Health inspection·January 24, 2025

F580 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §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. § 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 12/30/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating they received a report from an emergency room doctor that a resident (Resident 1) who had been transferred from the facility via 911 was diagnosed with a subdural hematoma ([SDH] a collection of blood on the surface of the brain). On 12/31/2024 the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation the CDPH determined Resident 1 who was receiving a Warfarin (a medication used to prevent blood clots from forming) due to a diagnosis of atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots), received 10 doses of Warfarin that should have been discontinued on 11/19/2024 when Resident 1's Nurse Practitioner (NP) implemented new orders for Warfarin administration. This led to critically high (values that are significantly outside the normal range) International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) levels. The critical high INR level was reported to Resident 1's physician without a response from the physician and no follow up by the facility's nursing staff for instructions from Resident 1's physician or the facility's Medical Director (MD). The facility failed to: 1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's NP. 2. Ensure licensed nurses did not administer extra doses of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024, including a dose of Warfarin that should have been discontinued on 11/19/2024. 3. Ensure licensed nurses monitored the number of doses of Warfarin and critical INR laboratory values to prevent and detect medication errors. 4. Ensure Resident 1's physician was notified when Resident 1's INR results were abnormal/critically high, and the nursing staff followed up with the physician and/or the MD when there was no response from Resident 1's physician in a timely manner. 5. Follow its Policy and Procedure (P/P), titled "Administering Medications" dated 2001, that indicated to administer medications in accordance with the prescriber's orders and the P/P, titled, "Critical Labs of Tests and Diagnostic Procedures-Reporting of" dated 1/2/2024, that indicated the response including any new orders/interventions related to the critical tests results and diagnostic procedures must occur within four (4) hours of reporting of results; and if clinician responsible for the resident is not available, the medical director (MD) shall be notified of the critical result. These failures resulted in Resident 1's transfer to a General Acute Hospital (GACH) on 12/27/2024 where he was diagnosed with a SDH measuring 12 millimeters ([mm] a metric unit of measurement, used for medication dosage and/or amount). Upon admission to the GACH Resident 1 was intubated (insertion of a tube either through the mouth or nose and into the airway to aid in breathing) and administered Andexxa (a medication given to patients who are on anticoagulant medication [a class of drugs that help prevent blood clots and dissolve existing ones] to treat life-threatening or uncontrolled bleeding. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 11/5/2024 with a diagnosis of Afib. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1's undated Care Plan, indicated Resident 1 was at risk for bleeding and bruising secondary to anticoagulant therapy related to the use of Warfarin. The Care Plan indicated labs should be completed as ordered and abnormal tests results should be reported to the physician. A review of Resident 1's Physician's Order dated 11/5/2024, indicated Resident 1's Prothrombin ([PT] a factor in the blood that helps it clot properly)/INR was to be drawn on 11/7/2024 one time only. A review of Resident 1's Physician's Order Summary Report dated 11/7/2024, indicated to administer Warfarin 4.5 milligrams ([mg] unit of measurement) one time a day (9 a.m.) for Afib. A review of Resident 1's Physician Order dated 11/7/2024, indicated to draw Resident 1's INR on 11/10/2024. A review of Resident 1's Laboratory results dated 11/12/2024, indicated Resident 1's INR was 4.27 (INR range 2.0-3.0) and was flagged as critical. A review of Resident 1's Change in Condition (COC) Note dated 11/13/2024, indicated Resident 1's INR of 4.27 was reported to Resident 1's physician, who ordered Vitamin K (a vitamin that plays a role in helping blood clot) 10 mg subcutaneous (beneath the skin) injection one time only, hold the Warfarin for two days, and repeat the INR test on 11/14/2024. A review of the Laboratory Services Patient Care Log indicated Resident 1 refused to have his blood drawn for the INR level on 11/14/2024 and 11/15/2024. A review of Resident 1's Laboratory results dated 11/18/2024, indicated Resident 1's INR was 1.18 and was flagged as abnormal (below the INR normal range of 2.0-3.0). A review of Resident 1's Physician's Order Summary Report dated 11/2024, indicated the following orders: 1. On 11/19/2024 - Administer Warfarin 4.5 mg in the afternoon every Tuesday, Thursday, and Saturday for Afib, monitor for s/s of bleeding. 2. On 11/19/2024 - Resident 1 may have PT and INR levels drawn every Tuesday and Thursday. 3. On 11/20/2024 - Administer Warfarin 4 mg, give one tablet in the afternoon every Monday, Wednesday, Friday, and Sunday for Afib, monitor for s/s of bleeding. A review of Resident 1's Laboratory results dated 11/22/2024, indicated Resident 1's INR was 1.12 and was flagged as abnormal. A review of Resident 1's Nursing Note, dated 11/22/2024 and timed at 8:59 p.m., indicated Resident 1's laboratory results dated 11/22/2024 were sent to Resident 1's physician. The Nursing Note indicated there was no response from the physician. A review of Resident 1's Nursing Note dated 11/23/2024 and timed at 7:41 a.m., indicated the facility refaxed Resident 1's INR results to Resident 1's Physician. The Nursing Note indicated there was no new order, the facility staff endorsed this to the next shift. A review of Resident 1's Medication Administration Record (MAR) dated 11/2024, indicated the 9 a.m., dose of Warfarin was not discontinued on 11/19/2024. The MAR indicated Resident 1's administration of Warfarin was as follows: 1. On 11/21/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). 2. On 11/22/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 11/23/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). 4. On 11/25/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 5. On 11/29/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 6. On 11/30/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg). A review of Resident 1's Laboratory results dated 12/2/2024, indicated Resident 1's INR was 6.19 and was flagged as critical. A review of Resident 1's Progress Note dated 12/2/2024, and timed at 9:38 p.m., indicated Resident 1's INR results of 6.19 were received and sent, via fax, to Resident 1's physician and the facility was awaiting orders. The Progress Note indicated Resident 1's lab results and the physician's pending response were endorsed to the next shift. The Progress Noted indicated there was no response from Resident 1's physician and no actions taken to notify the facility 's MD. A review of Resident 1's Laboratory results dated 12/5/2024 and timed at 6:58 p.m., indicated Resident 1's INR was 5.83 and was flagged as critical. A review of Resident 1's Progress Note dated 12/6/2024 and timed at 4:35 a.m., indicated Resident 1's INR result of 5.83 was relayed to Resident 1's physician, and the staff were waiting for a response. A review of Resident 1's MAR dated 12/2024, indicated the 9 a.m., dose of Warfarin was not discontinued on 11/19/2024. The MAR indicated Warfarin was administered to Resident 1 as follows: 1. On 12/1/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 2. On 12/2/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 3. On 12/9/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg). 4. On 12/10/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg). A review of Resident 1's Physician's Orders dated 12/11/2024, indicated to discontinue administration of Warfarin. A review of the Resident 1's Physician's Order dated 12/13/2024, indicated to administer Eliquis (an oral anticoagulant that helps prevent and treat blood clots) 5 mg two times a day for deep vein thrombosis ([DVT] occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (preventative treatment against disease). A review of Resident 1's MAR dated 12/2024, indicated Resident 1 received Eliquis as ordered from 12/13/2024 thru 12/27/2024. A review of Resident 1's Nurse's Note dated 12/27/2024, indicated Certified Nursing Assistant (CNA) 1 observed Resident 1 sitting in a wheelchair, not talking. The Nurse's Note indicated Resident 1 was assessed and 911 emergency services was called. The Nurse's Note indicated Resident 1 was transferred to the GACH for further intervention and assessment. A review of Resident 1's Physician's Orders dated 12/27/2024, indicated to transfer Resident 1 to the nearest GACH via 911 due to unresponsiveness. A review of the GACH's Emergency Physician's note dated 12/27/2024, indicated Resident 1 was brought to the GACH via ambulance with a chief complaint of a SDH that measured 12 millimeters ([mm] a unit of measurement). The Emergency Physician's note indicated Resident 1 was intubated and administered Andexxa for reversal of Eliquis. During an interview on 1/2/2025 at 2:04 p.m., and a subsequent interview on 1/3/2025 at 12:15 p.m., Licensed Vocational Nurse (LVN ) 1 stated Resident 1 received multiple doses of Warfarin that overlapped beginning on 11/19/2024. LVN 1 stated when Resident 1's laboratory results indicated his INR level was critically high on 12/2/2024, the results were sent to the physician but there was no follow up by facility's staff when Resident 1's physician did not respond to the fax. LVN 1 stated the staff should have followed up with the physician to determine if the laboratory results were received because the INR values were critically high, and Resident 1 was at risk for bleeding. During an interview on 1/2/2025 at 4:18 p.m., LVN 2 stated all lab results should be reported to the physician and a response from the physician was expected by the end of the shift. LVN 2 stated, if there was no response from the physician by the end of the shift, the lab results should be reported to the MD. During an interview on 1/2/2025 at 4:41 p.m., the NP stated when she revised the Warfarin order (11/19/2024) to indicate it should be administered to Resident 1 on alternating days of the week, she verbally instructed LVN 2 to discontinue the order for Warfarin 4.5 mg daily. The NP stated she was not aware Warfarin 4.5 mg daily order was still active. The NP stated Warfarin had a very narrow therapeutic range (level of medication in the blood to achieve its desired effect) and Resident 1's INR level could be affected if Warfarin was not administered as ordered and closely monitored. During an interview on 1/4/2025 at 1:18 p.m., the MD stated he had no knowledge that Resident 1's physician had not responded to a report of critical INR levels and was only aware of Resident 1's condition on 12/30/2024, when the GACH reported that Resident 1 sustained an SDH. The MD stated Warfarin was a complicated medication to administer because it involved constant monitoring, blood tests, dose adjustments, and daily monitoring for side effects such as bleeding and bruising. The MD stated if a resident's INR was low, there was a risk that the resident could develop blood clots and if the INR was too high, there was a risk that the resident could develop bleeding. During an interview on 1/4/2025 at 2:08 p.m., the DON stated when administering Warfarin, INR levels should be monitored because if the levels were out of the therapeutic range, residents could be at risk for bleeding or clotting. The DON stated licensed staff should report abnormal lab results to the physician within 24 hours, and critical lab results should be reported to the physician within 4 hours. The DON stated if there was no response from the physician, the MD should be contacted. The DON stated Resident 1's Warfarin 4.5 mg daily order should have been discontinued on 11/19/2024 when the revised Warfarin order was received. During an interview on 1/4/2025 at 2:47 p.m., the ADM stated the licensed nurses documented they administered Warfarin 4.5 mg daily (9 a.m.) in error and they did not administer Warfarin to Resident 1, so Resident 1 could not have received extra doses of Warfarin. A review of the facility's P/P, titled "Administering Medications" dated 2001, the P/P indicated medications were administered in accordance with the prescriber's orders, including any required time frame. During a review of the facility's P/P titled "Critical Labs of Tests and Diagnostic Procedures-Reporting of" dated 1/2/2024, the P/P indicated the response including any new orders/interventions related to the critical results of tests and diagnostic procedures must occur within four (4) hours of reporting of results. The P/P indicated if the Licensed Independent Practitioner ([LIP] a health care provider who is legally permitted to provide care without direct supervision) and or clinician responsible for the resident is not available and that LIP's alternate cannot be reached or is unavailable, the medical director under which the LIP is privileged shall be notified of the critical result. The facility failed to: 1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's NP. 2. Ensure licensed nurses did not administer extra doses of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024, including a dose of Warfarin that should have been