Health inspection·October 31, 2024

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. (k) Pain management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. 22 CCR 72311- Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed health care practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient. 22 CCR 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. On 9/10/2024, the California Department of Public Health (CDPH) received a complaint regarding insufficient nursing staff available to attend to residents' needs. On 9/11/2024 at 7:30 a.m., CDPH conducted an unannounced visit at the facility to investigate the allegation. During the investigation, Resident 65 stated that on 8/24/2024 at 11:00 p.m., he complained of severe abdominal pain to a Licensed Vocational Nurse (LVN) 9 and was not assessed and provided with pain relief interventions. The facility failed to: 1.) Monitor Resident 65, who had a suprapubic indwelling catheter (a medical device that helps drain urine from the bladder through a small incision in the abdomen), for urine output and document in the clinical record. 2.) Implement its policy and procedure (P&P), titled "Resident Examination and Assessment," by failing to assess Resident 65's for abdominal pain, abdominal distention, and urine output. 3.) Implement its P&P titled, "Pain management," which indicated the facility will assess and evaluate residents for pain and provide pain management as needed. 4.) Notify Resident 65's attending physician of Resident 65's initial complaint of new onset of severe abdominal pain. As a result, Resident 65 experienced severe abdominal pain for approximately 15 hours, and psychological harm manifested by the resident stating "I felt angry, scared, and frustrated." Resident 65 was transferred and admitted to a general acute care hospital (GACH) for evaluation and management of abdominal pain. Resident 65 had diagnosis of sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), urinary tract infection, dehydration, and acute kidney injury, and was treated with multiple intravenous antibiotics and pain medication. Resident 65 was a 57-year-old male, admitted to the facility on 2/23/2023 with diagnoses including peripheral vascular disease (a circulatory condition when blood vessels outside of the brain and heart narrowed, blocked, or spasmed), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), colostomy status (a surgical operation when a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), urinary tract infection (UTI- a bacterial infection in the organ that removes urine) and hereditary (inborn) and idiopathic (a disease of unknown cause) neuropathy. A review of Resident 65's physician orders dated 7/29/2024, indicated the following: 1. Monitor level of pain every shift (using zero [0]-10 numeric pain scale [a pain scale used in a facility with 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible]). 2. Oxycodone-Acetaminophen (a strong pain medicine) 5 milligrams (mg)/ 300 mg one (1) tablet by mouth (PO) every six (6) hours (Q6hrs) as needed (PRN) for moderate to severe pain. 3. Monitor suprapubic catheter drainage bag every shift and document signs and symptoms (S/S) of UTI such as bladder distention and burning sensation. 4. Change suprapubic catheter by wound care consultant every 6 months and PRN if blocked (obstructed) or pulled out. A review of Resident 65's History and Physical (H&P) dated 7/30/2024, indicated Resident 65 had the capacity to understand and make decisions. The H&P indicated Resident 65 had an intact suprapubic catheter. A review of Resident 65's Minimum Data Sheet ([MDS] a federally mandated resident assessment tool) dated 8/18/2024, indicated Resident 65 had an intact cognition (understanding). The MDS indicated Resident 65 had a suprapubic catheter. The MDS indicated Resident 65 required moderate assistance (helper does less than half the effort) with eating, maximal assistance (helper does more than half the effort) with oral hygiene and dependent with toileting hygiene, personal hygiene, showers, and upper and lower body dressing. The MDS indicated Resident 65 was dependent with toilet transfer, sit to stand position and chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair). A review of Resident 65's Medication Administration Record (MAR) for the month of August 2024 indicated the following: 1). On 8/24/2024, during the 11:00 p.m. to 7:00 a.m. shift, Resident 65 had a pain level of 10/10. 2). On 8/25/2024, (time unspecified), the MAR did not indicate Resident 65 was in pain. The MAR indicated a staff's (LVN 1) initial next to oxycodone. A review of Resident 65's Treatment Administration Record (TAR) dated 8/1/2024 to 8/23/2024, did not indicate any documented urine output. A review of Resident 65's Nurses' Notes dated 8/25/2024, at 1:03 a.m., indicated Resident 65 complained of abdominal pain. The notes did not indicate Resident 65 was assessed for the pain level, pain location, pain characteristics and if the suprapubic catheter was functioning and draining urine. The notes indicated Resident 65 was offered (unspecified) pain medication, but the resident refused. A review of Resident 65's Nurses' Notes dated 8/25/2024, at 2:00 a.m., indicated Resident 65 was offered pain medication and he refused. The notes indicated Resident 65 requested to go to hospital, and that Resident 65's doctor was notified on 8/25/2024 at 1:00 a.m. A review of Resident 65's Nurses' Notes dated 8/25/2024, at 3 a.m., indicated Resident 65's family member (FM 1) called and requested LVN 1 to call the paramedics. The notes indicated there was no order to call the paramedics. The notes indicated Resident 65 was offered pain medication, but he refused. A review of Resident 65's Nurses' Notes dated 8/25/2024, at 5:30 a.m., indicated Resident 65's doctor called the facility and ordered Resident 65 be transferred to the GACH on 8/25/2024 at 10:30 a.m. The notes indicated Resident 65 was not in compliance with care and refused his medication (unspecified). A review of Resident 65's Nurses' Notes dated 8/25/2024, at 2:30 p.m., indicated Resident 65 was picked up by the ambulance at 2:30 p.m. on 8/25/2024 with a pain level of 7/10 pain (severe pain). The nurses' notes did not indicate the facility called the ambulance to follow up and reasons for its delay to pick up Resident 65. The notes did not indicate pain assessment was conducted for Resident 65's complain of 7/10 pain and if pain intervention was provided to Resident 65. A review of a GACH emergency department (ED) triage note dated 8/25/2024, indicated Resident 65 arrived at the GACH on 8/25/2024 at 3:25 p.m. with a chief complaint of abdominal pain radiating (spreading) to the flank (sides of the body between ribs and hips) area that started last night on 8/24/2024. The ED notes indicated Resident 65 had gross pus (large amount of thick yellowish, whitish, or greenish fluid) from the suprapubic catheter and sepsis. The ED notes indicated Resident 65's suprapubic catheter was changed by the ED staff, and the abdominal pain improved. The ED notes indicated Resident 65 received antibiotics and pain medications, was admitted to the GACH for evaluation, treatment, and care for urinary tract infection, dehydration (body does not have enough water), and acute kidney injury (an abrupt decrease in kidney function). During an interview on 9/17/2024 at 4:23 p.m., Resident 65 stated on 8/24/2024 at 11:00 p.m., he complained of severe abdominal pain to LVN 9 and Registered Nurse (RN) 4. Resident 65 stated LVN 9 and RN 4 did not assess his pain, and he suffered severe abdominal pain from 11:00 p.m., on 8/24/2024 to 8/25/2024. Resident 65 stated on 8/25/2024 at 2:00 a.m., he asked LVN 9 to call 911 (emergency phone number) because he could not handle the pain anymore. Resident 65 stated LVN 9, did not assess him for pain, did not assess his suprapubic catheter, did not give him any pain medication, and did not call 911, to take him to the GACH. Resident 65 stated, "I suffered severe abdominal pain and felt angry, scared, and frustrated until I was transferred to the hospital on 8/25/2024 at 2:30 p.m." Resident 65 stated, "I would rather be dead than re-experience the pain on 8/25/2024." During a concurrent interview and record review on 9/18/2024 at 3:53 p.m., with RN 4, Resident 65's care plan titled "Potential for Pain," dated 7/25/2024, physician orders dated 7/29/2024, MAR for August 2024, and nurses' notes dated 8/24/2024 and 8/25/2024 were reviewed. RN 4 stated the care plan interventions indicated staff will assess Resident 65's pain symptoms, identify the frequency, location, quality, onset, and how Resident 65 expressed pain, provide non-pharmacological interventions such as relaxation techniques, deep breathing exercises, proper positioning, monitor the effectiveness of non-pharmacologic interventions, and notify the physician of increasing pain. RN 4 stated on 8/24/2024 and on 8/25/2024, the nurses' notes did not indicate Resident 65 was assessed for pain, when he complained of severe abdominal pain. RN 4 stated there was no documentation to indicate Resident 65's suprapubic catheter was assessed for blockage (obstruction) and urine output, which might have been the cause of pain. RN 4 stated failing to assess Resident 65's pain, or source of pain, caused the resident to experience severe pain for approximately 15 hours. RN 4 stated the MAR indicated on 8/25/2024, during the 11:00 p.m. to 7:00 a.m., shift Resident 65 had a pain level of 10/10, but the location was not indicated. RN 4 stated LVN 1's initial was next to Oxycodone on 8/25/2024 (time not specified), indicating the resident was medicated, for pain. RN 4 stated, Resident 65's nurses' notes and MAR did not indicate Resident 65's pain was assessed or reassessed on 8/25/2024, before and after the Oxycodone was administered. RN 4 stated Resident 65 should have been assessed prior to and one hour after Resident 65's Oxycodone was given, to evaluate its effectiveness. RN 4 stated on 8/25/2024 at 2:30 p.m., Resident 65 complained of abdominal pain rated at 7/10, but there was no pain assessment or pain intervention provided. During an interview on 9/18/2024 at 4:45 p.m., the Director of Nursing (DON), stated Resident 65's unresolved pain should have been reassessed frequently and interventions provided according to the facility's policy and resident's plan of care. The DON stated Resident 65's physician should have been notified of Resident 65's pain condition. The DON stated pain assessment and reassessment could identify the cause of pain and guide interventions. The DON stated unresolved severe abdominal pain was considered a medical emergency (a serious condition that requires immediate medical attention to prevent a person's worsening health and death) requiring immediate transfer to a GACH. The DON stated the delay in providing interventions and addressing Resident 65's severe pain could result in worsening condition and complications. A review of the facility's undated P&P titled, "Resident Examination and Assessment" indicated the facility will examine and assess the resident for any abnormalities in health status, such as abdominal distention and hardness, urine output if they were clear or cloudy, presence of foley catheter (a flexible tube that is inserted into the bladder through the urethra to drain urine), description, location, duration, severity of pain and factors that worsened the pain, current medication and treatments for pain. A review of the facility's undated P&P titled, "Pain Management" indicated the facility will ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. The P&P indicated pain assessment and evaluation should be done by nurses, practitioners and review resident's diagnosis or conditions and any additional factors that may have caused or contributed to pain, identifying the location, frequency, duration, onset, and pattern of pain. The P&P indicated staff will identify the current prescribed pain medications, dosage and frequency, resident's goals for pain management and the effectiveness of drugs and other treatments used in the past to treat pain. The P&P indicated, if the resident's pain was not controlled with the current treatment regimen, the practitioner should be notified. The facility failed to: 1.) Monitor Resident 65, who had a suprapubic indwelling catheter for urine output and document in the clinical record. 2.) Implement the facility's P&P, titled "Resident Examination and Assessment," by failing to assess Resident 65's for abdominal pain, abdominal distention, and urine output. 3.) Implement its P&P titled, "Pain management," which indicated the facility will assess and evaluate residents for pain and provide pain management as needed. 4.) Notify Resident 65's attending physician of Resident 65's initial complaint of new onset of severe abdominal pain. As a result, Resident 65 experienced severe abdominal pain for approximately 15 hours, and psychological harm manifested by the resident stating "I felt angry, scared, and frustrated." Resident 65 was transferred and admitted to a general acute care hospital (GACH) for evaluation and management of abdominal pain. Resident 65 had diagnosis of sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), urinary tract infection, dehydration, and acute kidney injury, and was treated with multiple intravenous antibiotics and pain medication. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.