Health inspection·February 29, 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 resident's choices, including but not limited to the following (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 § 72301 - Required Services (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. 22 CCR § 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. FINDINGS: On 1/17/2024, the California Department of Public Health (CDPH) received a complaint regarding a resident’s death and missed dialysis treatments. On 1/18/2024, CDPH conducted an unannounced visit to the facility to conduct a complaint investigation. Upon investigation, CDPH determined the facility failed to ensure Resident 1, a 55-year-old-male, received hemodialysis (a procedure where a machine is used to clean a person’s blood by mechanically removing waste products/toxins and excess fluid from the body) as ordered by a physician and as care planned for hemodialysis for Resident 1. The facility failed to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments on 1/6/2024, 1/9/2024, and 1/11/2024, and one make-up hemodialysis treatment on 1/8/2024, leaving Resident 1 without hemodialysis treatment for eight consecutive days. 2. Ensure the licensed nurses notified the hospice (health care service agency that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency when Resident 1 missed his first hemodialysis treatment on 1/6/2024, and missed three other hemodialysis treatments thereafter on 1/8/2024, 1/9/2024, and 1/11/2024, as indicated on Resident 1’s Physician Order Summary Report. 3. Ensure the licensed nurses followed the facility’s Policies and Procedures (P/P) titled, "Coordination of Hospice Services" to contact and communicate with hospice staff regarding Resident 1’s missed hemodialysis treatments. These deficient practices resulted in Resident 1 not receiving hemodialysis treatment for eight consecutive days and being transferred via 911 to a general acute care hospital (GACH) for emergency dialysis on 1/11/2024. At the GACH, Resident 1 was diagnosed with severe hyperkalemia (high Potassium levels that can cause a life-threatening condition of abnormal heart beats) level of 8.2 milliequivalent per Liter (mEq/L) with shortness of breath (SOB), and hypervolemia (too much fluid volume in the body). A dialysis resident's optimal range for blood Potassium level is 3.5 mEq/L to 5.5 mEq/L). On 1/11/2024, Resident 1 died at 9:32 p.m., three hours and 23 minutes after arriving to the GACH’s Emergency Department (ED) and receiving multiple rounds of life saving medications (names of medications not specified). A review of Resident 1’s Admission Record indicated the resident was originally admitted to the facility on 8/18/2023, and readmitted from a GACH on 1/4/2024, with diagnoses including renal (kidney) hemodialysis and hypertensive heart disease (high blood pressure) without heart failure. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/24/2023, indicated Resident 1 had intact cognitive (thinking, reasoning, or remembering) skills for daily decision making. The MDS indicated Resident 1 was receiving hemodialysis. A review of Resident 1’s last laboratory tests (diagnostic tests conducted from a sample of blood) results dated 12/27/2023, indicated Resident 1’s Potassium level was 5.6 mEq/L. A review of Resident 1’s Discharge Order from the GACH dated 1/3/2024, indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics for two weeks during his hemodialysis treatments. A review of Resident 1’s (readmission) Order Summary Report dated 1/2024, indicated the physician’s orders dated 1/4/2024, for the following: 1. Hemodialysis three times a week on Tuesdays, Thursdays, Saturdays. Chair time (appointment time) 4:45 a.m., transportation pick up time 3:45 a.m. 2. Continue orders for 45 days unless otherwise specified. A review of Resident 1’s care plan (untitled) initiated on 1/4/2024, indicated Resident 1 was receiving hemodialysis every Tuesday, Thursday, and Saturday with a hemodialysis chair time of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan indicated the goal for Resident 1 was for the facility to manage Resident 1’s clinical condition, with interventions that included communicating with dialysis center and hospice agency as needed, and coordinating transportation as needed with Resident 1’s Insurance Company and the hospice agency. A review of Resident 1’s Physician’s Certification for Hospice Benefits dated 1/5/2024, indicated the facility admitted Resident 1 on 1/4/2024 under a hospice agency's care and the resident’s qualifying diagnosis for hospice care which included hypertensive heart disease without heart failure. The Physician’s Certificate indicated the physician had informed the facility staff and that staff were aware to call the hospice agency for any concerns or changes in Resident 1’s condition. A review of Resident 1's Nurses Progress Notes dated 1/6/2024 (Saturday), indicated Resident 1's scheduled transportation company did not pick him up for his scheduled hemodialysis treatment and a make-up dialysis treatment was scheduled for 1/8/2024 (Monday). The Nurses Progress Notes did not indicate the hospice agency was notified that Resident 1 did not receive his hemodialysis treatment on 1/6/2024. A review of Resident 1's Nurses Progress Notes dated 1/8/2024, indicated Resident 1 missed his make-up dialysis on 1/8/2024, due to transportation issues. The Nurses Progress Notes did not indicate the hospice agency was notified that Resident 1 did not receive his dialysis treatment on 1/8/2024. A review of Resident 1’s Nurses Progress Notes dated 1/9/2024 (Tuesday), did not indicate the hospice agency was notified that Resident 1 had missed scheduled hemodialysis appointment on 1/9/2024, due to the transportation arriving two hours later than scheduled. A review of the Physician’s Progress Note dated 1/10/2024, indicated Resident 1 wished to continue dialysis treatments while on hospice and staff were to communicate with the hospice agency regarding hemodialysis treatments. A review of Resident 1’s Hospice Agency Communication Log dated 1/10/2024, indicated the facility informed the hospice agency on 1/10/2024, that on 1/6/2024 Resident 1 had missed dialysis due to transportation issues and that Resident 1 had not received dialysis since 1/2/2024. This was the first communication to the hospice agency regarding missed dialysis. Resident 1’s Hospice Agency Communication Log indicated Resident 1 was "currently stable" and hemodialysis was rescheduled for the next morning on 1/11/2024 (Thursday). A review of Resident 1’s Hospice Agency Communication log dated 1/11/2024, at 1:35 p.m., indicated the facility informed the hospice agency that Resident 1 missed hemodialysis again that morning due to transportation issues. A review of Resident 1’s Hospice Agency Communication log dated 1/11/2024, at 2:24 p.m., indicated the hospice agency reached out to Resident 1’s dialysis center to try to schedule an emergency dialysis treatment, but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center. The Communication log indicated Resident 1 required emergency hemodialysis due to missing more than two dialysis treatments consecutively on 1/6/2024, 1/8/2024, 1/9/2024 and 1/11/2024, and the facility was instructed to call 911 to send Resident 1 to the GACH. A review of Resident 1’s Hospice Agency Communication Log dated 1/11/2024, at 2:53 p.m., indicated the hospice agency spoke to the facility again and "reiterated the emergency" and instructed the facility to call 911. A review of Resident 1’s Change of Condition Evaluation dated 1/11/2024, indicated the hospice agency recommended sending Resident 1 to the GACH for hemodialysis after Resident 1 missed more than three consecutive, scheduled dialysis treatments on 1/6/2024, 1/8/2024, 1/9/2024, and 1/11/2024. A review of Resident 1’s Order Summary Report dated 1/2024, indicated a physician order dated 1/11/2024 to transfer Resident 1 to the GACH due to missed dialysis on 1/6/2024, 1/8/2024, 1/9/2024 and 1/11/2024, with a seven-day bed hold (reserve resident’s bed while receiving care in the hospital). A review of Resident 1' s GACH ED Note dated 1/11/2024, indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for eight consecutive days and was last dialyzed on 1/2/2024. The ED Note indicated Resident 1 presented with worsening SOB due to the missed dialysis treatments. The ED Note indicated Resident 1 informed the ED physician that there was a problem with his transportation to get to the dialysis center and that was why he had missed dialysis for eight consecutive days. A review of Resident 1’s GACH ED Note dated 1/11/2024, indicated Resident 1’s Potassium level was 8.2 mEq/L, and a hyperkalemia order set was initiated by administering medications to Resident 1 to lower the Potassium level. The GACH ED Note indicated Resident 1’s SOB was likely due to hypervolemia and the plan was to admit Resident 1 to the Intensive Care Unit (ICU) for emergency hemodialysis. A review of Resident 1’s GACH ED Note dated 1/11/2024, indicated before getting transferred to the ICU, Resident 1's heart rate began to drop to 30 beats per minute (the heart reference rate is 60 to 100 beats per minute) and Resident 1 became unconscious. A review of Resident 1’s GACH ED Note dated 1/11/2024, indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation, but lifesaving medications were to be given. Resident 1 received a total of five rounds of life saving medications in the ED before he expired. A review of Resident 1’s GACH Discharge Summary dated 1/11/2024, indicated Resident 1’s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed hemodialysis. 2. Fluid overload due to missed hemodialysis. 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis. 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis. A review of Resident 1’s GACH Discharge Summary dated 1/11/2024, indicated after multiple rounds of life saving medications in the ED, Resident 1 died at 9:32 p.m. on 1/11/2024. Reason for death was cardiopulmonary arrest. A review of Resident 1’s GACH Discharge Summary dated 1/11/2024, indicated Resident 1’s Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on 1/18/2024, at 11:53 a.m., Resident 1’s family member (FM 1) stated Resident 1 had been released from the GACH on 1/4/2024 on hospice. FM 1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infection on his hands, legs, feet and did not want to have to get amputations (removal of limbs) and wanted to continue to have his hemodialysis treatments while on hospice. During an interview on 1/18/2024, at 11:53 a.m., FM 1 stated the ED’s physician had called him on 1/11/2024 and informed him that Resident 1 had missed eight days of hemodialysis treatments due to transportation issues and that Resident 1’s laboratory results in the ED were "catastrophic" including Potassium level which was "twice what it should be." During an interview on 1/18/2024, at 11:53 a.m., FM 1 stated the next call he received was from the ED’s physician telling him Resident 1 had passed away. FM 1 stated the hospice agency called him (FM 1) after Resident 1’s death and the hospice agency said it was in the orders that Resident 1 was to continue dialysis at the facility, and the hospice agency was not aware the facility was having issues with transportation or why the resident missed hemodialysis on scheduled days (1/6/2024, 1/8/2024, 1/9/2024, 1/11/2024). During an interview on 1/18/2024, at 12:13 p.m., the hospice agency administrator (ADM 2) stated the hospice agency should have been made aware when Resident 1 missed the first hemodialysis treatment on 1/6/2024. However, the hospice was not notified until four days later, on 1/10/2024. ADM 2 stated the facility informed the hospice agency on 1/11/2024 that Resident 1 missed his dialysis appointment again on 1/11/2024, and the facility was directed to call 911 to send Resident 1 to the GACH for emergency hemodialysis treatment. During an interview on 1/19/2024, at 3:04 p.m., the Minimum Data Set nurse (MDSN) stated the facility nurses should have informed the hospice agency immediately when Resident 1 had missed a hemodialysis treatment on 1/6/2024. The MDSN stated it was very important that the facility had good communication with the hospice agency to ensure the hospice nurses and physician were informed of what was going on with Resident 1 because all orders for hospice patients needed to go through the hospice agency. The MDSN stated the importance of ensuring a resident received their hemodialysis treatments was a matter of "life or death". During an interview on 1/19/2024, at 4:12 p.m., the Director of Nursing (DON) stated the adverse effect of not receiving hemodialysis treatments included fluid overload, respiratory distress, toxins building up in the body, altered level of consciousness (confusion), and death. A review of the facility’s P/P titled, “Hemodialysis” dated 9/2/2022, indicated the facility will assure that arrangements are made for safe transportation to and from the dialysis facility. A review of the facility’s P/P titled, "Coordination of Hospice Services" dated 12/19/2022, indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident's highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident's status, clinical complications, or emergent situations. A review of the Hospice Agency Contract Agreement with the facility for Resident 1 dated 1/4/2024, indicated the hospice agency was to be notified if there were clinical complications that suggested a need to alter the resident's plan of care and/or a need to transfer the patient from the facility. The facility failed to ensure Resident 1, a 55-year-old-male, received hemodialysis treatment as ordered by a physician and care planned for hemodialysis for Resident 1. The facility failed to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments on 1/6/2024, 1/9/2024, and 1/11/2024, and one make-up hemodialysis treatment on 1/8/2024, leaving Resident 1 without hemodialysis treatment for eight consecutive days. 2. Ensure the licensed nurses notified the hospice agency when Resident 1 missed his first hemodialysis treatment on 1/6/2024, and missed three other hemodialysis treatments thereafter on 1/8/2024, 1/9/2