Health inspection·September 25, 2024

F684 § 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, including but not limited to the following: §72311(a)(2) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §72523(a) 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 8/7/2024 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was admitted to a General Acute Care Hospital (GACH) with a diagnosis of sepsis (a life threatening complication of an infection) and while Resident 1 was at the GACH, a complaint was made that while Resident 1 was at the facility he had urine retention (difficulty completely emptying the bladder) after having been observed with abdominal distention (a condition where the bladder stretches and becomes inflamed due to pressure when the bladder does not empty properly). On 8/13/2024 CDPH conducted an unannounced visit to investigate the complaint allegation. Upon investigation CDPH determined Resident 1 was at risk for urinary retention due to a diagnosis of benign prostatic hypertrophy ([BPH] a condition that causes the prostate gland to enlarge making it harder for the bladder to push out urine and can lead to urinary retention and a urinary tract infection ([UTI] an infection in any part of the urinary system such as kidneys, bladder, ureters, and urethra) and the licensed nurses failed to monitor and assess Resident 1's urine output. The facility failed to ensure: 1. Certified Nursing Assistants (CNA 2) and CNA 3 reported to licensed nursing staff when Resident 1 had a dry diaper (no urine output) during an eight-hour shift. 2. Licensed nurses conducted a physical assessment of Resident 1 to determine if he was in pain, had abdominal distension, a decrease in urine output and/or the inability to urinate, and did not rely on CNAs to report signs and symptoms (s/s) of urinary retention, including a dry diaper that they were not trained to detect, and was not the CNA's scope of practice. 3. Nursing staff followed the facility's policy and procedure (P/P), titled, "Resident Hydration and Prevention of Dehydration" which indicated the fluid intake and output monitoring will be initiated for those residents with the potential of inadequate intake or output, incorporate it into the care plan, and nursing staff will assess factors that may contribute to inadequate fluid intake and output, monitor and document fluid intake and output. As a result, Resident 1 was transferred to a GACH for evaluation and treatment after suffering a seizure (uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms) and was diagnosed with a UTI, severe sepsis (a life-threatening condition that occurs when sepsis [an inflammatory response to an infection] causes one or more of the body's organs to malfunction because of a low blood pressure (B/P) resulting from inflammation throughout the body), and urine retention, with 1900 milliliters ([ml] a unit of liquid measurement) of urine in Resident 1's bladder. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, was an 83 year-old male, was admitted to the facility on 8/1/2024, with diagnoses including secondary malignant neoplasm of the brain (cancer that spread to the brain), BPH, and acute kidney failure (when kidneys suddenly lose their ability to function). A review of Resident 1's untitled Care Plan dated 8/2/2024, indicated Resident 1 had an impaired nutrition and hydration status. One of the care plan's interventions included to observe and report if the resident had a decreased urine output, dark urine, and increased confusion. A review of Resident 1's Fluids Flow Sheet dated 8/3/2024 through 8/6/2024, indicated Resident 1 ingested 300 ml of fluid on 8/3/2024, 620 ml of fluid on 8/4/2024, 420 ml of fluid on 8/5/2024, and 120 ml of fluid on 8/6/2024, a total of 1460 ml in four days. The Fluids Flow Sheet indicated there was no documentation of Resident 1's fluid output (urine quantity). A review of Resident 1's Documentation Survey Report dated 8/2024, indicated Resident 1 was incontinent (inability to control bowel and bladder function) of urine on 8/1/2024, 8/3/2024, 8/4/2024, 8/5/2024, and 8/6/2024. The Survey Report indicated there was no documentation of Resident 1's urine output. A review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team) dated 8/6/2024 and timed at 8:10 a.m., indicated to transfer Resident 1 to a GACH via 911 due to uncontrolled seizures. A review of Resident 1's Emergency Medical Services record dated 8/6/2024 and timed at 8:19 a.m., indicated paramedics responded to a 911 call at the facility and upon arrival Resident 1 was noted with shortness of breath (SOB). The Emergency Medical Services Record indicated Resident 1 had an Oxygen saturation ([O2 Sat] a measurement of how much oxygen is in the blood, reference, range is 95% to 100%) level of 81% on room air (without administration of O2), was hypotensive (below normal B/P) with a B/P of 87/65 millimeters of mercury ([mmHg] a unit of B/P measurement. B/P reference range is 120/80) and tachycardic (when the heart rate (HR) is too fast) with a HR of 135 beats per minute ([bpm] HR reference range is 60-100 bpm). A review of the GACH's Encounter Information dated 8/6/2024, indicated Resident 1 arrived at the GACH's Emergency Room (ER) on 8/6/2024 at 8:49 a.m. A review of the GACH's Nephrology Consult Note dated 8/6/2024 and timed at 3:02 p.m., indicated Resident 1 was admitted to the Intensive Care Unit ([ICU] a unit in a hospital that manages patients who are critically ill) for acute kidney injury related to urinary retention, a UTI, severe sepsis, and hypoxic respiratory failure (occurs when the lungs are not able to get not enough oxygen in the blood and deprives the body's organs and tissues of oxygen). The Nephrology Consult Note indicated Resident 1's kidney function normalized after a urinary indwelling catheter (a flexible tube inserted into the bladder to collect and drain urine) was placed in Resident 1's bladder. A review of the GACH's Shift Outcome Evaluation record dated 8/6/2024 and timed at 7:21 p.m., indicated Resident 1's urinary bladder scan (a procedure that measures the volume of urine in the bladder) indicated Resident 1's bladder had 1900 ml of urine. During an interview on 8/13/2024 at 1:47 p.m., CNA 2 stated she cared for Resident 1 on 8/5/2024 from 7 a.m. to 3 p.m. and on 8/6/2024 from 7 a.m. until Resident 1 was transferred to the hospital around 8:30 a.m. CNA 2 stated on 8/5/2024 Resident 1's diaper was dry until he went to radiation therapy (a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors) at 1:30 p.m. CNA 2 stated Resident 1 did not return during her shift on 8/5/2024. CNA 2 stated on 8/6/2024 in the morning Resident 1 was confused, could not remember how to put a spoon in his mouth during breakfast and was lethargic (a state of weariness that involves diminished energy, mental capacity, and motivation). CNA 2 stated between 7:45 a.m., and 8:15 a.m., on 8/6/2024 Resident 1 had a seizure and was transferred to the GACH. During an interview on 8/13/2024 at 2:12 p.m., Licensed Vocational Nurse (LVN 1) stated if a resident had a dry diaper without any urine output halfway through the shift (four hours or more), she would assess the resident for bladder distention and she would inform the physician because the resident could be retaining urine. During an interview on 8/14/2024 at 9:40 a.m. Registered Nurse 1 (RN 1) stated, the registered nurses perform head to toe assessments ([comprehensive assessment] a physical exam that nurses perform to evaluate a resident's health status and identify potential issues) when admitting residents to the facility and when there is a change of condition ([COC] a sudden and significant change in a resident's physical, cognitive, behavioral, or functional state indicative of acute illnesses). RN 1 stated comprehensive assessments were not performed on residents daily but were prompted by concerns identified by CNAs and LVNs. During a concurrent interview and record review on 8/14/2024 at 10:22 a.m., with RN 1, Resident 1's Physician's Order dated 8/1/2024 was reviewed. The Physician's Order indicated Resident 1 was to receive Tamsulosin (used to treat men with symptoms of an enlarged prostate (benign prostate enlargement) for BPH. RN 1 stated residents who have a history of BPH should be monitored for urine output and urinary retention. During an interview on 8/15/2024 at 8:34 a.m., CNA 3 stated on 8/4/2024 during the 7 a.m. to 3 p.m., shift Resident 1's diaper was dry and without urine all shift. CNA 3 stated he did not report Resident 1's diaper was dry (without urine) for 8 hours because he did not realize it was unusual and needed to be reported. During an interview on 8/15/2024 at 10:52 a.m., LVN 2 stated she was Resident 1's assigned nurse on 8/5/2024 from 7 a.m. to 3 p.m., and during that time Resident 1 was awake but did not respond to questions. LVN 2 stated she was not aware that this was a change in Resident 1's condition because it was her first time caring for Resident 1. LVN 2 stated she should have reviewed Resident 1's clinical record to determine if this was Resident 1's normal behavior or not. LVN 2 stated she was not aware that she should monitor Resident 1 for urinary retention, and no one informed her that Resident 1's diaper had been dry, without urine on 8/5/2024 during the day shift. During an interview on 8/15/2024 at 12:20 p.m., the Director of Staff Development (DSD) stated CNAs could not perform assessments and were not taught the s/s of urinary retention or dehydration, but they were instructed to report to a licensed nurse about dry diapers, refusal of care, and refusal to eat. The DSD stated licensed nurses should look at the resident's care plans, and they were responsible for communicating care needs and what CNAs should look out for while caring for a resident. During an interview on 8/15/2024 at 1:48 p.m., LVN 2 stated she was Resident 1's assigned nurse on 8/5/2024 from 7 a.m. to 3 p.m. and was not aware of Resident 1's hydration care plan because during morning report, only Resident 1's increased confusion was mentioned. LVN 2 stated licensed nurses were responsible for assessing residents for dehydration and should have been monitoring Resident 1 for urinary retention every shift as ordered by the physician. During an interview on 8/15/2024 at 2:13 p.m., the Assistant Director of Nursing (ADON) stated licensed nurses were responsible for reviewing resident's care plans to implement interventions, especially when working with a resident for the first time. The ADON stated CNAs did not have access to care plans so licensed nurses were responsible for communicating the plan of care to the CNAs. The ADON stated when a care plan's interventions indicated to observe and report s/s of dehydration it was not appropriate to rely on CNAs to assess and report information to the licensed nurse, because the assessment required a licensed nurse to lay their eyes on the resident to determine the resident's status. A review of facility's P&P, titled "Resident Hydration and Prevention of Dehydration," dated 10/2017, indicated the fluids intake and output monitoring will be initiated for those residents with the potential of inadequate intake or output and incorporated into the care plan. The P&P indicated nursing staff will assess factors that may be contributing to inadequate fluid intake and output, monitor and document fluid intake and output. The facility failed to ensure: 1. CNA 2 and CNA 3 reported to licensed nursing staff when Resident 1 had a dry diaper during an eight-hour shift. 2. Licensed nurses conducted a physical assessment of Resident 1 to determine if he was in pain, had abdominal distension, a decrease in urine output and/or the inability to urinate, and did not rely on CNAs to report s/s of urinary retention, including a dry diaper that they were not trained to detect, and was not the CNA's scope of practice. 3. Nursing staff followed the facility's P/P, titled, "Resident Hydration and Prevention of Dehydration" which indicated the fluid intake and output monitoring will be initiated for those residents with the potential of inadequate intake or output, incorporate it into the care plan, and nursing staff will assess factors that may contribute to inadequate fluid intake and output, monitor and document fluid intake and output. As a result, Resident 1 was transferred to a GACH for evaluation and treatment after suffering a seizure, and was diagnosed with a UTI, severe sepsis, and urine retention, with 1900 ml of urine in Resident 1's bladder. This violation had the direct or immediate relationship to the health, safety, or security of Residents 1