Health inspection·July 18, 2024

§483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g) (14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9). 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 5/29/2024, the California Department of Public Health (CDPH) received a complaint regarding allegations related to resident rights and quality of life. On 5/30/2024, CDPH made an unannounced visit to the facility to investigate the complaint allegations. The facility failed to follow its policy and procedure (P&P) titled, "Change of Condition (COC – a major decline in a resident’s status)," which indicated the facility will notify the resident’s attending physician (MD) when there was a significant change in the resident’s condition, or when there was a need to transfer the resident to a general acute care hospital (GACH) for Resident 1who had a COC. The COC that started on 5/27/2024, at 9 a.m., indicated the dialysis site (location of the dialysis access by resident’s right upper chest area) was draining yellow exudate (fluid that leaks out of blood vessels into nearby tissues and usually an indication of infection) and the physician was not notified. As a result, Resident 1 was not transferred to the GACH until 5/28/2024, at 5:48 p.m., (32 hours after the COC was first observed) and was diagnosed with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), bacteremia (the presence of bacteria [microscopic living organisms that have only one cell] in your blood), and central venous catheter (permacath - a flexible tube inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava) related bloodstream infection (sepsis - an infection caused by bacteria entering the bloodstream). A review of Resident 1’s Admission Record indicated the resident was a 29-year-old male admitted to the facility on 5/16/2024, with diagnoses that included dependent on renal dialysis (hemodialysis - a procedure to remove waste products and excess water from the blood when the kidneys stop working properly), chronic kidney disease (when the kidneys have become damaged over time), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that is caused by an illness or organs that are not working as well as they should). A review of Resident 1’s Care Plan titled, “Dialysis: hemodialysis and is at risk for bleeding at access site, chest pain, deficient and or excess fluid volume, edema (swelling caused by fluid trapped in your body’s tissues), hypertension (high blood pressure), hypotension (low blood pressure), infection, nausea (feeling of sickness with an inclination to vomit) and or vomiting, pruritis (severe itching of the skin), shortness of breath, weakness, weight fluctuation,” developed on 5/16/2024, indicated staff will monitor Resident 1 for edema, chest pain, signs or symptoms of infection, nausea or vomiting, elevated blood pressure, or shortness of breath, and report abnormal findings to physician. A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 5/21/2024, indicated the resident had the ability to understand and be understood by others. The MDS indicated Resident 1 was dependent (helper does all the effort and the assistance of two or more helpers is required for the resident to complete the activity) on staff for showering and personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) putting on and taking off footwear, toileting, and oral hygiene. A review of Resident 1’s COC notes entered by Licensed Vocational Nurse 1 (LVN 1), dated 5/27/2024, at 9 a.m., indicated Resident 1’s dialysis site (location of the dialysis access by resident’s right upper chest area) was draining yellow exudate (fluid that leaks out of blood vessels into nearby tissues and usually an indication of infection). The notes indicated Resident 1 complained of soreness to the dialysis site but did not complain of pain. The notes indicated the MD was notified of the COC on 5/27/2024, at “00:00” (12:00 a.m.) and LVN 1 was awaiting response from the MD. A review of Resident 1’s Progress Notes entered by Registered Nurse 2 (RN 2), dated 5/27/2024, at 6:34 p.m., indicated upon assessment, there was yellow exudate observed outside Resident 1’s dialysis port (dialysis catheter entrance and exit point) dressing, located to the upper right area of the dressing. The notes indicated the area was cleansed and a small dressing was placed on the site. The notes also indicated there were no other signs of infection observed. A review of Resident 1’s physician’s order, dated 5/28/2024, at 3 p.m., indicated to send out (transfer) Resident 1 to a GACH emergency room (ER) as a non-emergent transfer (not requiring emergency transportation) due to dialysis site draining with purulent (with pus) yellow exudate. A review of Resident 1’s Progress Notes entered by LVN 1, dated 5/28/2024, at 4:28 p.m., indicated Medical Doctor 2 (MD 2) ordered Resident 1 to be sent to the ER due to yellow exudate draining from the dialysis site. The notes indicated Resident 1 was currently at dialysis and transportation was set up, to take Resident 1 to ER when the resident returned from dialysis. A review of Resident 1’s Progress Notes entered by LVN 2, dated 5/28/2024, at 5:48 p.m., indicated Resident 1 left the facility via a non-emergent transportation with the following vital signs (measurements of the body's most basic functions such as body temperature, heart [pulse] rate, respiration rate [rate of breathing], and blood pressure [BP - pressure of circulating blood against the walls of blood vessels]): BP: 95/60 millimeter of mercury (mm Hg – unit of pressure), pulse: 100 beats per minute, and oxygen saturation (a measurement of how much oxygen is in the blood, a normal level is usually 95% or higher): 92 percent (%). A review of Resident 1’s GACH Emergency Department (ED) Documentation, dated 5/28/2024, at 6:17 p.m., indicated the resident presented to the ED with a fever (elevated temperature) of 102.02 Fahrenheit (°F- scale for measuring temperature; 91.8 to 100.8 °F are normal temperature), redness, swelling, and drainage from his dialysis port. The documentation indicated Resident 1 was sent from the facility to the GACH ED for presumed sepsis due to an infection. The documentation indicated Resident 1 had a fever for approximately 2 days. The documentation indicated Resident 1 was in severe distress and his skin had erythema (any abnormal redness of the skin) to the right medial (towards the middle or center) clavicle (collarbone) area four centimeters (cm- unit of measurement) above the insertion site of the dialysis port. The documentation indicated Resident 1 presented with acute serious bacterial infection (SBI) consistent with sepsis; likely due to bacteremia as source of the SBI. Resident 1’s diagnoses in the ED included septic shock and infection associated with central venous catheter. A review of Resident 1’s GACH Discharge Summary, dated 6/6/2024, indicated the resident presented to the GACH with fatigue, fever, and chills, was in septic shock requiring vasopressors (medications used to make blood vessels become narrow in people with low blood pressure to increase blood flow to the heart, lungs, and brain). The summary indicated Resident 1’s infected permacath was removed on 5/29/2024 and was noted with pus drainage. The summary indicated a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart) was requested, and Resident 1 was to be on six weeks of cefazolin (antibiotic- medication used to treat bacterial infections) six grams (g – a unit of measure) daily, and zyvox (an antibacterial drug used to treat infections) 600 milligrams (mg - unit of measurement) orally (by mouth) twice a day until 6/16/2024. During an interview, on 5/30/2024, at 2:01 p.m., LVN 2 stated she received a report from LVN 1 on Tuesday, 5/28/2024 indicating that Resident 1’s dialysis port had yellow drainage and might be infected. LVN 2 stated when Resident 1 came back from the dialysis center that day, the site was red, but no drainage was observed. During an interview, on 5/30/2024, at 2:44 p.m., RN 2 stated on 5/27/2024 at around 6 p.m. LVN 1 accompanied RN 2 to Resident 1’s bed and showed him (RN 2), Resident 1’s dialysis port. RN 2 stated the port was observed with some swelling and pus was oozing out of it. RN 2 stated when he pushed on the reddened site, more pus came out. RN 2 stated he asked LVN 1 when the pus started and LVN 1 did not know because it was unclear when it started. RN 2 stated he asked LVN 1 to contact Resident 1’s MD. During an interview, on 5/30/2024, at 3:50 p.m., LVN 1 stated on 5/27/2024, she (LVN 1) observed drainage on Resident 1’s chest near the resident’s dialysis port. LVN 1 stated she contacted MD 1 and MD 2 but none of them responded. LVN 1 stated she did not follow-up the on the phone calls and did not text the MDs. LVN 1 stated she informed LVN 2 (the incoming LVN for the next shift) to await a call from MD 1 and MD 2, regarding Resident 1’s COC. LVN 1 stated the next morning on 5/28/2024, there was still no response from either MD 1 or MD 2. LVN 1 stated she called MD 2 on 5/28/2024, and MD 2 ordered Resident 1 to be transferred via a non-emergent transportation to the GACH. LVN 1 stated when she received the order, Resident 1 was still at the dialysis center and the resident was not transferred until later in the evening. During an interview, on 5/31/2024, at 10:23 a.m., Treatment Nurse 1 (TN 1) stated she could not recall the date but thought (by memory) on Sunday (5/26/2024), Resident 1 called her (TN 1) and asked if TN 1 could look at his (Resident 1’s) upper chest. TN 1 stated she observed visible pus to the top right area of Resident 1’s dialysis port site. TN 1 stated the site was covered with gauze. TN 1 stated she did not notify Resident 1’s MD of the COC. TN 1 stated the MD should have been notified immediately. TN 1 stated due to the presence of pus around Resident 1’s port, the MD should have been notified to prevent the resident’s condition from getting worse. TN 1 stated if MD 1 did not answer, MD 2 should have been notified to prevent Resident 1 becoming septic (widespread infection by harmful bacteria). During an interview, on 5/31/2024, at 11:10 a.m., RN 2 stated LVNs were the ones to notify the MDs of residents’ COCs, since they (LVNs) were familiar with the residents. RN 2 stated RNs could also call. RN 2 stated when she observed pus around Resident 1’s port on 5/27/2024, she did not notify Resident 1’s MD. RN 2 stated she should have called the MD immediately and if there was no response, she should have continued to call until she received a response. RN 2 stated she should have followed-up after 2 hours if the MD did not respond for possible orders like starting Resident 1 on antibiotics or sending the resident to a GACH for evaluation and treatment. RN 2 stated waiting a whole day for the MD to respond was too long, and placed Resident 1 at risk for infection, sepsis, and death. RN 2 stated the best way they should have handled the situation was to transfer Resident 1 to a GACH and then update the MD whenever the MD responded. During an interview, on 6/4/2024, at 10:10 a.m., MD 1 stated he (MD 1), the Nurse Practitioner (NP), and MD 2 were covering (assigned to manage the residents’ care) the skilled nursing facility (SNF). MD 1 stated he did not get a phone call on 5/27/2024 regarding Resident 1’s COC. MD 1 stated if the nurses were unable to reach him via phone call or text, the nurses should have insisted on trying to contact them (MD 1 and his team). MD 1 stated there were three members of his team assigned to the facility and they always responded to calls or texts even if they were not on-call (assigned to take over in medical care of the residents on behalf of another medical practitioner). MD 1 stated if he was aware of the presence of pus at Resident 1’s port, he would have sent Resident 1 to the GACH for further evaluation, ordered blood cultures, started Resident 1 on antibiotics, and removed the source of the infection (the dialysis access). MD 1 stated any source of pus could be a risk for infection and Resident 1 could become septic. During an interview, on 6/4/2024, at 4:16 p.m., the Director of Nursing (DON) stated Resident 1 had pus above his (Resident 1) dialysis port identified by the nurses on 5/27/2024. The DON stated if there was a COC, the staff had to keep attempting to contact the doctor. The DON stated if the doctor was not reachable, MD 2 should have been contacted. The DON stated if MD 2 did not respond and it was urgent, the resident should have been sent to the GACH. The DON stated not contacting the MD when there was a COC or not being able to get a hold of the MD placed Resident 1 at risk for worsening of COC and possible delay in the treatment. During an interview, on 6/4/2024 at 5 p.m., MD 2 stated he (MD 2) was notified on 5/28/2024 that Resident 1 had pus by his (Resident 1) dialysis site. MD 2 stated he gave orders for Resident 1 to be transferred to the GACH on 5/28/2024. MD 2 stated there was no prior notification of Resident 1’s condition before 5/28/2024. MD 2 stated he and his team including the NP and MD 1 take turns being on-call and were readily available. MD 2 stated even if one of them were not on-call, someone always responded to SNF calls. MD 2 stated Resident 1 required a GACH transfer because he (Resident 1) had pus near his dialysis site which meant there was a risk for sepsis. A review of the current facility’s P&P titled, "Change in a Resident’s Condition or Status," revised in 2/2021, indicated the facility will promptly notify the resident, his or her attending physician, and the resident’s representative of changes in the resident’s medical/mental condition and/or status. The P&P indicated the nurse will notify the resident’s attending physician on call when there has been a significant change in the resident’s physical/emotional/