Health inspection·September 7, 2023

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— (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary; and (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. §483.25(e)(3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. 42 CFR §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter 22 CCR § 72311 Nursing Services - 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: (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 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 7/19/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about allegations on quality of care/treatment and death. The facility failed to ensure Resident 1, who was incontinent (having no or insufficient voluntary control) of bladder, received the necessary care to promptly identify and treat urinary tract infection (UTI - an infection in any part of the urinary system) by failing to: a. Accurately label a cup (container) with Resident 1's urine sample for laboratory test Resident 1's physician (Physician 1) ordered on 5/23/2023 to rule out UTI. b. Promptly notify Physician 1 that after a call from the laboratory on 5/24/2023 about not doing the test because the urine cup was mislabeled and after Physician 1 ordering another urine test, the nurses were unable to obtain the urine sample because Resident 1 was not urinating (oliguric). c. Accurately document that Resident 1's urine sample was not collected instead of documenting its collection on 5/24/2023 at 9:26 p.m. d. Follow up with the laboratory between 5/25/2023 and 5/30/2023 about the status of Resident 1's laboratory test result wrongly documented as collected on 5/24/2023 at 9:26 p.m. and would have learned there was no sample submitted to the laboratory. e. Inform Physician 1 that after ordering the urine test for Resident 1 on 5/30/2023, the licensed nurses were unable to obtain the urine sample using a straight catheter (a small hollow, flexible tube that is used to empty urine from the bladder intermittently) the same day it was ordered at 10:06 p.m. because Resident 1 was non-compliant. f. Explore the reason Resident 1 did not allow the nurses to obtain the urine sample with the straight catheter, assess for pain to urinate, abdominal pain, etc. g. Make further attempts between 5/31/2023 and 6/1/2023 to obtain Resident 1's urinary test sample and document the reason for not obtaining the urine sample and notify Physician 1 and Resident 1's representative (RP) if unable to get the needed urine sample. h. Make further attempts between 6/3/2023 and 6/10/2023 to obtain Resident 1's urinary test. i. Identify Resident 1's pain during urination before RP notify the licensed nurse on 6/9/2023 to obtain a medication order. j. Develop a plan of care for Resident 1's suspected UTI since 5/23/2023 with the interventions staff needed to implement including monitoring Resident 1 for signs and symptoms of UTI: lower abdominal pain, pain during urination, confusion, reduced volume of urine, urinary frequency, sensation of bladder fullness, characteristic of the urine (color, odor, volume, and clarity). As a result, on 6/13/2023, at 1:30 p.m., RP noticed and informed the licensed nurses that Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. Resident 1 was found lethargic (sluggish and apathetic [having little or no feeling or emotion]), the blood pressure, respiratory and heart rate, and the oxygenation were abnormal. Paramedics were called and transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) at 2:05 p.m. where she was diagnosed with urinary tract infection (UTI - an infection in any part of the urinary system), emphysematous cystitis (EC, is a rare and life-threatening type of complicated UTI mostly seen in elderly females with diabetes, characterized by gas [from gas-forming bacteria - organisms that have only one single cell] within the bladder lumen [the cavity of a tubular organ or part] and wall), hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), distended (bloating and swelling) bladder, and sepsis (a life-threatening complication of an infection that can cause multiple organ failure). Resident 1 expired at GACH 1 on 7/4/2023. A review of Resident 1's Admission Record indicated Resident 1 was a 76-year-old female originally admitted to the facility on 11/22/2020 and readmitted on 6/3/2022. Resident 1's diagnoses included dependence of hemodialysis treatment (process of removing excess water, solutes (substances that are dissolved in a solution), and toxins (poisonous substances) from the blood through a machine in people whose kidneys can no longer perform these functions naturally), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes), and unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 1's History and Physical (H&P), dated 6/26/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/5/2023, indicated Resident 1 was cognitively intact (had no memory problem and was able to understand, and make decisions), needed extensive assistance with personal hygiene, dressing and bathing. Resident 1 was incontinent of urine (inability to control urination) and received hemodialysis treatments. A review of Resident 1's SBAR (Situation-Background-Assessment-Recommendation - a written communication tool that helps provide essential, concise information, usually during crucial situations about the resident) Communication Form and Progress Note, dated 5/23/2023, indicated Resident 1 exhibited increased confusion in the morning and Physician 1 ordered a urine laboratory test for culture and sensitivity (C&S, a culture test can identify bacteria or yeast [a fungus] causing a UTI. If bacteria multiply, an antibiotic sensitivity test can identify the antibiotic most likely to kill those bacteria). A review of the National Institute of Health (NIH -www.nih.gov) indicated UTIs can cause sudden confusion (also known as delirium) in older people. A review of Resident 1's medication administration record (MAR), dated 5/23/2023, indicated Resident 1's urine sample was collected on 5/23/2023 at 6:33 p.m. A review of Resident 1's Laboratory Results Report, collected on 5/23/2023, indicated Resident 1's full name was not on the cup the urine was collected. A review of Resident 1's Health Status Note, dated 5/24/2023 timed at 2:01 p.m., indicated the laboratory called and informed a licensed nurse that the urine sample collected on 5/23/2023 was mislabeled and requested to collect another urine sample. A review of Physician 1's order for Resident 1, dated 5/24/2023, indicated to collect (another) sample of urine for C&S. A review of Resident 1's Health Status Note, dated 5/24/2023 timed at 2:01 p.m., indicated the nursing staff were unable to collect the urine sample because Resident 1 was oliguric (production of abnormally small amounts of urine), and Resident 1 just went to dialysis treatment (to an outside dialysis provider). A review of Resident 1's Care Plan, initiated 5/24/2023, for the resident's risk for increase in confusion secondary to episodes of confusion. The interventions included anticipate and attend to daily needs to maintain dignity; ask questions that can be answered by yes or no; encourage family members and friends to visit resident; and notify the physician as needed. A review of Resident 1's care plans indicated there was no plan of care developed to address the resident's possible UTI as Physician 1 suspected UTI and ordered urine test. A review of Resident 1's MAR, dated 5/24/2023, indicated Resident 1's urine C&S was collected on 5/24/2023, at 9:26 p.m. A review of Resident 1's laboratory test results and nursing notes between 5/25/2023 and 5/30/2023, indicated no urine test results from the sample collected on 5/24/2023 (the results of C&S take 24 to 48 hours). A review of Physician 1's order for Resident 1, dated 5/30/2023, indicated to collect (another) sample of urine for C&S. A review of Resident 1's Health Status Notes dated 5/30/2023, timed at 10:06 p.m. indicated the nursing staff tried to obtain a urine specimen using a straight catheter (a thin, hollow, flexible tube that are used to insert into the bladder to drain urine), but Resident 1 was non-compliant for the procedure. Obtaining the urine sample was endorsed to the next shift. The notes did not indicate if Physician 1 and the resident's representative were notified. A review of Resident 1's Health Status Notes, dated 5/31/2023 and 6/1/2023, did not indicate nursing staff attempted to collect Resident 1's urine. There was no documentation Physician 1 and RP were notified about inability to collect the urine sample. A review of Resident 1's Health Status Note, dated 6/2/2023, indicated Resident 1 continued to refuse allowing nurses to obtain the urine sample and Physician 1 was notified. The note did not indicate if Physician 1 gave new orders and if RP was notified. A review of Resident 1's Health Status Note from 6/3/2023 to 6/8/2023, did not include if nursing staff attempted to obtain Resident 1's urine and if Physician 1 and RP were notified. A review of Resident 1's Health Status Note, dated 6/9/2023, indicated Resident 1 complained to RP 1 that it felt like Resident 1 had to urinate and it hurt. RP reported to the Charge Nurse the Resident 1's complaint. Physician 1 was notified and ordered for Pyridium (a pain medication used to relieve urinary urgency, pain, and discomfort caused by a UTI) 200 milligrams (mg - a unit of measure) three times a day for two days. The licensed nurse asked Physician 1 for a new order for urine laboratory test due to the lack of follow up the previous week (5/28/2023 through 6/3/2023). Physician 1's ordered a urinary test. A review of Resident 1's Health Status Note, dated 6/12/2023, at 6:13 p.m., indicated Resident 1's urine sample was collected on 6/11/2023 and was picked up by the laboratory staff on 6/12/2023. A review of Resident 1's Laboratory Results Report collected from Resident 1 on 6/12/2023, indicated the C&S and the urinalysis (urine test) showed white blood cell (WBC - cells in the body responsible for protecting the body from infection) was greater than 182 WBC/ high power field (HPF - a unit of measure) the reference range (normal values) is zero to five WBC/HPF). A review of Resident 1's Laboratory Results Report of the C&S that was pending for Resident 1, was reported on 6/14/2023 and indicated Resident 1's urine bacteria was greater than 100,000 colonies (a group of bacteria derived from the same mother cell) per milliliters (ml - unit of measure) of Proteus mirabilis (a type of bacteria) and 40,000 colonies per ml mixed bacterial morphotypes (any of a group of different types of individuals of the same species in a population) observed. A review of Resident 1’s Health Status Note, dated 6/13/2023, at 1:30 p.m., indicated RP visited Resident 1 and informed the nurses Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. The licensed nurse contacted Physician 1, who agreed and ordered to transfer Resident 1 to GACH 1. A review of Resident 1's Health Status Note, dated 6/13/2023, at 2:47 p.m., indicated at 1:40 p.m., Resident 1 was noted as lethargic and breathing rapidly. Resident 1's blood pressure was 77/66 millimeters of mercury (mmHg, a unit of pressure; low blood pressure is a reading of less than 90/60 mmHg); the heart rate was 110 beats per minute (bpm, tachycardia in adults refers to a heart rate of more than 100 bpm); the oxygen saturation (O2 Sat, amount of oxygen circulating in the blood obtained) could not be obtained (when the O2 Sat is too low it cannot be read using a medical device that clips to the finger, called a pulse oximeter); the respiratory rate was 22 breaths per minute (normal breathing 12 to 20 breaths per minute). The licensed nurse administered Resident 1 oxygen at 15 liters per minute (L/min) through a non-rebreather mask (NRB, allow for the delivery of higher concentrations of oxygen). Resident 1's O2 Sat reading was 90% (normal range 97-100 percent). The note indicated Emergency Medical Services (EMS, known also as paramedics, EMS, a system that responds to emergencies in need of highly skilled pre-hospital clinicians) was called and arrived at 1:45 p.m. and Resident 1 left the facility at 2:05 p.m. A review of Resident 1's GACH 1 Emergency Documentation, dated 6/13/2023, indicated Resident 1 was brought to the emergency department (ED) with altered mental status (a disruption in how the brain works that causes a change in behavior) and hypotension (low blood pressure). Resident 1's Computed Tomography (CT - a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) of the abdomen (area around the stomach) and pelvis (area around the hips) showed emphysematous cystitis, hydronephrosis, and distended bladder. A urinary indwelling catheter (a catheter that is left in the bladder and collects urine by attaching to a drainage bag) and antibiotics (medications that kill bacteria) were recommended. Resident 1's urinary catheter drained thick, purulent (pus, liquid produced in infected tissue), and brown in color. Resident 1 was also diagnosed with sepsis (life-threatening complication of an infection). A review of Resident 1's GACH 1 Nephrologist (branch of medicine that specializes in kidney care and diseases) Consultation, dated 6/14/2023, indicated an assessment/plan of sepsis most likely secondary to UTI. A review of Resident 1's GACH 1 Urology (branch of medicine and physiology [is the study of how the human body works] concerned with the function and disorders of the urinary system) Consultation, dated 6/14/2023, indicated an assessment/plan of emphysematous cystitis and sepsis. A review of Resident 1's GAC