Health inspection·September 15, 2023

42 CFR § 483.25(l) Dialysis The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. 22 CCR § 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. 22 CCR § 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. On 7/18/2023, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding an allegation of resident-to-resident physical and verbal abuse between Resident 1, Resident 2, and Resident 3. On 8/1/2023, CDPH conducted an unannounced visit at the facility. Findings unrelated to the original allegation were found. The facility failed to: 1. Conduct an Interdisciplinary Team (IDT, (a group of health professionals with various expertise) meeting after Resident 1 refused hemodialysis [(HD), a treatment to filter wastes, water, and balance essential minerals such as potassium, sodium, and calcium in the blood)] on Saturday, 7/15/2023 per the facility’s policy and procedure. 2. Notify the dialysis (a treatment process for people whose kidneys are failing) center (DC) that Resident 1 refused HD treatment on 7/15/2023. 3. Implement the physician’s order for Resident 1 to receive HD care, treatment, and services on Tuesday, 7/18/2023 from an off-site dialysis center.  4. Notify Resident 1’s primary medical doctor (PMD) of the missed HD treatment and services on 7/18/2023. 5. Implement Resident 1’s care plan to receive HD services on 7/18/2023. 6. Ensure Licensed Vocational Nurse (LVN) 1, the night shift nurse (worked from 11 p.m. to 7 a.m.), notified LVN 2, the day shift nurse (worked from 7 a.m. to 3 p.m.), that Resident 1 missed dialysis on 7/18/2023. 7. Ensure Resident 1 had pre (before) and post (after) dialysis communication form on 7/18/2023. As a result, Resident 1 had a change of condition (COC) and died on 7/19/2023 after not receiving six days of HD (from 7/14/2023 to 7/19/2023). A review of Resident 1’s Admission Record, dated 8/1/2023, the Admission Record indicated, Resident 1 was a 56 year old male initially admitted to the facility on 6/6/2023, and readmitted on 7/13/2023 with diagnoses including cardiomyopathy (heart failure, when the heart is unable to pump enough blood throughout the body), end stage renal disease (ESRD, when the kidneys are unable to eliminate wastes and excess fluids in the blood), diabetes (abnormal blood sugar) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The Admission Record indicated Resident 1 died and was discharged to a mortician (a person who prepares the dead for a funeral) on 7/19/2023. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/13/2023, indicated the resident’s cognition (ability to think and understand) was severely impaired. A review of Resident 1’s general acute care hospital (GACH) records, dated 7/13/2023, indicated, nephrology (a branch of medicine concerned with the kidneys) made arrangements for HD per the resident’s TTS routine schedule prior to re-admission to the skilled nursing facility (SNF). A review of Resident 1’s Care Plans (CP) titled “Dialysis”, dated 7/14/2023, indicated Resident 1 needed HD related to ESRD. The CP interventions indicated to encourage resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday.  A review of the facility’s electronic document titled “eINTERACT SBAR (situation, background, assessment, recommendation) SUMMARY for Providers”, dated 7/15/2023 at 6:26 a.m., indicated “pt (patient) refused dialysis 3 times”.  A review of Resident 1’s Care Plans (CP) titled, “The resident is resistive to care related to refusing dialysis three times,” dated 7/15/23, indicated, “monitor resident for change in condition and provide resident with opportunities for choice during care provision.” A review of Resident 1’s “Medical Practitioner Narrative Note” (MPNN), dated 7/18/2023 at 1:26 p.m., indicated that Resident 1’s PMD recommended to continue HD for Resident 1’s due to ESRD and heart failure diagnoses.  A review of Resident 1’s nurses notes, dated 7/18/2023 at 8:44 p.m., indicated, Resident 1 refused some activities of daily living (ADL, daily self-care activities such as eating, bathing, and moving), meals and medications.  A review of Resident 1’s eINTERACT SBAR (situation, background, assessment, recommendation) SUMMARY for Providers”, dated 7/19/2023 at 8:02 a.m., indicated, Resident 1 refused ADLs, all meals, vital signs (reflects the essential body functions, including the resident’s heartbeat, breathing rate, temperature, and blood pressure [measure of the force that the heart uses to pump blood around the body]), and was yelling at staff. Resident 1’s primary doctor recommended a psychiatric evaluation (used to determine a patient’s mental state and guide recommendations for the best treatment).  A review of Resident 1’s Alert Note (AN), dated 7/19/2023 at 9:04 a.m., indicated Resident 1 refused all care and dialysis. The AN indicated Resident 1’s PMD was aware of Resident 1’s refusal and recommended to be sent out to GACH. The AN indicated an ambulance was set up for transportation at 9:02 a.m. A review of Resident 1’s nurses note, dated 7/19/2023 at 10:50 a.m., indicated Code Blue [when a patient requires immediate medical attention, most often as the result of not breathing or heart stopped beating] was called at 9:46 a.m. while a regular Basic Life Support (BLS, non-critical, unable to inject medications) ambulance personnel were at bedside and cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure) was initiated at 9:48 a.m. Between 9:57 a.m. to 10:37 a.m., the Fire Department and Paramedics (a more highly trained emergency medical technician capable of more advanced medical procedures) took over the rescue efforts while a doctor from a GACH was on the phone providing orders and instructions. At 10:38 a.m., lifesaving procedures were halted, and Resident 1 was pronounced dead. During a concurrent interview and record review of the nursing notes on 8/2/2023 at 1:20 p.m., with the MDS nurse, the MDS nurse stated, Resident 1 returned to the facility from a GACH on 7/13/2023 at 8:30 p.m. The MDS nurse stated, LVN 1 (nurse who admitted the resident to the facility) had no documentation on the nursing notes of Resident 1 receiving dialysis while outside the facility. The MDS nurse stated, Resident 1’s PMD wrote a note on 7/18/2023 at 1:26 p.m. indicating the resident was seen by the PMD.  During a concurrent interview and record review on 8/2/2023, at 1:20 p.m., with the MDS nurse, Resident 1’s Change of Condition (COC), dated 7/15/2023, was reviewed. The COC indicated, Resident 1 was assessed to have behavioral issues when the resident refused to go to HD and yelled at Certified Nurse Assistant. The COC indicated the Registered Nurse spoke to the resident, but the resident continued to refuse HD. The COC indicated the primary doctor’s recommendations were to continue to monitor and do a COC.  During a concurrent interview and record review of Resident 1’s clinical record (IDT notes) on 8/3/2023, at 10:04 a.m., with MDS nurse, MDS nurse stated Resident 1’s refusal to treatments of medication and HD should have been brought up in the daily stand-up meetings and the IDT but there was no IDT about his refusals. During an interview on 8/3/2023, at 11:36 a.m., with LVN 2, LVN 2 stated, on 7/18/2023 during the morning shift (7 a.m. to 3 p.m.), Resident 1 was asked if the resident had gone for HD during the night shift (the resident’s HD appointment starts at 4:45 a.m.). LVN 2 stated, the resident stated he had gone to HD. LVN 2 stated she did not check Resident 1’s pre and post dialysis communication forms to verify whether the resident had gone to HD. LVN 2 stated, “If a resident comes back from dialysis, there is a post dialysis assessment, the doctor is contacted if there are critical (very low or high) laboratory (blood test) levels.” LVN 2 stated, because Resident 1 was still refusing care on 7/19/2023, LVN 2 called the HD center to verify if Resident 1 received HD (on 7/18/2023). LVN 2 stated, she was notified by the HD center that Resident 1 did not go to dialysis on 7/18/2023. LVN 2 stated she initiated a COC and notified the doctor (on 7/19/2023); however, she did not report (to the doctor) that the resident had missed HD on 7/18/2023.  During an interview on 8/3/2023, at 12:20 p.m., with the DON, the DON stated, when a resident refuses dialysis, the nurse’s responsibility was to let the next shift’s nurse and dialysis center know about the refusal and do a COC. The DON stated, the facility had an appointment book but was not sure if HD schedules were included.   During an interview on 8/3/2023, at 1:16 p.m., with Resident 1’s PMD, the PMD stated, she does not recall if the facility notified her about Resident 1 refusing HD on 7/18/2023. The PMD stated, she was aware Resident 1 refused medications, care, and HD previously. The PMD stated, if a resident missed HD and the doctor was not notified, the possible outcomes were arrhythmia (irregular heartbeat), heart failure, and death. The PMD stated, there were no alternatives to dialysis except temporary medications and stabilizing the laboratory (blood test) levels. The PMD stated, she did not think about ordering laboratory tests because those were usually done at the dialysis center. The PMD stated, she referred Resident 1 for psychiatric evaluation to determine his decision-making capacity to refuse but Resident 1 died on that day (7/19/2023). During a telephone interview on 8/3/23, at 3:58 p.m., with Dialysis Clinical Coordinator (DCC), the DCC stated, Resident 1’s last HD at their center was on 6/22/2023. DCC stated, a call was received from a nurse in Resident 1’s facility on 7/19/2023 asking if Resident 1 received HD on 7/18/2023. DCC stated, their center called (on 7/20/2023) Resident 1’s facility asking why Resident 1 has not returned for HD but was notified Resident 1 died on 7/19/2023. DCC stated, “the facility should have called the dialysis center when a resident refuses dialysis to re-schedule another dialysis.” During an interview on 8/4/23, at 4:36 p.m., with Medical Director (MD), MD stated, if a resident refused dialysis, a doctor must assess for mental capacity to refuse. MD stated, if the resident was alert, oriented with decision-making capacity, the doctor will educate medical care and dialysis compliance whether they are in a skilled nursing facility or hospital about the risks and benefits. The MD stated, “collect baseline (first)laboratory tests to monitor (resident’s condition)”. During a concurrent interview and record review on 8/4/2023 at 5:23 p.m., with Medical Records (MR), Resident 1’s Pre (before) and Post (after) Dialysis Communication Forms (PPDC) from re-admission date on 7/13/2023 to discharge date on 7/19/2023 were reviewed. MR stated, there were no “PPDC” forms initiated or completed indicating if Resident 1 had HD at an off-site dialysis center. During a concurrent interview and record review on 8/4/2023 at 5:23 p.m., with Medical Records (MR), Resident 1’s Interdisciplinary Team (IDT) from re-admission date on 7/13/2023 to discharge date on 7/19/2023 were reviewed. Medical Records stated, there were no “IDT” forms related to refusal of treatments, medications, and HD. A review of the facility’s policy and procedure (P&P) titled, “Care Plans, Comprehensive Person-Centered”, dated 03/2022, the P&P indicated the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental and psychosocial wellbeing that the resident desires or that is possible, including serviced that would otherwise be provided for the above. A review of the facility’s P&P titled “End- Stage Renal Disease, Care of a Resident with” dated 09/2010, the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care. Conclusion: The facility failed to: 1. Conduct an Interdisciplinary Team (IDT, (a group of health professionals with various expertise) meeting after Resident 1 refused HD on Saturday, 7/15/2023 per the facility’s policy and procedure. 2. Notify the dialysis (a treatment process for people whose kidneys are failing) center (DC) that Resident 1 refused HD treatment on 7/15/2023. 3. Implement the physician’s order for Resident 1 to receive HD care, treatment, and services on Tuesday, 7/18/2023 from an off-site dialysis center.  4. Notify Resident 1’s PMD of the missed HD treatment and services on 7/18/2023. 5. Implement Resident 1’s care plan to receive HD services on 7/18/2023. 6. Ensure Licensed Vocational Nurse (LVN) 1, the night shift nurse (worked from 11 p.m. to 7 a.m.), notified LVN 2, the day shift nurse (worked from 7 a.m. to 3 p.m.), that Resident 1 missed dialysis on 7/18/2023. 7. Ensure Resident 1 had pre (before) and post (after) dialysis communication form on 7/18/2023. As a result, Resident 1 had a change of condition (COC) and died on 7/19/2023 after not receiving HD for six days (from 7/14/2023 to 7/19/2023). 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.