Other·October 11, 2023

F580 Code of Federal Regulations, Title 42, Section 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); (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. California Code of Regulations, Title 22, Section 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 8/11/2023, the California Department of Public Health (CDPH) received a complaint allegation that Resident 1’s death was a result of abuse and neglect by the facility. On 8/15/2023, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, it was determined there was no response from Resident 1’s Physician, when nursing staff notified him via facsimile (fax) of Resident 1’s laboratory test result for white blood count ([WBC] part of the immune system that protects the body from infection, reference range is 4,000 - 11,000 cells per microliter [cells/ul] a unit of measurement), being out of range. During the investigation it was also determined the licensed nurses did not follow up with Resident 1’s physician and/or the facility’s Medical Director (MD) for confirmation and clarification of the receipt of the out-of-range laboratory test results to obtain an order for treatment and/or specific interventions. The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) or other licensed nurses followed up with Resident 1’s physician and/or the facility’s MD when Resident 1’s physician did not respond to the notification of out-of-range laboratory test results of Resident 1’s WBCs. 2. Ensure the licensed nursing staff followed the facility’s Policy and Procedure (P&P), “Lab and Diagnostic Test Results-Clinical Protocol,” and “Emergency and/or Alternative Physician Care,” to contact the MD, when Resident 1’s physician did not respond within an hour to LVN 1’s notification of Resident 1’s out of range WBC’s laboratory test results. These deficient practices resulted in the delay of Resident 1’s evaluation and treatment, and lead to an increase of Resident 1’s WBCs from 15.90 cells/ul on 11/5/2021 to 20.51 cells/ul on 11/11/2021. Resident 1 was subsequently transferred to a General Acute Care Hospital (GACH 1) on 11/12/2021 with an elevated WBC of 45.0 cells/ul, hematuria (blood in the urine), and was diagnosed with severe sepsis (a life-threatening complication of an infection that can lead to the malfunctioning of various organs, shock, and death), septic shock (a condition sometimes occurring in severe sepsis, in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen), acute cystitis (inflammation of the urinary bladder) with hematuria, and acute renal (kidney) failure. On 12/13/2021 Resident 1 was transferred from GACH 1 to GACH 2 where he was evaluated and treated for acute Klebsiella (a bacteria that causes respiratory, urinary, and wound infections) urinary tract infection ([UTI] occurs when the bacteria enter the urinary tract, there is a higher chance of this infection when there is an indwelling catheter in place [a tube place in your body to drain and collect urine from the bladder]), hematuria, cystitis, urinary retention (difficulty urinating and completely emptying the bladder), acute kidney injury (a condition in which the kidneys suddenly can’t filter waste form the blood) with Stage III chronic kidney disease ([CKD] when the kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), leukocytosis (elevated WBCs), and sepsis. A review of Resident 1’s Admission Records (Face Sheet) indicated Resident 1, an 86-year-old male, was admitted to the facility on 11/2/2021, with diagnosis including malignant neoplasm of the brain (a fast growing cancer that spreads to other areas of the brain and spine), chronic kidney disease, type two diabetes mellitus ([DM] a chronic [long term condition affecting the way the body processes blood sugar), and essential primary hypertension ([HTN] high blood pressure that is not due to another medical condition). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/10/2021, indicated Resident 1’s cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 had an indwelling urinary catheter in place. A review of Resident 1’s Physician Order Report (POR) dated 11/5/2021 indicated an order for a Complete Blood Count ([CBC] a set of medical laboratory test that provides information about the cells in a person’s blood). A review of Resident 1’s Laboratory Report (LR) dated 11/5/2021, and timed at 1:54 p.m., indicated Resident 1's WBC were 15.90 cells/ul. The LR indicated there was a written notation that the laboratory test results were reported to Resident 1’s physician’s office on 11/5/2021 at 3:30 p.m., and the writer (an unknown person) was waiting for Resident 1’s physician’s response. The LR indicated Resident 1’s LR were sent to the physician again on 11/6/2021 at 12 p.m. A review of Resident 1’s licensed nurses’ progress notes (LNPN) dated 11/6/2021, and timed at 11:59 a.m., indicated Resident 1’s physician was notified of Resident 1’s CBC test results. The LNPNs indicated there was no documentation indicating Resident 1’s physician responded to the notification. A review of Resident 1’s Nurse Practitioner’s (NP) notes, dated 11/8/2021 and timed at 6:22 p.m., indicated, under the “Data Review” section, there were no new laboratory tests results. However, per the POR and LR both dated 11/5/2021, a laboratory test for a CBC was ordered, and results were received on 11/5/2021. A review of Resident 1’s POR, dated 11/10/2021 (five days after the initial out of range test results for WBC’s received on 11/5/2021 and the physician never responded) indicated an order for a STAT (immediate) urinalysis ([UA] a urine test used to detect UTIs kidney disease and diabetes) with a culture and sensitivity ([C&S] a test to check for bacteria in a urine sample), a CBC with differential (measures the number of each type of white blood cells) and a Comprehensive Metabolic Panel ([CMP] a blood test that gives doctors information about the body’s fluid balance). The POR indicated there was no documentation indicating Resident 1’s physician made an order for Resident 1’s treatment due to the abnormal WBC test results received on 11/5/2021 and there was no indication that Resident 1’s physician received and responded to the abnormal WBC results received on 11/5/2021. A review of Resident 1’s LR dated 11/11/2021 and timed at 2:26 p.m., indicated Resident 1’s WBCs increased from 15.90 cells/ul on 11/5/2021 to 20.51 cells/ul on 11/11/2021. A review of Resident 1’s LNPNs dated 11/11/2021 and timed at 12:51 a.m., indicated after receiving Resident 1’s LR on 11/11/2021, Resident 1’s physician ordered intravenous ([IV] into the vein) antibiotics for seven days. A review of Resident 1’s POR dated 11/11/2021 indicated a physician’s order for Ceftriaxone 1.0 gram ([gm] a unit of weight measurement) via IV once a day at 9 a.m. Resident 1 was transferred to GACH 1 on the same day as IV antibiotic was to be started (11/12/2021). A review of Resident 1’s LNPNs dated 11/12/2021 and timed at 5:54 a.m., indicated Resident 1 was found with moderate to severe bleeding from the urethra/penial area, with vital signs ([v/s] measurement of the body’s most basic functions) including blood pressure (BP) 89/74 millimeters of mercury ([mmHg] a unit of measurement. The reference range for BP is 90/60 - 120/80 mmHg), heart rate (HR) 115 beats per minute ([bpm]- reference range is 60-100 bpm), and a blood sugar (b/s) of 142 milligrams per deciliter ([mg/dl] a unit of measurement. The reference range is of 80-100 mg/dl). A review of Resident 1’s Physician’s Order (PO), dated 11/12/2021 and timed at 6:30 a.m., indicated to transfer Resident 1 to GACH 1 for further evaluation. A review of GACH 1’s Admission Record, indicated Resident 1 was admitted to GACH 1 on 11/12/2021. A review of GACH 1’s LR dated 11/12/2021, indicated Resident 1’s WBCs (blood test) were 45.0 cells/ul. GACH 1’s LRs indicated Resident 1’s UA result, dated 11/12/2021, was as follows: 1. Protein +1 (reference range is negative). 2. Blood + 3 (reference range is negative). 3. Leukocytes 250 (reference range is negative). 4. Urine color red (reference range is straw yellow). 5. WBCs 10-15 high power field ([hpf] to indicate infections, inflammation, or contamination, reference range is 0-5 hpf). 6. Bacteria 5-10 hpf (reference range is zero, 10 or higher is highly suggestive of a UTI in symptomatic patients). A review of GACH 1’s Preliminary Emergency Department Report dated 11/12/2021 indicated Resident 1 had severe sepsis with septic shock and acute cystitis with hematuria, and acute renal failure. A review of GACH 1’s Transfer Form, dated 11/12/2021 indicated Resident 1 was transferred to GACH 2, a higher level of care. A review of GACH 2’s History and Physical/Admission Notes indicated Resident 1 was admitted to GACH 2 on 11/13/2021. A review of the History of Present Illness (HPI), upon arrival, indicated Resident 1 continued to have persistent hematuria and was seen by a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) who inserted an indwelling urinary catheter and irrigated (the process of washing out an organ or wound with a continuous flow of water or medication) Resident 1’s bladder, which resulted in fresh hematuria. Resident 1 was weaned (stop) off pressors (medications that raise the blood pressure), but Resident 1’s BP dropped again. A review of GACH 2’s Discharge Summary, dated 12/10/2021 (28 days after admission), indicated Resident 1 was treated for acute Klebsiella UTI orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down), altered mental status with acute agitation/delirium (a disturbed state of mine characterized by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinations) , hematuria and cystitis, urinary retention likely due to benign prostate hypertrophy [(BPH) a condition in men in which the prostate gland is enlarged and not cancerous], acute blood loss anemia (a condition in which the body does not have enough healthy red blood cells) with iron deficiency, acute kidney injury with Stage III CKD, leukocytosis due to steroid (man-made hormones) use and UTI, elevated INR ([International Normalized Ratio] tells how long it takes for the blood to clot) due to sepsis and hematuria. During an interview on 6/20/2023, at 2:40 p.m., LVN 1 stated she did not recall if she notified Resident 1’s physician of Resident 1’s LR dated 11/5/2021. LVN 1 stated if a physician does not respond within 30 minutes, staff are instructed to contact a resident’s physician and/or on-call physician. If neither one of the physicians respond, the staff are instructed to contact the MD so there is no delay in care and treatment. LVN 1 stated when WBCs are high, it can indicate an infection is present and if a resident is not treated timely the infection can lead to sepsis. During an interview with the Assistant Director of Nursing (ADON) on 6/20/2023 at 3:25 p.m., the ADON reviewed Resident 1’s LRs dated 11/5/2021 and 11/11/2021 and stated when the physician does not respond within 30 minutes the MD should be called to expedite any order needed to treat the resident. The ADON stated it is important to notify the physician right away so there is no delay in care and treatment that could possibly lead to sepsis and a resident’s death. A review of the facility’s P&P, titled, “Lab and Diagnostic Test Results- Clinical Protocol,” revised 9/2012, the P&P indicated a physician should respond within one hour regarding a laboratory test result requiring immediate notification. If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the MD for assistance. A review of the facility’s P&P, titled “Emergency and/or Alternative Physician Care,” revised 4/2013, indicated all resident shall be provided with emergency and/or alternative physician care. If a physician and his/her backup coverage do not respond in a timely or appropriate manner to staff’s notification of medical issues, the nursing staff will contact the MD for assistance. The facility failed to: 1. Ensure LVN 1 or other licensed nurses followed up with Resident 1’s physician and/or the facility’s MD when Resident 1’s physician did not respond to the notification of out-of-range laboratory test results of Resident 1’s WBCs. 2. Ensure the licensed nursing staff followed the facility’s P&P, “Lab and Diagnostic Test Results-Clinical Protocol,” and “Emergency and/or Alternative Physician Care,” to contact the MD, when Resident 1’s physician did not respond within an hour to LVN 1’s notification of Resident 1’s out of -range WBC’s laboratory test results. These deficient practices resulted in the delay of Resident 1’s evaluation and treatment, and lead to an increase of Resident 1’s WBCs from 15.90 cells/ul on 11/5/2021 to 20.51 cells/ul on 11/11/2021. Resident 1 was subsequently transferred to a GACH on 11/12/2021 with an elevated WBC of 45.0 cells/ul, hematuria, and was diagnosed with severe sepsis, septic shock, acute cystitis with hematuria, and acute renal failure. On 12/13/2021 Resident 1 was transferred from GACH 1 to GACH 2 where he was evaluated and treated for acute Klebsiella urinary tract infection, hematuria, cystitis, urinary retention, acute kidney injury with Stage III chronic kidney disease, leukocytosis, and sepsis. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1.