Health inspection·July 3, 2024

42 CFR § 483.21 Comprehensive person-centered care planning. (b) Comprehensive care plan (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 42 CFR § 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 . . . . 42 CFR § 483.10 Resident rights. (g) Information and communication. (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). 42 CFR § 483.50 Laboratory, radiology, and other diagnostic services. (a) Laboratory services. (2) The facility must: (i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. 22 CCR 72301 Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 5/18/2024, the California Department of Public Health (CDPH) conducted the annual Recertification Survey. The facility failed to: 1. Ensure Resident 38, who had diagnosis of type 2 diabetes mellitus (abnormal blood sugar) and was receiving medication Sitagliptin Phosphate (medication to lower blood sugar) had a weekly complete blood count ([CBC] a laboratory test which gives information about the production of all blood cells in the body) and comprehensive metabolic panel ([CMP] a group of blood tests which provide information about the body's metabolism [chemical reaction in the body's cells which change food into energy]) done from 1/10/2024 to 3/5/2024 per physician order. 2. Ensure Resident 38's blood sugar level was checked when Resident 38 had a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember], behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by increased confusion on 3/4/2024 , in and out of sleep throughout the night, moaning and calling for his family members on 3/7/2024 and a slurred speech (slow speech that can be difficult to understand) on 3/10/2024. 3. Ensure the licensed nurses monitored Resident 38's vital signs and symptoms of hyperglycemia (high blood sugar) such as increased thirst, dry skin, stupor (altered level of consciousness), and coma, (a period of prolonged unconsciousness brought on by illness or injury). 4. Ensure the licensed nurses documented the results of Resident 38's vital signs and signs of hyperglycemia monitoring when the resident's condition changed and notified the resident's physician ([MD 1] medical doctor) in accordance with the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition or Status," which indicated prior to notifying the physician the nurse will make a resident's detailed observations and gather relevant and pertinent information for MD, including information prompted by the Situation, Background, Assessment, and Recommendation ([SBAR] a structured communication tool which enhances the communication between members of the healthcare team) Communication Form. As a result of these failures Resident 38 had a critically (result that represents a pathophysiological state at such variance with normal [expected values] as to be life-threatening unless something is done promptly and for which some corrective action could be taken) high blood sugar of 728 milligrams per deciliter ([mg/dL] a unit of measurement]; the blood sugar reference range is 70-100 mg/dl), hypernatremia (high Sodium [salt] level; the Sodium reference range is between 136-145 mEq/L), and tachypnea (rapid breathing over 20 breaths per minute; the respiratory rate reference range is 12 to 20 breaths per minute ). On 3/10/2024, Resident 38 was admitted to the general acute care hospital's (GACH) Intensive Care Unit ([ICU] a unit with specialized staff, equipment, and standards to handle severe, life-threatening illnesses). A review of Resident 38's Admission Record indicated Resident 38, an 89-year-old male, was admitted to the facility on 1/30/2024 with diagnoses including type 2 diabetes mellitus, cancer (growth of abnormal cells in your body tissue), of the kidney, and had gastrostomy tube ([GT] a soft flexible tube surgically placed directly into the stomach through the wall to provide nutrition and/or medication). A review of Resident 38's History and Physical (H&P), dated 3/14/2024, indicated Resident 38 did not have the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/3/2024, indicated Resident 38 had a moderate impairment in cognitive skills for daily decision-making. The MDS indicated Resident 38 had a diagnosis of diabetes mellitus (DM). A review of Resident 38's Care Plan titled "Diabetes Mellitus," dated 1/31/2024, indicated Resident 38 will be free from any signs and symptoms of hyperglycemia and will have no complications related to diabetes. The Care Plan interventions included monitoring Resident 38 by the licensed nurses for any signs and symptoms of hyperglycemia such as increased thirst, fatigue, dry skin, abdominal pain, stupor, and coma, and documenting the results of monitoring. A review of Resident 38's Physician's Order Summary Report dated 1/30/2024, indicated an order for Sitagliptin Phosphate 50 mg once a day via GT for diabetes, and blood test for CBC, and CMP every Wednesday. A review of Resident 38's medical record, from 1/2024 to 3/4/2024, indicated the weekly CBC and CMP tests results were not available for review nor were Resident 38's blood glucose level monitored by the licensed nurses during that period. During a concurrent interview and record review on 5/18/2024 at 2:20 p.m., with Registered Nurse (RN 1) Resident 38's SBAR form dated 3/4/2024, was reviewed. The SBAR indicated Resident 38 had an increased confusion on 3/4/2024 (unspecified time). The SBAR indicated Licensed Vocational Nurse (LVN 2) notified Resident 38's MD 1 on 3/4/2024 at 7:47 a.m. of Resident 38's change in condition (increased confusion) and received orders for CBC and CMP blood test. RN 1 stated the resident's blood was not collected for CBC and CMP until 3/6/2024, two days after the order was received. RN 1 stated Resident 38's blood sugar level was not checked upon Resident 38's change in condition manifested by increased confusion on 3/4/2024. A review of Resident 38's Nurse's Notes dated 3/4/2024 and timed at 6:10 p.m., indicated Resident 38 was disoriented. The Nurse's Notes did not indicate Resident 38's blood sugar was checked or that MD 1 was notified of Resident 38's increased confusion and being disoriented. During a concurrent interview and record review on 5/18/2024 at 2:35 p.m., with RN 1 Resident 38's Weekly Summary Notes, dated 3/5/2024 and timed at 12:06 a.m., and 4:09 a.m., were reviewed. The Weekly Summary Notes indicated Resident 38 continued to moan and ask for family members throughout the day and night hours. RN 1 stated Resident 38's blood sugar was not checked on 3/5/2024, and MD 1 was not notified of Resident 38's altered mental status. A review of Resident 38's Nurses Notes dated 3/6/2024 and timed at 4:40 a.m., indicated Resident 38 was in and out of sleep throughout the night, moaning and calling for his family members. The Nurses Notes did not indicate Resident 38's blood sugar was checked on 3/6/2024, or MD 1 was notified of Resident 38's status of moaning and calling for his family members. A review of Resident 38's Nurses Notes dated 3/6/2024 and timed at 10:59 p.m., indicated Resident 38 continued to have episodes of confusion. During an interview on 5/18/2024 at 2:42 p.m., LVN 2 stated when Resident 38 was found with slurred speech on 3/10/2024, he (LVN 2) did not check Resident 38's blood sugar. LVN 2 stated it was possible Resident 2 had hyperglycemia and dehydration because of Resident 38's altered mental status, increased confusion, and dry/cracked lips. LVN 2 stated he contacted the on-call physician (MD 2) by phone on 3/10/2024 (time unknown) but MD 2 did not respond. LVN 2 stated he should have notified the Director of Nursing (DON) and recommended Resident 38 be transferred to a GACH for further evaluation and treatment. During a concurrent interview and record review on 5/18/2024 at 5:35 p.m., with RN 1, Resident 38's SBAR and the Medication Administration Record (MAR) were reviewed. RN 1 stated prior to 3/4/2024, Resident 38 could verbalize his needs and communicate with staff, so the signs and symptom Resident 38 experienced starting on 3/4/2024 through 3/7/2024 constituted a significant change in Resident 38's mental status. RN 1 stated prior to 3/4/2024 Resident 38 was able to verbalize if he was in pain to staff. RN 1 stated Resident 38's blood sugar was not checked during the change in condition (COC) on 3/4/2024 through 3/7/2024. RN 1 stated there was no documentation in Resident 38's Progress Notes or in the MAR to indicate the resident's blood sugar was checked. RN 1 stated license nurses did not check the resident's blood sugar, not even once. During a concurrent interview and record review on 5/18/2024 a 6:00 p.m., with RN 1, Resident 38's 72-hour (from the onset of change in condition on 3/4/2024) Charting dated 3/6/2024, and timed at 2:47 p.m., was reviewed. The 72-hour Charting indicated Resident 38 was disoriented to situations. RN 1 stated Resident 38's blood sugar was not checked, and MD 1 was not notified of Resident 38's altered mental status. A review of Resident 38's Laboratory Results Report dated 3/6/2024 and reported via telephone to LVN 3 at 9:57 p.m., indicated Resident 38's blood sugar (glucose level) was 217 mg/dL, with critical laboratory results as follows: 1.Blood Urea Nitrogen ([BUN] a blood test which measures the amount of urea nitrogen [waste product when the liver breaks down protein] in the blood which if elevated can be indicative of poor kidney function or damage) level of 81 mg/dL. The BUN reference range is between 7-25 mg/dL. 2. Sodium level of 160 milliequivalents per liter ([mEq/L] a measures fluid volume). The Sodium reference range is between 136-145 mEq/L. Elevated Sodium levels can lead to confusion, muscle twitching, seizures (a sudden, uncontrolled burst of electrical activity in the brain which can result in changes in behavior, movements, feelings, and level of consciousness), coma (when the person doesn't respond to voices, other sounds, or any sort of activity), and death. During a concurrent interview and record review on 5/18/2024 at 6:25 p.m., with RN 1 Resident 38's Nurses Notes, dated 3/6/2024 and timed at 10:59 p.m., were reviewed. The Nurses Notes indicated Resident 38 continued to have increased confusion and his CBC and CMP laboratory results were faxed to MD 1 on 3/6/2024 at 10:59 p.m. RN 1 stated there was no documented evidence that MD 1 (who was also the Medical Director) acknowledged and responded to faxed Resident 38's laboratory results or the licensed nurses followed up with MD 1 to ensure MD 1 received faxed test results and was aware of critical values. A review of Resident 38's Nurses Notes dated 3/7/2024 and timed at 4:02 a.m., indicated Resident 38 was in and out of sleep and moaning throughout the night calling for his wife and niece. A review of Resident 38's Nurses Notes dated 3/7/2024 and timed at 2:55 p.m., indicated Resident 38 continued to have episodes of confusion. The Nurses Notes did not indicate Resident 38's blood sugar was checked, and that MD 1 was notified of Resident 38's status (change in mental status), or critical laboratory test results dated 3/6/2024. During a concurrent interview and record review on 5/18/2024 at 6:46 p.m., with RN 1 Resident 38's Nurses Progress Notes dated 3/9/2024 and timed at 3:55 p.m., were reviewed. The Nurses Progress Notes indicated RN 1 notified MD 2 of Resident 38's CMP tests results. RN 1 stated she did not inform MD 2 about Resident 38's diagnosis of diabetes. RN 1 stated she informed MD 2 only of the BUN results because RN 1 was concerned about Resident 38's signs and symptoms of dehydration. RN 1 stated Resident 38's Sodium level of 161 mEq/L was not relayed to MD 2. RN 1 stated she did not inform MD 2 of Resident 38's clinical symptoms which included increased confusion on 3/4/2024 and being in and out of sleep throughout the night, moaning and calling for his family members on 3/7/2024. A review of Resident 38's COC dated 3/10/2024, and timed at 11:56 a.m., indicated Resident 38's Family Member (FM 1) informed LVN 4 that Resident 38 was not responsive as usual (baseline). A review of Resident 38's SBAR Communication Form dated 3/10/2024, indicated LVN 4 paged MD 2 at 12 p.m., to notify MD 2 of Resident 38's chapped lips, tear to his upper left lip, and decreased communication (not responding). There was no documentation to indicate Resident 38's blood sugar level was checked, and if MD 2 responded to the page. A review of Resident 38's Nurses Progress Notes dated 3/10/2024, and timed at 3:11 p.m., indicated Resident 38 was noted with a slurred speech. The Nurse's Notes indicated MD 2 was called (time not indicated) and was awaiting his response. There was no documentation to indicate Resident 38's blood sugar level was checked. A review of Resident 38's COC dated 3/10/2024 and timed at 6:43 p.m., indicated Resident 38 was still noted with increased weakness and less verbal. The COC indicated Resident 38's FM 1 requested Resident 38 to be transferred to a GACH for evaluation and treatment. The COC also indicated Resident 38 would be transferred to the GACH via a regular ambulance transport. A review of Resident 38's GACH's H&P dated 3/10/2024, and timed at 7:43 p.m., indicated Resident 38 presented to the Emergency Department (ED) with a respiratory rate ranging between 25 to 37 breaths per minute and increased confusion. The GACH's H&P indicated FM 1 stated Resident 38's altered mental status continued to worsen and the resident had labored breathing. The GACH's H&P indicated the following Resident 38's laboratory tests res