Health inspection·February 9, 2023

42 CFR § 483.25 (I) Dialyses 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. 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. 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 12/9/2022 the California Department of Public Health (CDPH) received a complaint regarding quality of care provided to a resident receiving hemodialysis ([HD] a treatment to filter wastes and water from the blood). On 12/21/2022, CDPH the Department conducted an unannounced visit at the facility to investigate the complaint. Resident 1, an 80-year-old male, who had diagnoses of end stage renal disease ([ESRD] when kidneys are no longer able to function to meet the body's needs) and COVID-19 (a highly infectious disease caused by a virus), did not receive three HD treatments as scheduled to remove waste and extra water from the blood and to keep body chemicals in balance. The facility failed to: 1. Ensure Resident 1received HD treatment and services three times a week (every Tuesday, Thursday, and Saturday) as ordered by the physician, at the HD center accepting COVID-19 positive residents. 2. Ensure Resident 1 received HD treatment three times a week on Tuesday, Thursday, and Saturday as indicated in the care plan (CP) titled "Hemodialysis " initiated on 7/22/2022. 3. Ensure Resident 1's physician was notified the resident missed HD treatment on three consecutive days: 12/13/2022, 12/14/2022, and 12/15/2022. Resident 1's last HD treatment was on 12/10/2022. 4. Ensure Resident 1 was transported to and from the Covid -19 positive HD center on 12/14/2022 5. Ensure the HD center accepting COVID-19 positive residents was contacted and notified that Resident 1 could not go to the COVID-19 HD center for the re-scheduled dialysis treatment on 12/14/2022 at 6:30 p.m. due to a lack of transportation. As a result, Resident 1 did not receive HD treatment on three consecutive days, 12/13/2022, 12/14/2022 and 12/15/22, and developed diarrhea, abdominal pain, and bloody stools on 12/15/2022. On 12/16/2022. Resident 1's condition continued to deteriorate, and Resident 1 was transferred to a general acute care hospital (GACH) where Resident 1 was diagnosed with hyperkalemia (a higher-than-normal level of potassium [the electrolyte (a mineral in a blood and other body fluids that carry an electric charge) that maintains normal levels of fluid inside the body cells]) in the bloodstream. On 12/16/2022, Resident 1 was admitted to the intensive care unit ([ICU] a unit in a GACH that provides the highest level of care for critically ill patients) and had an emergent HD treatment. According to Resident 1's Admission Record, the resident was admitted to the facility on 2/3/2022, with diagnoses including ESRD, hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body), cerebral infarction (damage to tissues in the brain due to a loss of oxygen ), diabetes mellitus (abnormal blood sugar due to the inability of the body to process sugar for energy), and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) of left foot first and second toes. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 11/9/2022, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to think, understand and reason) were intact. The MDS indicated Resident 1 required extensive assistance (the resident was involved in activity; staff provide weight bearing support) from one staff physical assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 1's physician's order dated 10/20/2022, the physician's order indicated Resident 1 was to receive dialysis treatment three times a week at 12 p.m. every Tuesday, Thursday, and Saturday. During a review of Resident 1's CP titled "Hemodialysis," initiated on 7/22/2022, the CP indicated interventions including dialysis treatment three times a week on Tuesday, Thursday, and Saturday at 12:30 p.m. via arteriovenous shunt ([AV] Shunt- a U-shaped plastic tube inserted between an artery and a vein) with pick up time from the facility for transportation to the contracted HD center at 11 a.m. During a review of Resident 1's Situation-Background-Assessment-Recommendation ([SBAR] a tool for communication between members of the health care team about a resident's emergent condition) Communication Form, dated 12/15/2022, and timed at 3 p.m., the SBAR indicated, Resident 1 had abdominal pain rated 7 out of 10 on a pain scale (a numeric pain scale with zero for no pain, 7 for severe pain, and 10 for the worst imaginable pain), diarrhea, and blood in stool. The SBAR, dated 12/16/2022, and timed at 12 a.m., indicated Resident 1 complained of abdominal pain rated 10 out of 10, with dark stool (which can indicate bleeding within the digestive system) four times in two hours. Toradol was given for pain rated 10 out of 10, but it was not effective. On 12/16/2022 at 2:05 a.m. Resident 1 was transferred to the GACH emergency room (ER) via emergency medical services (EMS) after a 911 call. During a review of Resident 1's GACH's ER physician's note, dated 12/16/2022, the ER physician's note indicated Resident 1's blood tests result as follows: 1. Potassium elevated at 8.4 millimole per liter ([mmol/L] a unit of measure. Reference range 3.5 - 5.1 mmol/L with hyperkalemia. 2. Blood Urea Nitrogen ([BUN] a test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that the kidney removes from the blood. High BUN level means the kidneys are not filtering toxins from the body) elevated at 250 milligrams per deciliter ([mg/dl] a unit of measure. Reference range 7 - 18 mg/dL. 3. Creatinine (a waste product produced by muscles. Creatinine stays in the blood until the kidneys eliminate them) elevated at16.96 mg/dL. Reference range is 0.70 - 1.30 mg/dL, and severe acute upper gastrointestinal bleeding. During an interview on 12/21/2022, at 10:15 a.m., the facility's Social Service Director (SSD) stated, each resident's insurance company arranges each resident's transportation. The SSD stated, the insurance company needed to be notified to arrange transportation 48 to 72 hours in advance. The SSD stated, the facility has contracts with one emergency transportation company (TC 1), but the transportation company could not guarantee transport for Resident 1 on 12/14/2022. The SSD stated the facility only utilized TC 1 for emergencies. During an interview on 12/21/2022, at 11:20 a.m., the case manager (CM) stated, Resident 1 missed the HD appointment on 12/13/2022 (Tuesday) because the resident tested positive for COVID-19 on 12/12/2022. The CM stated Resident 1's regular HD center referred Resident 1 to a COVID-19 positive HD center and an appointment was made for 12/14/2022 (Wednesday) at 6:30 p.m. The CM stated, the TC 1 could not accommodate Resident 1's transportation needs, resulting in Resident 1 missing the appointment on 12/14/2022. The CM stated there was no follow-up HD appointment made for 12/15/2022 (Thursday) because "the follow up appointment was a nursing responsibility." The CM stated Resident 1 should have been transferred to a GACH due to the resident's severe abdominal pain of 10 out 10, bloody stool, and altered mental status on 12/14/2022 after the missed appointment for emergency HD (on 12/14/2022 at 6:30 p.m.). During an interview on 12/21/2022, at 2:50 p.m., the licensed vocational nurse (LVN 1) stated Resident 1's HD appointment at the COVID-19 positive HD center on 12/14/2022 was missed because the facility gave short notice to TC 1 of Resident 1's need for transport to the HD center. LVN 1 stated she noticed Resident 1 had two dark and loose stools during the 3 pm to 11 pm shift on 12/15/2022. LVN 1 stated Resident 1's SBAR report was not completed on 12/15/2022 and the physician was not notified regarding Resident 1's missed HD appointments (on 12/13/2022, 12/14/2022, and 12/15/2022) or about Resident 1 having dark stools on 12/15/2022. LVN 1 stated, the SSD oversees HD appointments for residents receiving dialysis and follows up with the transportation company about taking residents to HD centers and driving them back to the facility. LVN 1 stated, missing HD appointments could result in life threatening issues due to electrolyte imbalance (an elevated or reduced level of certain salts and minerals in the body). During a phone interview on 12/21/2022, at 3:28 p.m., the Registered Nurse (RN 2) from the COVID-19 positive HD center stated, Resident 1 was a "no show" for a scheduled appointment on 12/14/2022. RN 2 stated, there was no documentation indicating LVN 1 called and notified the COVID-19 positive HD center that Resident 1 was unable to be transported for treatment. RN 2 stated the COVID-19 positive HD center was only open on Monday, Wednesday, and Friday from 6:30 p.m. to 8 p.m. During a telephone interview on 12/22/2022, at 12:03 p.m., LVN 4 stated on 12/15/2022 during the shift change at 11 p.m., LVN 4 received a report from the outgoing LVN 1 stating Resident 1 was having multiple dark stools and complaining of 7 out of 10 abdominal pain. LVN 4 stated, he attempted to contact Resident 1's primary care physician (PD), who was also the facility's Medical Director. However, the PD did not call back after multiple call attempts. LVN 4 stated, on 12/15/2022 at 11 p.m. Resident 1 was "screaming" from abdominal pain rated 10 out of 10 and was having multiple dark stools with some blood. LVN 4 stated Resident 1 was transferred to a GACH ER via EMS on 12/16/2022 at 2:05 a.m. per facility's protocol. LVN 4 stated, missing HD appointments was concerning because high Potassium levels could cause a heart attack (a deadly medical emergency where there is blockage of blood flow to the heart muscle which can cause the heart to stop). On 12/22/2022 at 12:30 p.m., during a concurrent interview and record review of the facility's Emergency Preparedness Plan (EPP), dated 2022, the DON stated the facility did not have an EPP for COVID-19 positive residents who were receiving HD treatment. The DON stated missing HD appointments could result in life threatening conditions like heart attack and death, "because the body could not get rid of toxins without HD". During a telephone interview on 12/22/2022, at 4:34 p.m., Resident 1's PD stated, he did not get any notification from the facility regarding Resident 1's missed HD treatment on three consecutive days, 12/13/2022, 12/14/2022, and 12/15/2022, and about Resident 1's change of condition on 12/15/2022 including that the resident had abdominal pain 10 out of 10 and bloody diarrhea. The PD stated, he would have ordered the resident to be transferred to the ER to receive emergency HD if he had been informed of Resident 1's missed HD treatments. Resident 1's PD stated it was critically important to receive HD according to the order and the schedule. A review of an undated article titled "Missing Dialysis Treatment is Dangerous for Your Health," from National Kidney Foundation website, indicated that kidneys are responsible for helping to control blood pressure and for keeping a safe balance of key minerals, such as Potassium and Phosphorus, in the body. Missing dialysis treatments places a patient at risk for building up high levels of these two minerals: High Potassium, which can lead to heart problems including arrhythmia (irregular heart rate), heart attack and death. High Phosphorus, which can weaken a patient's person your bones over time and increases the risk for heart disease. In addition, if a patient misses a dialysis treatment, the patient may feel the effects of fluid overload, which include shortness of breath due to fluid in patient's lungs. If this happens, the patient may needs to go to the hospital's emergency department for dialysis. (https://www.kidney.org/atoz/content/missing-dialysis-treatment-dangerous-your-health#:~:text=Missing%20dialysis%20treatments%20places%20you,%2C%20heart%20attack%2C%20and%20death.) During a review of the facility 's policy and procedure (P&P) titled," Hemodialysis Care", dated 9/2007, section" Facility and Dialysis Center Communication Guidelines" of the P&P indicated: "the facility, and the dialysis center will communicate by telephone or in writing. Matters of difficulty with transportation.... Licensed Nurse -Managing Dialysis related complications: GI disturbances (diarrhea)-monitor for symptoms of electrolyte imbalance/neurological symptoms, notify MD and dialysis center of manifested symptoms." The facility failed to: 1. Ensure Resident 1 received HD treatment and services three times a week (every Tuesday, Thursday, and Saturday) as ordered by the physician, at the HD center accepting COVID-19 positive residents. 2. Ensure Resident 1 received HD treatment three times a week on Tuesday, Thursday, and Saturday as indicated in the CP titled "Hemodialysis" initiated on 7/22/2022. 3. Ensure Resident 1's physician was notified the resident missed HD treatment on three consecutive days: 12/13/2022, 12/14/2022, and 12/15/2022. Resident 1's last HD treatment was on 12/10/2022. 4. Ensure Resident 1 was transported to and from the Covid -19 HD center on 12/14/2022 5. Ensure the HD center accepting COVID-19 positive residents was contacted and notified that Resident 1 could not go to the COVID-19 positive HD center for the re-scheduled dialysis treatment on 12/14/2022 at 6:30 p.m. due to a lack of transportation. As a result, Resident 1 did not receive HD treatment on three consecutive days, 12/13/2022, 12/14/2022 and 12/15/22, and developed diarrhea, abdominal pain, and bloody stools on 12/15/2022. On 12/16/2022, Resident 1's condition continued to deteriorate, and the resident was transferred to a GACH where Resident 1 was diagnosed with hyperkalemia in the bloodstream. On 12/16/2022 Resident 1 was admitted to the ICU and had an emergent HD treatment. These violations, jointly, separated 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.