Other·June 1, 2023

42 CFR § 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 42 CFR §483.25(h) Parenteral Fluids Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences. 22 CCR § 72311 Nursing Service - General (a) Nursing service shall include, but not 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 professional involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed with seven days after admission. On 4/14/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care and resident abuse. The facility failed to protect Resident 1’s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) and failed to monitor and provide central venous catheter (CVC - a tube placed in a large vein [blood vessel that carries blood to the heart] also known as a central line, to give fluids, blood, medications or to do medical tests) line care by failing to: 1. Ensure staff identified Resident 1’s CVC upon admission on 4/5/2022 and readmission on 5/28/2022. 2. Ensure Licensed Nurses provided the necessary care and treatment for Resident 1’s CVC which included routine inspection (daily and as needed), flushing (injecting a solution into the tube to keep it from getting clogged or blocked), and dressing changes (a transparent [clear] protective cover placed over the tube to be changed every seven days to prevent infection) from the time of Resident 1’s admission on 4/5/2022 to 4/11/2023. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 notified a Registered Nurse (RN) supervisor of Resident 1’s CVC when the line was first identified. 4. Ensure LVN 1 acted on and reported Resident 1’s concerns and requests regarding the resident’s CVC being left without a dressing. 5. Ensure LVN 1 and Certified Nursing Assistant 1 (CNA) did not provide treatments outside of their scope and practice when LVN 1 and CNA 1 applied dressings to Resident 1’s CVC. As a result, Resident 1 was placed at risk for sepsis, due to inadequate provision of care to the CVC for approximately one year, (the body's extreme response to an infection; sepsis is a life-threatening medical emergency) from a central line-associated bloodstream infection (CLABSI - a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line). A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 57-year-old male, on 4/5/2022 with a readmission date of 5/28/2022 with diagnoses that included sepsis, left leg below the knee amputation (BKA-removal by surgery of a limb [arm or leg] or other body part because of injury or disease), end stage renal disease (ESRD, a medical condition in which the kidneys stop functioning) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working), and diabetes mellitus (a group of diseases that result in too much sugar in the blood [high blood glucose]). A review of Resident 1’s History and Physical, dated 6/2/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – an assessment and screening tool) dated 4/12/2022, indicated the resident had the ability to understand others and to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. Further review of Resident 1’s MDS dated 4/13/2023, indicated the resident had the ability to understand others and to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. A review of Resident 1’s General Acute Care Hospital (GACH) record titled “Diagnostic Imaging” report dated 3/31/2022, indicated that the resident had the following central line inserted on 3/30/2022: a) Right intrajugular tunneled CVC (a thin tube that is placed under the skin in the internal jugular vein [IJV- vein under the collarbone] allowing long-term access to the vein). A review of Resident 1’s Physician Orders indicated orders for the following: a) Body check upon returning to facility, every evening shift; every Monday, Wednesday, and Friday, dated 4/28/2022 and discontinued on 5/24/2022 b) Body check to be performed upon Resident 1’s return to facility, every day shift; every Monday, Wednesday, and Friday, dated 5/30/2022. c) IV central line active therapy orders: dressing change every seven days and as needed, remove old dressing, using sterile technique (technique used to prevent contamination of a site with microbes [bacteria], preventing infection), site cleanse with a chlorhexidine gluconate solution (a cleaning product that helps eliminate germs and bacteria) or povidone-iodine (a solution used on the skin to treat or prevent skin infection) as needed, every day shift every Sunday, dated 4/11/2023. d) IV central lines: flush each lumen (line) with 10 cubic centimeters (cc-a unit of measurement for liquids) with normal saline (solution used to clear the contents of a central line) before and after medication administration every shift, dated 4/11/2023. A review of Resident 1’s GACH “Discharge to Skilled Nursing Facility (SNF) Summary and Transfer Orders” dated 4/5/2022, indicated Resident 1 with a five (5) french (fr- unit of measure) single lumen (one line) CVC placement on 3/30/2022. During an observation and interview on 4/14/2023 at 3:45 p.m., Resident 1 was observed lying in bed inside his room. Resident 1 stated, while tearful, that he had a CVC that the facility was not taking care of. Resident 1 pulled up the right side of his t-shirt revealing a purple, single lumen CVC sutured (held in place with stiches) to the resident’s right upper chest (RUC). The CVC was covered with a chlorhexidine gluconate protective disk (a small circular dressing placed over the insertion site of a CVC to help reduce local infections) with a transparent dressing dated 4/11/2023. Resident 1 stated that the dressing currently on his CVC was the first dressing the facility applied since his admission on 4/5/2022. Resident 1 stated he had been asking the facility nurses to cover his CVC since his admission on 4/5/2022, but nothing was being done. Resident 1 stated that facility nursing staff would place a dressing or a plastic bag over his CVC during shower times, but all other times the CVC remained uncovered. Resident 1 stated his CVC line on his RUC goes to his heart and he is worried about infections. During an interview and record review on 4/14/2023 at 4:40 p.m., Registered Nurse 1 (RN 1) reviewed Resident 1’s medical records including all face sheets, history and physical, physician orders, progress notes, care plans and skin assessments from 4/5/2022 to 4/14/2023. RN 1 stated that there was no documented evidence that the facility was aware of or treated Resident 1’s CVC prior to 4/11/2023. RN 1 stated she was not aware of Resident 1’s CVC until 4/10/2023. RN 1 stated that Resident 1 had informed her that he had the CVC for “over a year”. During an interview and record review on 4/17/2023 at 9:00 a.m. with Treatment Nurse 1 (TN 1), Resident 1’s Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2023 documented by TN 1 were reviewed. TN 1 stated that when residents are admitted to the facility, the admitting nurse completes a full body skin assessment to identify any catheter lines such as CVCs. TN 1 stated that after the admitting nurse completes her full body assessment, the treatment nurse is to complete another full body assessment. TN 1 reviewed Resident 1’s Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2022, and stated there was no documented evidence that indicated Resident 1 had a RUC CVC. TN 1 stated that she completed a body check for Resident 1 on 4/6/2022 and 5/30/2022 but stated that she never saw Resident 1’s CVC until 4/11/2023. During an interview on 4/17/2023 at 9:45 a.m., CNA 1 stated that Resident 1 already had his CVC to his RUC when she first started caring for him six months ago. CNA 1 stated that Resident 1’s CVC was left uncovered without a dressing during the time she cared for the resident. During an interview and record review on 4/17/2023 at 10:10 a.m. with the Director of Nursing (DON), Resident 1’s medical records from 4/5/2022 to 4/17/2023 were reviewed. The DON stated that she was unaware that Resident 1 had the CVC until the resident informed her on 4/11/2023. The DON stated that Resident 1 could have potentially developed an infection and become septic from the CVC on his RUC that was not provided the necessary care to prevent infection such as applying dressing to the CVC and monitoring the CVC for signs and symptoms of infection. The DON further stated there was no documented evidence of a physician orders for Resident 1’s CVC care that should have included central line dressing changes, central line flushing, or monitoring for signs and symptoms of infection prior to 4/11/2023. The DON stated she assessed Resident 1’s CVC on 4/11/2023 and at the time it was not covered. During an interview on 4/17/2023 at 10:45 a.m., the Nurse Practitioner (NP) stated that it was concerning that Resident 1 had a CVC without a dressing or monitoring being done because the CVC places Resident 1 at increased risk for infections. The NP stated that the facility should have conducted a full physical assessment of Resident 1 upon admission that included a full skin check. The NP stated that the facility should have been able to identify Resident 1’s CVC during their full skin check During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on 4/5/2022. LVN 1 stated she did not know Resident 1 had a CVC until the “end of 2022”. LVN 1 stated that she continued to see Resident 1’s CVC on his right upper chest without a dressing for a couple of months. LVN 1 stated LVNs do not provide care for central lines, and that it was the RN’s responsibility to provide care for the central lines. LVN 1 stated she notified the RN to assess and monitor Resident 1’s CVC, but she does not remember who she notified or what they said. LVN 1 stated there were no orders for dressing changes or monitoring for Resident 1’s CVC to his RUC prior to 4/11/2023. LVN 1 stated that around the beginning of January 2023, Resident 1 had asked her on multiple occasions why he had the CVC and why was it not removed. During a concurrent interview and record review on 4/17/2023 at 12:00 p.m. with the DON, Resident 1’s Wound and Weekly Monitoring Assessment forms dated 4/6/2022 and 5/30/2022 were reviewed. The DON stated that there was no documented evidence of Resident 1’s RUC CVC on the Wound and Weekly Monitoring Assessment forms. The DON stated the licensed nurses were not doing their job because the licensed nurses either did not assess Resident 1’s skin thoroughly since the nurses did not know the resident had a CVC to his RUC, or the licensed nurses did not document the presence of the RUC CVC. The DON stated that licensed nurses should have done a full body assessment as ordered by the physician on 4/28/2022 and again on 5/30/2022 which was three times a week after Resident 1’s hemodialysis (HD- a process where a machine filters the waste from your body because your kidneys have failed) treatments. The DON stated if the licensed nurses were really conducting a full body assessment on Resident 1, then the licensed nurses would have identified Resident 1’s CVC. The DON stated that the licensed nurse’s failure to conduct a thorough body assessment on Resident 1 resulting in the resident’s CVC being untreated and monitored for over one year could be considered neglect because the facility failed to provide the needed care and treatment for Resident 1’s CVC placing the resident at continued risk for infection. During a follow-up interview on 4/17/2023 at 12:00 p.m., the DON stated that when Resident 1 complained to LVN 1 about his CVC being left uncovered, LVN 1 should have notified the RN Supervisor. The DON stated LVN 1 did not provide the care Resident 1 needed because she knowingly left the resident’s CVC uncovered and did not notify the RN Supervisors. The DON stated that knowingly not providing the necessary care to a resident is a form a neglect. During an interview on 4/17/2023 at 12:28 p.m., LVN 1 stated that a resident’s central lines needed to be monitored, flushed, and have weekly dressing changes. LVN 1 stated Resident 1 could have been harmed because the resident’s CVC could have gotten infected. During an interview on 4/17/2023 at 1 p.m., Resident 1 stated that he spoke with LVN 1 about his CVC and that it needed to be covered. Resident 1 stated that LVN 1 informed him that she would speak with the supervisors, but nobody came back. Resident 1 stated the facility absolutely did not provide “good care” and it made him feel scared because they were supposed to know how to take care of his CVC. During a concurrent interview and record review on 4/18/2023 at 11:12 a.m., RN 2 reviewed Resident 1’s GACH “Discharge to Skilled Nursing Facility Summary and Transfer Orders” dated 4/5/2022 and stated that the summary indicated Resident 1 was admitted to the facility with the CVC on his RUC in place. RN 2 stated that the admitting nurse should have done a skin assessment on Resident 1 upon admission on 4/5/22 and 5/28/22 to identify any central lines such as Resident 1’s CVC. RN 2 stated that the summary provided to the facility indicating that Resident 1 had a CVC in place should have alerted the admitting nurses of the presence of Resident 1’s CVC. RN 2 stated TN 1 should have also performed a head-to-toe assessment on Resident 1 on admission and readmission and should have been able to identify Resident 1’s CVC. RN 2 stated TN 1 should have performed weekly skin assessments on Resident 1 and had multiple opportunities to identify the resident’s CVC. RN 2 stated central lines need dressings to keep them covered, secure, and safe. RN 2 stated a central line goes into the heart and you do not want germs and bacteria getting in there due to the risk of infection. RN 2 stated an LVN should be able to identify a central line and should notify the RNs. RN 2 stated if an RN was notified of a CVC, she should have assessed the resident, looked for documentation, then notified the physician for clarification and orders. RN 2 stated there were multiple missed opportunities to identify Resident 1’s CVC that included the admitting nurse on 4/5/2022 and 5/28/2022, TN 1 upon admission on 4/5/2022 and 5/28/2022, treatment nurses conducting weekly skin assessments, and licensed nurses doing weekly skin assessments as ordered by the physician. RN 2 stated that it was negligent that the facility did not identify Resident 1’s CVC despite the resident telling facility staff of its presence. RN 2 stated it was negligent that the facility failed to provide Resident 1 with the needed care and treatment for the resident’s CVC. During an interview on 4/19/2023 at 8:58 a.m., CNA 1 stated she gave Resident 1 a shower approximately once a week and covered the resident’s CVC on his RUC h