Other·May 24, 2024

42CFR §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— (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 =(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. 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 § 72315. Nursing Service-Patient Care. (i) Measures shall be implemented to prevent and reduce incontinence for each patient…. 22 CCR § 72313. Nursing Service – Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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 4/13/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a recertification survey. The facility failed to: 1. Notify the physician of Resident 37 who continued to have blood in the urine (hematuria) with presence of clots. Resident 37, who had an indwelling urinary catheter (IUC, a hollow flexible tube inserted in the bladder [the organ that stores urine] to drain urine) and was on blood thinner medication, had hematuria from 1/12/2024 at 11:40 a.m. to 1/15/2024 and the attending physician (Physician 1) was not informed. 2. Follow physician’s orders and ensure that Resident 37 received care and services to prevent complications including continued hematuria, urinary retention (inability to urinate) and/or obstruction (blockage), and urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body] and infect the urinary tract). 3. Follow policies and procedures for catheters and changes in condition. As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required an emergency transfer to General Acute Care Hospital 1 (GACH 1) where Resident 37 was found with elevated body temperature (fever) and abdominal distention (abnormally swollen outward) requiring removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization (draining urine by passing a catheter through the urethra) obtaining 800 milliliters (ml, unit of measure) of dark red urine. Resident 37 was diagnosed with septic shock (a life-threatening widespread infection causing organ failure and dangerously low blood pressure), UTI, and pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi). A review of Resident 37's Admission Record indicated the facility admitted the 76-year old male resident on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024, indicated Resident 37 had severe cognitive impairment (involving conscious intellectual activity such as thinking, reasoning, or remembering). The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs, such as oral hygiene, toilet use, bathing, dressing, etc.). The MDS further indicated Resident 37 was admitted to the facility with an IUC. A review of Resident 37's Physician Order, dated 12/27/2023, indicated apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37’s Physician Order dated 12/28/2023. indicated to insert an IUC for acute urinary retention (inability to urinate) and/or obstruction (blockage). A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Progress Note, dated 1/10/2024, indicated to start continuous bladder irrigation (CBI - is used to reduce the risk of clot formation and IUC patency by continuously irrigating the bladder via a three-way catheter [allows fluid to flow into and out of the bladder simultaneously]) due to Resident 37's IUC bag having blood-tinged urine; continue to hold Eliquis, and would re-evaluate on Friday (1/12/2024). A review of Resident 37's Physician Order, dated 1/10/2024, indicated CBI management as follows: - Run CBI at a rate to always keep pink or clearer. - Do not let CBI run out. - Do not let blood clots form in bladder or tubing. - Do not remove IUC without physician's order. - If new onset of heavy or uncontrolled blood in urine appears, notify the physician. A review of Resident 37's Nurse Progress Note, dated 1/11/2024 at 6:48 p.m., indicated urine had been clear since start of CBI, Physician 1 was informed and ordered to hold the CBI but if Resident 37 started having hematuria, continue with the CBI. A review of Resident 37's Physician Progress Note, dated 1/12/2024 timed at 2:31 p.m., indicated Resident 37's urine was clear, re-start Eliquis, and monitor for hematuria. A review of Resident 37's Intake and Output indicated the urine characteristics was described as red, light, and with clots or red/pink on 1/12/2024 at 11:40 a.m. and at 9:42 p.m.; on 1/13/2024 at 11 a.m.; on 1/14/2024 at 1:55 a.m., at 11:34 a.m., and at 10:10 p.m.; and on 1/15/2024 at 11:30 a.m. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:29 p.m., indicated Resident 37 was on the ventilator, hyperventilating (an abnormally rapid rate), respiratory rate in the high 50s (normal rate 12 to 16 breaths per minute), normal oxygen saturation (O2 Sat, normal above 92 %), and to monitor at bedside. A review of Resident 37's Respiratory Therapist Progress Note, dated 1/15/2023 timed at 7:50 p.m., indicated Resident 37 continued to hyperventilate with respiratory rate in the low 60s. A review of Resident 37's Nurses Progress Note, dated 1/15/2023 timed at 7:55 p.m., indicated Resident 37 appeared to have shortness of breath and the heart rate was 155 beats per minutes (bpm, normal range 60 to 100). Physician 1 was informed and ordered to transfer Resident 37 to the GACH via paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 9 p.m., described Resident 37's urine output was dark red with foul odor. A review of Resident 37's GACH 1 Emergency Department (ED) Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated a Computed Tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan of Resident 37 showed inflammation around the bladder which could represent urinary tract infection. A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 at 9:23 p.m., indicated Resident 37's body temperature was 103 degrees Fahrenheit (ºF, normal range between 97 ºF and 99 ºF; the heart rate was 150 bpm, the respiratory rate was 41 breath per minute, and the blood pressure (is the pressure of circulating blood against the walls of blood vessels) was 158/114 millimeters of mercury (mmHg, unit of pressure; normal range 120/80 to 139/89 ). A review of Resident 37's GACH 1 ED Progress Noted, dated 1/15/2024 timed at 11:49 p.m., indicated Resident 37 arrived hot to touch, abdomen distended and firm, IUC in place with drainage bag to gravity with 100 ml with tea-colored urine. At 9:45 p.m., IUC removed with significant hematuria (blood in urine) drainage from penis immediately after removal. Intermittent catheterization (draining urine by passing a catheter through the urethra into the bladder; the catheter is removed after the urine has been drained) removed 800 ml (the bladder can store up to 700 ml of urine in men) of dark red output, an IUC was inserted and drained 200 ml of dark sanguineous (with blood) urine. A review of Resident 37's GACH 1 record of the Pulmonary and Critical Care Consultation note, dated 1/16/2024 at 8 a.m. indicated Resident 37 was diagnosed with pneumonia, septic shock, abdominal distention, and hematuria. A review of Resident 37's GACH 1 History and Physical, dated 1/20/2024, included in the Infections Disease Assessment and Plan that Resident 37 had septic shock and UTI. During an interview on 4/14/2024 at 6:41 p.m., the Nurse Manager (NM) stated Resident 37 had hematuria from 1/12/2024 to 1/15/2024 and Physician 1 should have been notified because this was a change of condition. The NM stated Physician 1 needed to be notified as Resident 37 was back on Eliquis and continued bleeding. During an interview on 4/14/2024 at 7:51 p.m., Physician 1 stated licensed nurses did not inform him that Resident 37 continued to have hematuria. If notified, he could have ordered to stop the Eliquis and transferred Resident 37 to a hospital sooner if the bleeding did not stop. A review of the facility-provided policy and procedure (P&P) titled, "Change of Condition, Notification (Sub Acute)," revised on 12/2021, indicated to ensure that the attending physician and responsible party are promptly notified upon significant change in the resident's condition. 1. Notify the resident's primary physician for the following conditions: B. Any sudden and/or marked adverse change in vital signs (are measurements of the body's most basic functions including body temperature, blood pressure, pulse and respiratory [breathing] rate), symptoms, or a significant divergence from the resident's established pattern of behavior. A review of the current facility-provided P&P titled, "Indwelling Urinary Catheter Care and Management," last revised on 12/10/2023, indicated monitor intake and output, as ordered; monitor for changes in urine output, including volume and color; and notify practitioner of abnormal findings. The facility failed to: 1. Notify the physician of Resident 37 who continued to have blood in the urine with presence of clots. Resident 37, who had an IUC and was on blood thinner medication, had hematuria from 1/12/2024 at 11:40 a.m. to 1/15/2024 and the attending physician (Physician 1) was not informed. 2. Follow physician’s orders and ensure that Resident 37 received care and services to prevent complications including continued hematuria, urinary retention and/or obstruction, and UTI. 3. Follow policies and procedures for catheters and changes in condition. As a result, on 1/15/2024 at 9:11 p.m., Resident 37 required an emergency transfer to GACH 1 where Resident 37 was found with elevated body temperature and abdominal distention requiring removal of the IUC with significant hematuria draining immediately after its removal. Resident 37 required intermittent catheterization obtaining 800 ml of dark red urine. Resident 37 was diagnosed with septic shock, UTI, and pneumonia. 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 37.