Health inspection·December 31, 2024

CFR 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- (A)An accident involving the resident which results in injury and has the potential for requiring physician intervention; (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); (C)A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D)A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). CFR, Section 483.21(b) Comprehensive Care Plans. (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii)Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). CFR 42, Section 483.25(g) Assisted nutrition and hydration. (g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; CCR, Section 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) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 healthcare 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. CCR 22, Section 72315 Nursing Service- Patient Care. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. (j) Fluid intake and output shall be recorded for each patient as follows: (1) If ordered by the physician. (2) For each patient with an indwelling catheter: (A) Intake and output records shall be evaluated at least weekly, and each evaluation shall be included in the licensed nurses' progress notes. (B) After 30 days the patient shall be reevaluated by the licensed nurse to determine further need for the recording of intake and output. CCR 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2)(D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 11/8/2024, the California Department of Public Health (CDPH) conducted an annual recertification survey. Upon investigation CDPH determined the facility failed to: 1. Inform Resident 58's physician (MD) of low urine output (a measurement of how much urine a person produces) when Resident 58's urine output was 50 cubic centimeters ([cc]- a unit of measure of volume) within eight hours on 8/26/2024 during the 7:00 a.m. to 3:00 p.m. shift. 2. Initiate a change of condition ([COC]-tool used by health care professionals when a patient's condition has a significant decline, or improvement) when Resident 58's urine output was 50 cc on 8/26/2024 during the 7:00 a.m. to 3:00 p.m. shift. 3. Monitor Resident 58's urine output, as one of the signs of dehydration from 8/27/2024 to 9/13/2024 per care plan titled, "Dehydration/fluid maintenance related to diuretics therapy for bilateral leg edema and CHF" dated 8/21/2024, to recognize the resident had low urinary output and notify the physician to obtain an order for interventions to correct dehydration. As a result of these failures Resident 58, who had signs and symptoms (s/s) of dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) including dry mucus membranes and low urine output, was transferred to a General Acute Care Hospital (GACH) for evaluation where she was diagnosed with acute (s/s that begin and worsen quickly) kidney injury due to prerenal azotemia (condition in which kidneys fail to adequately filter waste products from the blood) and dehydration. Resident 58 was admitted to the GACH from 9/13/2024-9/24/2024 (11 days) for treatment. These failures placed the resident at risk for low blood pressure, weakness, confusion, loses consciousness, brain damage and possible death. A review of Resident 58's Admission Record, indicated the resident, an 88-year-old female, was admitted to the facility on 8/14/2024 with diagnoses including congestive heart failure ([CHF]-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (a gradual loss of kidney function) and Non- ST elevation (NSTEMI) myocardial infarction (heart attack). A review of Resident 58's Minimum Data Set ([MDS] a resident assessment tool) dated 8/26/2024, indicated Resident 58 was able to express ideas and wants to others and usually understood others. The MDS indicated Resident 58 was partially dependent on staff with eating and totally dependent on staff for bathing, toileting hygiene and personal hygiene. Resident 58 was taking diuretics (medication that help reduce fluid buildup in the body) during the last seven days (look back time period) of the MDS assessment and had an indwelling urinary catheter (flexible soft tubing inserted into the bladder [organ that stores urine] to drain urine). A record review of Resident 58's Physician Order Report from 8/14/2024-9/30/2024, indicated an order dated 8/14/2024 for Furosemide (a diuretic that may cause dehydration and electrolyte imbalance) 20 milligram (mg- unit of measure of mass) twice daily for bilateral (both) for lower extremity edema (excess fluid collecting in the tissues); Black Box warning (strict warning labels used when labeling medication) of dehydration and electrolyte (minerals that have an important role in hydration [vital fluids in the body]) depletion. The Physician's Order Report dated 8/14/2024 indicated an order to place an indwelling urinary catheter due to the resident's diagnosis of urine retention. During a concurrent interview and record review on 11/9/2024 at 2:56 p.m., Resident's 58's Progress Notes Monthly Weight, Intake and Output (I&O) and COC for the month of 8/2024 and 9/2024 were reviewed with the Assistant Director of Nursing (ADON). The ADON stated the Progress Notes dated 8/15/2024 indicated Resident 58 was admitted with dependent (swelling that occurs when fluids build up in areas of the body below the heart) edema on both legs. The ADON stated the I&O dated 8/26/2024 indicated Resident 58's urine output for the 7:00-3:00 p.m. shift was 50 cc. The ADON stated the Progress Notes dated 9/13/2024 at 11:31 a.m., indicated Resident 58 returned from her primary care physician's (PCP) appointment accompanied by a family member (FM 1) at approximately 9:47a.m. The ADON stated according to the progress notes, FM 1 informed staff that Resident 58's PCP stated Resident 58 needed to go to the Emergency Room (ER). The ADON stated the Progress Notes indicated FM 1 and Resident 58 returned to the facility before going to the ER to collect the resident's belongings. During a concurrent interview and record review on 11/9/2024 at 3:35 p.m., Resident 58's care plan titled, "Dehydration/fluid maintenance related to diuretics therapy for bilateral leg edema and CHF" dated 8/21/2024, was reviewed with the ADON. The ADON stated the care plan interventions included to assess for s/s of dehydration and electrolyte imbalance including dizziness while changing position from sitting to standing, change in mental status, decreased urine output, poor skin turgor (skin's inability to return to normal after pinching, which is a sign of dehydration), dry mucus membrane (moist lining of some organs and body cavities), sunken eyes, and constipation (bowel movements that are infrequent, uncomfortable or difficult to pass, which may be a sign of dehydration). The ADON stated assessing Resident 58 for dehydration was a care planned intervention but there was no documentation to show that licensed nurses assessed and monitored Resident 58 for s/s of dehydration during any shift. The ADON stated that when nurses see these s/s of dehydration such as low urine output, they should start documenting the s/s and notify Resident 58's MD of s/s of dehydration. The ADON stated the MD was not notified when Resident 58's urine output was 50 cc over eight hours. The ADON stated it was important to notify the MD for prompt interventions and to prevent the resident's condition from worsening. During an interview on 11/10/2024 at 2:17 p.m., Licensed Vocational Nurse (LVN) 3 stated that monitoring a resident's (in general) I&O is to know whether the resident was retaining fluid, especially for Resident 58 who had CHF, which can cause fluid retention. LVN 3 stated she was the one who documented that Resident 58 had 50 cc output of urine on 8/26/2024 on the 7:00-3:00 p.m. during her shift. LVN 3 stated she did not initiate a COC, and she did not notify Resident 58's MD of low urine output of 50 cc within eight hours. According to the Center for Disease Control and Prevention (CDC) a patient normal urine output is 0.5 to 1.5 cc/ kilogram/hour. https://www.cdc.gov/dengue/training/cme/ccm/page57297.html A record review of Resident 50's ER Notes dated 9/13/2024, indicated Resident 58 had dry mucus membranes (soft inner lining of some organs). The ER notes also indicated Resident 58's laboratory (medical diagnostic testing using blood samples) test results indicated the blood urea nitrogen ([BUN]- a blood test for dehydration) was 44 milligram per deciliter ([mg/dcl] a unit of fluid volume measure; an indicator of possible dehydration) which was out of range. BUN reference range is 7-18 mg/dcl. A record review of Resident 58's GACH's Progress Records dated 9/14/2024 indicated Resident 58's admitting diagnoses included acute kidney injury likely due to prerenal azotemia. The ER Notes indicated Resident 58 was dehydrated. During an interview on 11/13/2024 at 1:12 p.m., the Director of Nursing (DON) stated if a resident's urine output is less than 100 cc for the entire eight-hour shift the MD should be notified and a COC initiated to closely monitor the resident's intake and output. A record review of the facility's Policy & Procedure (P&P) titled "comprehensive Assessments and the care delivery process" dated 12/2016, indicated comprehensive assessment, care planning and the care delivery process involved collecting and analyzing information, choosing, and initiating interventions, then monitoring results and adjusting interventions. A record review of the facility's P&P titled "Change in a Resident's condition or status" dated 12/2016, indicated the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly and need to transfer the resident to a hospital/ treatment center. The facility failed to: 1. Inform Resident 58's MD of low urine output when Resident 58's urine output was 50 ccs within eight hours on 8/26/2024 during the 7:00 a.m. to 3:00 p.m. shift. 2. Initiate COC when Resident 58's urine output was 50 cc on 8/26/2024 during the 7:00 a.m. to 3:00 p.m. shift. 3. Monitor Resident 58's urine output, as one of the signs of dehydration from 8/27/2024 to 9/13/2024 per care plan titled, "Dehydration/fluid maintenance related to diuretics therapy for bilateral leg edema and CHF" dated 8/21/2024, to recognize the resident had low urinary output and notify the physician to obtain an order for interventions to correct dehydration. As a result of these failures, Resident 58 who had s/s of dehydration including dry mucous membranes, was transferred to a GACH for evaluation where she was diagnosed with acute kidney injury due to prerenal azotemia and dehydration. Resident 58 was admitted to the GACH from 9/13/2024-9/24/2024 (11 days) for treatment. These failures placed the resident at risk for low blood pressure, weakness, confusion, loses consciousness, brain damage and possible death. The above violations jointly, separately, or in combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 58.