Health inspection·December 5, 2024

§ 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). (a) Sufficient Staff (1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: § 72329.1 - Nursing Service – Staff (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirements required by this section are minimum standards only. Skilled nursing facilities shall employ, and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g). (d) Facilities licensed for 100 or more beds shall have at least one registered nurse, awake and on duty, in the facility at all times, day and night, in addition to the Director of Nursing services. The Director of Nursing services shall not have charge nurse responsibilities. 22CCR §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 10/15/2024, the California Department of Public Health (CDPH) received a complaint regarding quality-of-care issues and allegations indicating the facility had no Supervisor (Registered Nurse, RN) to administer antibiotics on the weekend and a resident (Resident 1), did not receive his second dose of intravenous (IV- administration of medication through a needle inserted into the vein) antibiotics (date and name of antibiotics not specified). On 10/16/2024 at 8:00 a.m., an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to: 1. Ensure a RN was awake and on duty (working), in the facility, day and night, on 10/5/2024 to 10/16/2024. 2. Implement its policy and procedure (P&P) titled, “Medication Administration,” dated 1/2022, which indicated the facility should have sufficient staff to ensure safe administration of medications without unnecessary interruptions. As a result, Resident 1, and Resident 2’s IV antibiotic medications were not given. These failures placed Resident 1 and Resident 2 at risk for complications such as sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), hospitalization and death. 1). Resident 1 was a 48-year-old male, originally admitted to the facility on 6/10/2017 and readmitted on 8/11/2024. Resident 1’s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of the bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control.) A review of Resident 1's History and Physical (H&P) dated 1/14/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/1/2024, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (catheter that drains urine from bladder into a bag outside the body). A review of Resident 1's Care plan titled, "On IV antibiotics therapy Meropenem due to sepsis related to urinary tract infection (UTI)/chronic use of foley (a tube inserted into the bladder to drain urine)", dated 10/12/2024, the intervention indicated to give antibiotic as ordered. A review of Resident 1's physician order dated 10/12/2024, indicated to administer Meropenem (medication to treat infections) IV Solution 500 milligrams ([mg] unit of measurement) every six (6) hours (6 a.m., 12 noon, 6 p.m., 12 a.m.) for UTI for three (3) days (until 10/15/2024). A review of the facility’s RN “Nursing Staff Assignment and Sign-In Sheet” did not indicate a RN was on duty on the following dates and shift: 1. 10/5/2024, 11 p.m.-7 a.m. and (3 p.m.-11 p.m. 2. 10/6/2024, 3 p.m.-11 p.m. 3. 10/7/2024, 3 p.m.-11 p.m. 4. 10/8/2024, 11p.m.- 7 a.m. shift. 5. 10/9/2024, 11p.m.- 7 a.m. shift. 6. 10/10/2024, 3 p.m.-11 p.m. and 11p.m.- 7 a.m. shift. 7. 10/11/2024, 11p.m.- 7 a.m. shift. 8. 10/12/2024, 7 a.m.-3 p.m. shift. 9. 10/13/2024, 7 a.m.-3 p.m. and 3 p.m.-11p.m. shift. 10. 10/14/2024, 7 a.m.-3 p.m. and 11p.m.- 7 a.m. shift. 11. 10/15/2024, 11p.m.- 7 a.m. shift. 12. 10/16/2024, 3 p.m.-11p.m. and 11p.m.-7 a.m. shift. During a concurrent interview and record review on 10/16/2024 at 9:08 a.m., with RN 1, the IV Medication Administration Record (MAR) was reviewed. RN 1 stated the IV MAR dated 10/13/2024, for 12:00 a.m. and 12:00 p.m., indicated there were no nurse’s initials. RN 1 stated, no nurse’s initials meant there was no RN on duty to administer the IV antibiotics. RN 1 stated Resident 1’s Meropenem doses were not administered. During an interview on 10/16/2024 at 1:27 p.m., Resident 1 stated he did not receive his antibiotics (Meropenem) on 10/13/2024 at 6:00 a.m., 12:00 noon and 6:00 p.m. Resident 1 stated there was no RN working at the facility on 10/13/2024. Resident 1 stated RN 1 was informed, his infection would not get better if his antibiotics were not given. Resident 1 stated on 10/16/2024, he did not receive his 12:00 p.m. Meropenem dose on time. During a concurrent observation and interview on 10/16/2024 at 2:19 p.m., with RN 1, the IV cart at nurse’s Station A was observed. RN 1 confirmed the IV cart had two Meropenem vials left for Resident 1. RN 1 stated she forgot to administer the two Meropenem doses. 2). Residents 2 was a 58-year-old female, originally admitted to the facility on 3/14/2023, and readmitted on 10/4/2024, with diagnoses including muscle weakness and hydroureter (condition where the ureter becomes abnormally enlarged due to a backup of urine.) A review of Resident 2's H&P dated 8/18/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s MDS dated 10/1/2024, indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 was dependent with ADLs such as toileting hygiene, dressing and personal hygiene. The MDS indicated Resident 2 required substantial assistance with bed mobility. The MDS indicated Resident 2 had an indwelling catheter and was always incontinent of bowel. A review of Resident 2's physician order dated 10/4/2024, indicated Piperacillin sodium, tazobactam (antibiotic medication for infection) IV solution 3.375 grams ([gm] a unit of measurement) every eight (8) hours (6 a.m., 2 p.m., 10 p.m.) for Extended-spectrum beta-lactamases (ESBL – a type of bacterial infection) infection of urine for 7 days (until 10/11/2024). A review of Resident 2’s IV MAR for October 2024, indicated there was no RN’s initials for the administration of Piperacillin on: 10/5/2024 at 6:00 a.m. and 10:00 p.m. 10/6/2024 at 6:00 a.m., 2:00 p.m. and 10:00 p.m. 10/8/2024 at 6:00 a.m. 10/12/2024 at 10:00 p.m. A review of Resident 2's care plan titled, "on IV antibiotics therapy Piperacillin sodium tazobactam IV solution," dated 10/7/2024, the intervention indicated to give medication (antibiotic) as ordered. During an interview on 10/16/2024 at 9:08 a.m., RN 1 stated Resident 2’s physician’s order dated 10/7/2024, indicated the Piperacillin was ordered 10/7/2024 to 10/14/2024. RN 1 stated, according to the MAR, Resident 2 missed his Piperacillin doses on 10/5/2024 at 6:00 a.m. and 10:00 p.m., on 10/6/2024 at 6:00 a.m., 12:00 p.m. and 10:00 p.m., on 10/8/2024 at 6:00 a.m. and on 10/12/2024 at 10:00 p.m. (total of 7 doses of Piperacillin missed). During an interview on 10/16/2024 at 12:28 p.m., the Director of Nurses (DON) stated the facility had always RN coverage to administer IV antibiotics. The DON stated, antibiotics should have been administered as ordered to maintain therapeutic (beneficial) levels. The DON stated when IV antibiotic medications are not given as ordered, it could lead to worsening infection including septic shock (blood poisoning), hospitalization or death. During an interview on 10/16/2024 at 2:19 p.m., RN 1 stated, “I was always late in administering Resident 2’s Meropenem because I was super busy with the new admission and had no help.” During an interview on 10/17/2024 at 12:07 p.m., Resident 2 stated she did not receive the antibiotics on the weekend (dates not remembered) because there was no other RN working to administer the IV antibiotics. During an interview on 10/24/2024 at 11:16 a.m., RN 1 stated when Resident 2 returned from the hospital on 10/4/2024 (time not specified), Resident 2 had a physician’s order for Piperacillin every 8 hours for ESBL in the urine for 7 days (until 10/11/2024). RN 1 stated the Piperacillin was not administered on 10/5/2024 because there was no RN on duty. RN 1 stated she documented the Piperacillin in the IV MAR as given on 10/5/2024 (Saturday, time not specified) to remove the “pink flag” (warning indicating medication was not administered) in the computer. RN 1 stated the facility did not receive the Piperacillin from the pharmacy until 10/7/2024. During an interview on 10/24/2024 at 11:17 a.m., the DON stated she (DON) was not aware Resident 2 had an order for Piperacillin IV antibiotics every 8 hours on 10/4/2024. The DON stated there was one (1) RN on duty on 10/5/2024, afternoon shift (3 p.m.-11 p.m.). The DON stated, not having an RN on duty had delayed the administration of Resident 2’s IV antibiotics. A review of the facility’s P&P titled, “Medication Administration,” dated 1/2022, indicated the facility should have sufficient staff to ensure safe administration of medications without unnecessary interruptions. The P&P indicated medications are administered in accordance with the written orders of the prescriber and medications should be administered without unnecessary interruptions. The facility failed to: 1. Ensure a RN was awake and on duty, in the facility, day and night, on 10/5/2024 to 10/16/2024. 2. Implement its P&P titled, “Medication Administration,” dated 1/2022, which indicated the facility should have sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions As a result, Resident 1, and Resident 2’s IV antibiotic medications were not given. These failures placed Resident 1 and Resident 2 at risk for complications such as sepsis, hospitalization, and death. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.