Other·December 6, 2023

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. § 72311. Nursing Service - 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: (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. § 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. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. § 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 10/24/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an annual recertification survey. The facility failed to: 1. Check Resident 268's blood glucose level (amount of sugar in the blood stream, normal value is between 70 milligrams per deciliter [mg/dL] and 100 mg/dL) prior to administering Insulin Glulisine (a fast-acting medication to lower high blood sugar) on 10/26/2023 and 10/27/2023. 2. Accurately transcribe Resident 268's discharge medication order for Insulin Glargine (a long-acting medication to lower high blood sugar) when readmitted to the facility on 10/25/2023 from a long-term acute care hospital (LTACH). As a result, Resident 268 was improperly administered Insulin Glulisine instead of Insulin Glargine without blood glucose monitoring prior to administration on 10/26/2023 and 10/27/2023. This failure led to Resident 268 having a hypoglycemic (low blood glucose level, below 70 mg/dL) episode, altered mental status (AMS, changes in cognition [process of thinking], mood behavior, and/or arousal), which required Resident 268’s transfer on 10/27/2023 to a general acute care hospital (GACH). a. A review of Resident 268’s Admission Record (Face Sheet), indicated Resident 268 was initially admitted to the facility on 6/12/2023 and readmitted to the facility on 10/25/2023 with diagnoses that included [CA1]metabolic encephalopathy (problem in the brain caused by a chemical imbalance of the blood), sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), anemia (problem of not having enough healthy red blood cells to carry oxygen to the body’s tissues), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 268’s Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/25/2023, indicated Resident 268’s cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 268 did not have the ability to understand and be understood by others. The MDS indicated Resident 268 was totally dependent on staff and required one-person physical assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident 268 was receiving insulin. A review of Resident 268’s Order Summary Review, dated 10/27/2023, indicated the following orders: 1. Enteral feeding (food delivered through a feeding tube) of Glucerna 1.2 (name of enteral feeding) infused on a feeding pump at 35 milliliters (mL, unit of measurement) per hour for 20 hours. 2. Insulin Glulisine Injection Solution, inject 10 unit (unit of measurement) subcutaneously (injection into the fatty tissue, just under the skin) one time a day, at 9 a.m., for diabetes mellitus management. 3. Insulin Lispro Injection Solution (a fast-acting medication to control high blood sugar), inject per sliding scale (administration of pre-meal insulin dose based on the blood glucose level before the meal) subcutaneously before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. and at bedtime, at 9 p.m., for diabetes mellitus management. A review of Resident 268’s Medication Administration Record (MAR), for the month of October 2023, indicated on 10/27/2023 at 6:30 a.m., Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro. The MAR indicated Resident 268 was administered Insulin Glulisine 10 units subcutaneously on 10/26/2023 and 10/27/2023 at 9 a.m. A review of Resident 268’s Change in Condition Evaluation (COC), dated 10/27/2023, indicated at 12:20 p.m. on 10/27/2023, Resident 268 had a blood glucose level of 45 mg/dL and sluggish eyes with no eye contact. The COC indicated a code blue was announced and Resident 268 received 1mg of Glucagon (medication to increase blood glucose level) intramuscularly (IM, injection deep in the muscle). The COC indicated paramedics were called and arrived at the facility, and Resident 268 was transferred to the GACH. A review of the paramedic’s Responsive Report, dated 10/27/2023, indicated Resident 268’s chief complaint (statement describing the symptoms, problem, or condition of an individual) was hypoglycemia. The Responsive Report indicated at 12:38 p.m., on 10/27/2023, Resident 268 was administered 125 mL of Dextrose 10% (D10, liquid solution with concentrated level of sugar) intravenously (in the vein). The Responsive Report indicated at 12:39 p.m., Resident 268 had a blood glucose level of 43 mg/dL then at 12:51 p.m., Resident 268 had a blood glucose level of 128 mg/dL. A review of Resident 268’s Emergency Department (ED) Note, dated 10/27/2023, indicated Resident 268 was brought to the ED due to altered mental status and hypoglycemia. The ED Note indicated after Resident 268 arrived in the ED, she was administered 250 mL of D10 intravenously. The ED Note indicated at 1:43 p.m., Resident 268’s blood glucose level was 150 mg/dL. The ED Note indicated Resident 268 was admitted to the intensive care unit (ICU, unit in the hospital that provides specialized treatment to patients who require critical medical care) for hypoglycemia, concern for sepsis (a life-threatening complication of an infection), hypothermia (a significant and potentially dangerous drop in body temperature), hydrocephalus (a condition in which fluid builds up in the brain), and possible left-side basilar pneumonia (lung inflammation of the lower left side of the lungs caused by bacteria or viral infection).[CA2] During an interview on 10/27/2023 at 12:46 p.m., Licensed Vocational Nurse (LVN) 1 stated she had gone into Resident 268’s room around 12:15 p.m. on 10/27/2023 to check the resident’s blood glucose and noticed the resident was “foaming at the mouth.” When LVN 1 checked Resident 268’s blood glucose level it was 45 mg/dL. LVN 1 stated she placed the pulse oximeter (device to check the oxygen level in the blood) on Resident 268’s finger and when there was no reading, so LVN 1 announced a code blue. LVN 1 stated once staff arrived to assist, Glucagon was administered. LVN 1 stated Resident 268’s blood glucose level was checked after five minutes, and it resulted as 35 mg/dL. LVN 1 stated she last saw Resident 268 at 11 a.m. (on 10/27/2023) before the incident and the resident “was okay.” During a concurrent interview and record review on 10/27/2023 at 2:39 p.m. with LVN 1, Resident 268’s MAR, for the month of October 2023, was reviewed. The MAR indicated Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro on 10/27/2023 at 6:30 a.m. LVN 1 stated Insulin Lispro was administered during the prior shift, and LVN 1 administered Insulin Glulisine within an hour after the Insulin Lispro was administered. LVN 1 stated Insulin Glulisine was a fast-acting insulin and could decrease the resident’s blood glucose level within 30 minutes. LVN 1 stated Resident 268’s blood glucose was checked during the prior shift and LVN 1 “felt okay giving” Insulin Glulisine. LVN 1 stated blood glucose levels should be checked prior to insulin administration. LVN 1 stated Resident 268’s enteral feeding was turned off at 9 a.m. per the physician’s order. LVN 1 stated after administrating insulin, food was usually given to the resident. LVN 1 stated that failure to check the blood glucose level prior to insulin administration could cause hypoglycemia that could cause the resident to become nonresponsive or lead to death. LVN 1 stated the combination of the administration of Insulin Lispro, Insulin Glulisine, and the discontinuation of the enteral feeding may have caused Resident 268’s hypoglycemic episode. During an interview on 10/27/2023 at 3:30 p.m., Registered Nurse (RN) 1 stated residents need to have their blood glucose level checked before rapid-acting insulin is administered. RN 1 stated Insulin Lispro and Insulin Glulisine were both rapid-acting insulins. RN 1 stated due to the rapid action of both insulins, it was important to check the blood glucose level because the blood glucose level could decrease quickly in response to the rapid-acting insulin. RN 1 stated she (RN 1) would have clarified the order for the lack of blood glucose monitoring and the actual order for Insulin Glulisine due to the fact Resident 268 was already receiving Insulin Lispro. RN 1 stated the combination of insulins had the possibility to drop Resident 268’s blood glucose level significantly. During an interview on 10/27/2023 at 4:25 p.m., the Director of Nursing (DON) stated the purpose of administering insulin was to treat hyperglycemia (high blood sugar level) by decreasing the blood glucose level, and the blood glucose level should be checked before administering insulin. The DON stated checking the blood glucose level was important because if the blood glucose level was within the normal range and insulin was administered, that could cause hypoglycemia. The DON stated on10/27/2023, Resident 268 was hard to arouse, had her eyes closed, and did not respond to stimuli (anything that can trigger a physical or behavioral change). The DON stated if staff had not intervened during Resident 268’s hypoglycemic episode, the resident could have gotten worse, became more nonresponsive, and had “the potential to drift away” [CA3][referring to the possibility of a resident's death]. b. During a concurrent interview and record review on 10/27/2023 at 3:40 p.m. with RN 1, Resident 268’s LTACH Discharge Medications, dated 10/25/2023, were reviewed. The LTACH Discharge Medications indicated to continue Insulin Glargine, 10 units, subcutaneous injection, daily. RN 1 stated Insulin Glulisine was not on the discharge paperwork from the LTACH. RN 1 stated the action type between Insulin Glulisine and Insulin Glargine were different and had different effects on blood glucose levels. RN 1 stated the RN who admitted Resident 268 to the facility was responsible for transcribing the medication order correctly from the LTACH. RN 1 stated there was a mix up when Resident 268’s discharge medications were transcribed incorrectly. During an interview on 10/27/2023 at 3:50 p.m., Physician 1 stated the normal process was to continue the discharge medications from the LTACH. Physician 1 stated he had not placed the order for Insulin Glulisine. Physician 1 stated the blood glucose level should always be checked prior to administering insulin. Physician 1 stated Resident 268 should not have had two rapid-acting insulins ordered together as this caused Resident 268’s hypoglycemic episode. Physician 1 stated there was an error in the discharge medication transcription and the facility should have followed the orders from the LTACH. During an interview on 10/27/2023 at 4:30 p.m., the DON stated the normal process was to review the discharge medications from the discharging facility and to input those orders into the system. The DON stated there was a transcription error because Resident 268 was receiving Insulin Glargine at the LTACH and was supposed to be continued at the facility. The DON stated Insulin Glulisine should not have been ordered and Resident 268 should not have received the medication. The DON stated this was a medication error and this affected the resident where her blood glucose level “dropped quickly.” During a review of the facility’s policy and procedure (P&P) titled, “Consulting Physician/Practitioner Orders,” dated 12/19/2022, the P&P indicated “for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order… [and] follow the facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medical or treatment administration record, when appropriate.” The facility failed to: 1. Check Resident 268's blood glucose level prior to administering Insulin Glulisine on 10/26/2023 and 10/27/2023. 2. Accurately transcribe Resident 268's discharge medication order for Insulin Glargine when readmitted to the facility on 10/25/2023 from a LTACH. As a result, Resident 268 was improperly administered Insulin Glulisine instead of Insulin Glargine without blood glucose monitoring prior to administration on 10/26/2023 and 10/27/2023. This failure led to Resident 268 having a hypoglycemic episode, AMS, which required Resident 268’s transfer on 10/27/2023 to GACH. These 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.