling catheter and had hematuria (presence of blood in urine). The catheter was replaced, and hematuria was then noted to be flowing into his urinary drainage bag. The physician was informed and ordered to monitor Resident 1. A review of Resident 1’s Care Plan, developed on 3/1/2024, regarding Resident 1’s pulling out the indwelling catheter, indicated interventions that included monitoring for signs and symptoms of UTI and to notify physician as indicated. A review of Resident 1’s Care Plan, developed on 3/1/2024, regarding Resident 1’s alteration in urinary elimination and at risk for UTI secondary to use of the indwelling catheter, indicated interventions that included changing catheter / bag as ordered, monitoring urine for sediment, cloudiness, odor, blood and amount of urine output; report urine output findings; and monitor Resident 1 for pain, elevated temperature, increased heart rate, and decreased blood pressure, or change in level of consciousness, and promptly to the physician. A review of Resident 1’s Total Intake and Output Record from 2/22/2024 to 3/3/2024 indicated recording every shift (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.) of the intake of liquids and the output of urine. The form included a description of the urine for the week. The forms indicated Resident 1’s urine was yellow, clear, and with normal odor. There was no recording of intake and output for 3/4/2024. A review of Resident 1’s COC/Interactive Assessment form, dated 3/4/2024, indicated that at 7:40 p.m., Resident 1 was visited by a family member and was seen “leaning forward drastically while experiencing vigorous checks.” Resident 1’s temperature was 99.3 degrees Fahrenheit (ºF, normal range is between 97 to 99 ºF), the blood pressure was 142/92 millimeters of mercury (mmHg, normal range is between 90/60 to 120/80 mmHg), the heart rate was 145 beats per minutes (bpm, normal range is between 60 to 100 bpm), and the blood glucose was 401 milligrams per deciliters (mg/dL, normal range is between 70 to 100 mg/dL), the oxygen saturation (O2 Sat, amount of oxygen a person has circulating in the blood) was 99% (normal level is 95% or higher). The paramedics were called and took Resident 1 to GACH 1. A review of the paramedics Patient Care Report, dated 3/4/2024, indicated an arrival time to Resident 1’s bedside at 8 p.m. Resident 1’s blood pressure reading was 120/52 mmHg, the heart rate was 130 bpm, and the blood glucose was 401 mg/dL. Resident 1’s indwelling catheter tube was dark brown and murky in appearance, the tube seemed to be backed up or clogged. A review of Resident 1’s GACH 1 Admission Record, dated 3/4/2024, indicated Resident 1 arrived with altered level of consciousness (ALOC, a change in a patient's state of awareness), fever of 104 ºF, and O2 Sat of 80%. Resident 1 was assessed with dry mucous membranes and dark orange urine. Resident 1 was diagnosed with sepsis and UTI and was admitted for intravenous (IV) antibiotics (medications given to treat infections). During an interview on 3/21/2024 at 12:19 p.m., Treatment Nurse 1 (TN 1) stated that a resident with a foley catheter, the nurse must flush the catheter as ordered and as needed, monitor catheter, output, sediment, hematuria, and report to the physician, and change it when it is clogged or pulled out. TN 1 stated that if the catheter is not being monitored, the nurse will not be able to determine if there is a change in the resident, which can lead to a delay in care. TN 1 stated that the only issue Resident 1 was having with the foley catheter was hematuria. During an interview on 3/21/2024 at 1:40 p.m., Licensed Vocational Nurse (LVN 1) stated that for residents with indwelling catheters the nurse must check urine in the catheter bag per shift, check for signs of infection, and ensure the catheter bag is below the bladder. LVN 1 stated for sign of infection, the nurse must look for blood, cloudiness, and any pain. During an interview on 3/22/2024 at 4 p.m., LVN 2 stated he worked with Resident 1 on 3/4/2024 before the resident was transferred to the hospital. LVN 2 stated Resident 1’s urine was dark. LVN 2 stated around 7 p.m. Resident was shaking and unable to sit straight while sitting up in the wheelchair. LVN 2 stated Resident 1’s urine was dark due to the hematuria. LVN 2 stated the treatment nurse is the one that documents about the catheter including any changes or signs of infection. LVN 2 stated for the output it is measured by the certified nursing assistants (CNAs) at the end of the shift and LVNs will document it. During an interview on 3/22/2024 at 4:43 p.m., the Director of Nursing (DON) stated for residents with indwelling catheters all nursing staff must observe the catheter. The DON stated the CNAs provide care and if they see hematuria, they will report to the charge nurse. The charge nurses will check the catheter and if there are any changes, they call the physician and inform the Registered Nurse (RN) supervisor. On 3/22/2024 at 5:30 p.m., during an interview with the DON and a concurrent review of Resident 1’s nursing notes, care plans, and Total Intake and Output Record forms, the DON stated there was no documented evidence licensed nurses were implementing the physician’s orders and the care plan by not continuously monitoring and accurately documenting Resident 1’s urine status to promptly identify abnormal findings, implement interventions, and prevent complications. A review of the current facility-provided policy and procedure (P&P) titled, “Catheter Care, Urinary,” last revised on 8/2022, indicated to prevent urinary catheter-associated complication, including urinary tract infections. Observe the resident’s urine level for noticeable increase or decreases. Follow the facility procedure for measuring and documenting input and output if physician orders. Observer the resident for complications associated with urinary catheters. Report unusual findings to the physician: b. If urine has unusual appearance (i.e., color, blood, etc.). e. If signs and symptoms of urinary tract infection or urinary retention occur. The facility failed to ensure Resident 1, who was at risk for UTI, received care and services to prevent UTI. Resident 1 had an indwelling urinary catheter and the facility failed to: 1. Accurately and continuously monitor Resident 1 for signs and symptoms of UTI to prevent complications. 2. Monitor and accurately document Resident 1’s urine characteristics to promptly identify UTI and intervene to mitigate the infection and prevent complications as indicated in the plan of care. As a result, on 3/4/2024 at 7:54 p.m., Resident 1 required emergency transfer by paramedics who, upon arrival to the facility, found Resident 1 with the indwelling catheter tube dark brown and murky in appearance. At GACH 1, Resident 1 was diagnosed with severe sepsis and UTI. 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.