Health inspection·May 9, 2025

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- (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 (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. §483.21(b) Comprehensive Care Plans §483.21(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). §483.50(a) Laboratory Services. (1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (2) The facility must- (i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. §72313 Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. §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: (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. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. §72523(a) 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 3/10/2025 the California Department of Health (CDPH) received a complaint alleging a diagnostic laboratory called the facility for hours to report a critical (a laboratory test result that indicates a life-threatening condition and requires immediate medical attention) laboratory test result, without a response from the facility. On 3/20/2025 at 10:36 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined a resident (Resident 1), who had a history of gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum, this can lead to respiratory distress, stroke, infection, shock and death), anemia (when the blood doesn't have enough healthy red blood cells and hemoglobin [a protein in the red blood cells that carries oxygen to carry oxygen all through the body), and low hemoglobin (carries oxygen throughout the body), had a STAT (immediate) laboratory (lab) order for a Complete Blood Count([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body's immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when a blood vessel is damaged}, hemoglobin and hematocrit}a measure of the proportion of red blood cells in the total volume of blood}, was carried out, per the physician's order, and followed up to ensure lab results were obtained promptly (within two to six hours). The facility failed to: 1. Administer treatment as prescribed when the physician ordered a STAT CBC on 3/7/2025 at 2:20 p.m., but facility staff did not inform the laboratory personnel that the order was "STAT" and the first attempt to draw blood did not occur until 10:09 p.m., on 3/07/2025. The facility failed to administer treatment as prescribed when a follow up STAT CBC on 3/7/2025, at 11:59 p.m., did not occur until the following day (3/8/2025) at 9:44 a.m. (almost 10 hours after the order was placed). 2. Notify the physician when Resident 1 refused the STAT CBC blood draw on 3/7/2025 at 10:09 p.m. 3. Provide and obtain timely laboratory services to meet the needs of Resident 1 when the facility delayed carrying out two physician's orders for STAT CBC laboratory services and then missed five calls over the course of several hours from laboratory personnel attempting to report Resident 1's critically low hemoglobin results. 4. Implement Resident 1's Care Plan on anemia dated 2/18/2025 interventions including obtaining and monitoring laboratory work as ordered, reporting the laboratory results to Resident 1's physician, and following up as indicated. 5. Follow their Policies and Procedure (P/P), titled "Processing Physician Orders" that indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patients/residents' risks. 6. Follow their P/P, titled "Reporting Laboratory Test Results" that indicated the facility shall ensure all emergency laboratory draws should have results in two to six hours. As a result of these deficient practices there was a delay in obtaining Resident 1's blood specimen, which caused a delay in obtaining Resident 1's STAT CBC results. Resident 1's hemoglobin was critically low, which resulted in Resident 1's admission to a General Acute Care Hospital (GACH), where he received one unit of blood and was subsequently admitted to the GACH's Telemetry unit (a specialized ward where patients requiring continuous cardiac monitoring receive care) because his condition was unstable. This deficient practice had the potential for Resident 1 to suffer severe complications such as heart failure, organ damage, and death. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 73 year old male, was admitted to the facility on 1/31/2025 with diagnoses including GI bleed and anemia. A review Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/5/2025, indicated Resident 1 was unable to make decisions for himself that were consistent and reasonable. A review of Resident 1's Care Plan on anemia dated 2/18/2025, indicated a goal for Resident 1 to maintain his laboratory values within acceptable parameters and to be free from signs/symptom (s/s) and complications of anemia. The Care Plan's interventions included observing, documenting, and reporting to Resident 1's physician any s/s of fatigue, dizziness, change in cognition, paleness, low hemoglobin, obtain and monitor laboratory work as ordered, report the results to Resident 1's physician, and follow up as indicated. A review of Resident 1's COC dated 3/5/2025 and timed at 5:37 a.m., indicated Resident 1 had increased confusion, hit his right leg on the bed frame, and was bleeding from a skin tear on his lower right leg. A review of Resident 1's COC dated 3/5/2025 and timed at 6:01 a.m., indicated Resident 1 was tired, more confused and drowsier after an incident of bleeding from his right leg skin tear and swelling on his right lower leg. A review of Resident 1's Fall Incident Report dated 3/5/2025 and timed at 11:27 a.m., indicated Resident 1 had an unwitnessed fall and was found on the floor near his bathroom with more confusion. A review of Resident 1's COC dated 3/6/2025 and timed at 2:09 p.m., indicated Resident 1 had a small amount of black tarry stool (occurs when there is bleeding in the upper digestive system, black or brown in color, with a sticky consistency and may have an unpleasant odor). The COC indicated Resident 1's physician ordered a STAT CBC. A review of Resident 1's Lab Results Report dated 3/6/2025 and timed at 8:05 p.m., indicated Resident 1's hemoglobin result was 7.0 grams per deciliter ([g/dl] the reference range is 13.5 g/dl to 16.9 g/dl). A review of Resident 1's Nursing Progress Notes dated 3/6/2025 and timed at 11:31 p.m., indicated Resident 1's physician was notified of Resident 1's hemoglobin result, "pending a response (order)." A review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 8:12 a.m., indicated Resident 1 was hypotensive (low blood pressure [BP]) with a BP of 86/48 millimeters of mercury (mm/Hg), (reference range 120/80 mm/Hg)). The Nursing Progress Notes indicated the facility staff called the paramedics but Resident 1's Responsible Party (RP) refused to transfer Resident 1 to a GACH due to a paracentesis (a medical procedure that removes fluid from the abdominal cavity) appointment that was scheduled for that day (3/7/2025). The Nursing Progress Notes indicated Resident 1's physician was aware that Resident 1's RP refused to transfer Resident 1 to the GACH and ordered a STAT CBC to be completed when Resident 1 returned from his appointment. A review of Resident 1's Order Summary Report (Physician's Order) dated 3/24/2025, indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m., and reordered at 2:20 p.m., upon Resident 1's return to the facility from his paracentesis appointment. A review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., indicated Resident 1 returned to the facility after his paracentesis appointment and facility staff (Licensed Vocational Nurse [LVN 1]) called the lab to confirm Resident 1's order for a STAT CBC. A review of the Laboratory Call Log Recording on 3/7/2025 at 2:20 p.m., indicated LVN 1 spoke to laboratory personnel indicating she was following up on an order for a CBC for Resident 1. The Laboratory Call Log Recording did not indicate that LVN 1 said the lab order was STAT. A review of the Laboratory's Dispatch Log dated 3/7/2025, indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1's blood on 3/7/2025 at 10:09 p.m. (approximately eight hours after the order was placed on 3/7/2025 at 2:20 p.m.) but Resident 1 refused. A review of Resident 1's untimed Nursing Progress Note dated 3/7/2025 indicated there was no documentation to indicate that Resident 1's physician or RP was notified when Resident 1 refused to have his blood drawn on 3/7/2025 at 10:09 p.m. A review of Resident 1's Lab Results Report dated 3/8/2025, indicated Resident 1's labs were drawn on 3/8/2025, at 9:44 a.m., (almost 10 hours after the order was made on 3/7/2025 at 11:59 p.m.). The Lab Results Report indicated Resident 1's hemoglobin result was critical at 6.7 g/dl, his hematocrit count was 21.5%, (reference range is 39.5% to 50.0%) and his platelet count was 52,000 platelets per microliter ([mcl] with a reference range of 150, 000 to 400,000 platelets per mcl). The Lab Results Report indicated Resident 1's lab results were available at 11 a.m., on 3/8/2025, and the lab attempted several times to notify the facility of Resident 1's critical lab value but was unable to reach the facility until 3/8/2025 at 1:31 p.m., because "no one at the facility picked up the phone." A review of the Laboratory Call Log dated 3/8/2025, indicated lab personnel attempted to report Resident 1's critical hemoglobin result to the facility at 11 a.m., 11:54 a.m., 12:19 p.m., 12:53 p.m., and 1:14 p.m. The Laboratory Call Log indicated Resident 1's critical laboratory result (hemoglobin) was "finally" reported to the facility on 3/8/2025 at 1:31 p.m. A review of Resident 1's Transfer Form dated 3/8/2025 and timed at 2:17 p.m., indicated Resident 1 was transferred to a GACH at 3:30 p.m., due to black tarry stools, a decreased hemoglobin, a low hematocrit and a low platelet count. A review of the GACH's Emergency Department (ED) Note dated 3/8/2025 and timed at 4:10 p.m., indicated Resident 1 was admitted to the ED with a chief complaint of three episodes of black tarry stools within two days, a hemoglobin of 6.7 g/dl, and a chronic (last for an extended period, typically, for three months or more) hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) in Resident 1's lower extremities (legs). The ED Note indicated Resident 1 received 1 unit of packed red blood cells ([PRBC] a concentrated preparation of red blood cells obtained from whole blood after the plasma is removed) and was admitted to the GACH's telemetry unit because his condition was unstable. During an interview on 3/20/2025 at 1:20 p.m., Registered Nurse Supervisor (RNS) 1 stated a STAT lab order should be completed within four hours and the lab result should be reported to the facility within two hours. During a subsequent interview on the same day at 2:05 p.m., RNS 1 stated Resident 1 had an order for a STAT CBC on 3/7/2025 at 2:20 p.m., but Resident 1's blood was not drawn until 3/8/2024 at 9:44 a.m. (over 19 hours after the order for a STAT lab was given). RNS 1 stated there was a miscommunication in processing Resident 1's blood draw between the licensed nursing staff on 3/7/2024 on all shifts which delayed Resident 1's STAT lab order. RNS 1 stated there was no follow up on Resident 1's lab order to ensure his labs were completed and results obtained. During an interview on 3/20/2025 at 3:31 p.m., RNS 2 stated she worked the 3 p.m. to 11 p.m. shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m. to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order (3/7/2025 at 2:20 pm.) but when the lab technician came to the facility (3/7/2025 at 10:09 p.m.) Resident 1 refused to have his blood drawn. During a subsequent interview on 3/24/2025 at 6:24 p.m., RNS 2 stated she reordered another STAT CBC for Resident 1 on 3/7/2025 at 11:59 p.m., verbally endorsed the order to the 11 p.m. to 7 a.m. shift and documented the endorsement on the facility's communication board through their electronic medical record system. RNS 2 stated she did not call Resident 1's physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1's RP to notify them of Resident 1's refusal and allow Resident 1's physician to give instructions for Resident 1's care. During an interview on 3/20/2025 at 3:50 p.m., RNS 3, who worked from 7 a.m. to 3 p.m., on 3/8/2025, stated he did receive an endorsement from the 11 p.m., to 7 a.m. shift regarding a STAT CBC for Resident 1. RNS 3 stated he checked the facility's Electronic Communication Board after conducting resident rounds and saw an order for a STAT lab for Resident 1. RNS 3 stated the STAT lab order had not been completed and there was no documentation in Resident 1's Progress Notes, why it had not been done. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1's Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1's refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated and treated instead of waiting. During an interview on 3/25/2025 at 2 p.m., the Administrator (ADM ) acknowledged and stated there was a gap of time between Resident 1's lab order and results of his labs caused by the licensed nursing staff. During an interview and listening to the Laboratory Audio Call Log on 3/25/2025 at 5 p.m., LVN 1 acknowledged and stated, on 3/7/2025 at 2:20 p