Health inspection·July 3, 2024

Code of Federal Regulations, Title 42, Section 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences. California Code of Regulations, Title 22, Section 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, 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. California Code of Regulations, Title 22, Section 72313. Nursing Service - Administration of Medications and Treatments. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. California Code of Regulations, Title 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. On 5/18/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care and treatment. As a result of the investigation, CDPH determines that the facility failed to implement its policies and procedures (P&P) titled, "IV (an intravenous [within a vein] line is a soft, flexible tube placed inside a vein, usually in the hand or arm) Administration," and "Central Venous (a thin, flexible tube that is inserted into a vein, usually below the right collarbone) and Midline Catheter (a catheter inserted in the upper arm with the tip located just below the axilla) Care," and follow the manufacturer's instructions for care of the central venous catheter (CVC- an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment) for Resident 1 by failing to: 1. Ensure Registered Nurse Supervisor (RNS) 3 flushed (method of clearing intravenous [IV] line) Resident 1's permanent catheter (Permacath- a type of CVC used for short-term or long-term hemodialysis [a treatment to filter wastes and water from the blood, as the kidneys did when the kidneys were healthy]) with saline (a solution of salt in water) after the completion of the IV infusion and documented the procedure in Resident 1's clinical record. 2. Ensure RNS 3 clamped (to hold or press tightly together with a securing device) and capped (covered or closed with a cap) Resident 1's Permacath when the Permacath was not in use. 3. Ensure Licensed Nurses (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]) implemented the Untitled Care Plan (CP) dated 5/8/2024, to inspect, monitor, document, and report to MD 1 as needed for any signs and symptoms (s/sx) of infection to the catheter site (Permacath) such as redness, swelling, warmth or drainage, and any s/sx of bleeding. These violations resulted in Resident 1 experiencing "massive" bleeding from Resident 1's Permacath on 5/10/2024 at 12:45 AM. Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) 1's Intensive Care Unit on 5/10/2024 at 1:14 AM for further evaluation and treatment. A review of Resident 1's Admission Record indicated, the facility originally admitted Resident 1, a 40-year-old male, on 4/25/2024, and readmitted Resident 1 on 5/7/2024, with diagnoses that included type 2 diabetes mellitus (a condition in which the body had trouble controlling blood sugar and using it for energy), anxiety disorder, end stage renal disease (ESRD- a medical condition in which a person's kidney ceased functioning on a permanent basis), and dependence on renal (kidney) hemodialysis treatment. A review of Resident 1's History and Physical dated 4/28/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Physician Order (PO) dated 5/4/2024, indicated Resident 1 had an order for heparin sodium injection solution (medication used to thin the blood and prevent blood clots) 5000 unit per milliliter (unit/ml), inject 5000 unit/ml subcutaneously (beneath the skin) every 12 hours for deep vein thrombosis (DVT- blood clot in a deep vein, usually in the legs) prophylaxis. A review of Resident 1's PO dated 5/7/2024, indicated Resident 1 had an order to inspect Resident 1's dialysis site/Permacath to Resident 1's right upper chest for color, warmth, redness, edema, and/or bleeding every shift and to contact Resident 1's Primary Physician/Medical Doctor 1 (MD 1) if present. A review of Resident 1's untitled Care Plan (CP) dated 5/8/2024, indicated Resident 1 needed hemodialysis related to ESRD. The CP interventions included for staff to monitor, document, and report to MD 1 as needed for any s/sx of infection to access site (Permacath) such as redness, swelling, warmth or drainage, and any s/sx of bleeding. A review of Resident 1's Nurse's Dialysis Communication Record (NDCR) dated 5/9/2024, timed at 8:20 AM, indicated Resident 1 left the facility for Resident 1's dialysis treatment (on 5/9/2024) at 8:20 AM and returned to the facility (on 5/9/2024) at 12:30 PM. The NDCR indicated Resident 1 had a CVC (Permacath) to Resident 1's right chest. The NDCR dated 5/9/2024, indicated there was no documentation the facility staff assessed Resident 1's CVC site for redness, swelling, drainage, and/or bleeding as required on the NDCR. A review of Resident 1's PO dated 5/9/2024, indicated Resident 1 had an order to administer Dextrose (a form of glucose [sugar]) IV solution 10 percent (%) at 100 milliliters per hour (ml/hr) due to hypoglycemia (low blood sugar) and Resident 1's inability to swallow.[PWL1][DLZ2] The PO was for one liter and a one-time order. A review of Resident 1's PO dated 5/9/2024, indicated Resident 1 had an order that staff may use Resident 1's Permacath for intravenous administration of medication. A review of Resident 1's IV Medication Administration Record (IVMAR) dated 5/9/2024, indicated on 5/9/2024, at 3 PM, RNS 2 started to administer Dextrose IV solution 10% at 100 ml/hr intravenously for Resident 1. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/10/2024, indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required setup or clean-up assistance for eating and oral hygiene. The MDS indicated Resident 1 depends on staff for toileting hygiene, showering/bathing, lower body dressing, rolling left and right in bed, and toilet transfer. During a review of Resident 1's Paramedic Report (PR) dated 5/10/2024, timed at 12:25 AM, indicated paramedics arrived at the facility on 5/10/2024 at 12:29 AM, and was at Resident 1's bedside at 12:30 AM for complaint of Resident 1 bleeding. The PR indicated the paramedics found Resident 1 in bed bleeding from Resident 1's dialysis port (extension tubing that made it easier to access the vein through the Permacath). The PR indicated facility staff had Resident 1's bleeding controlled with direct pressure and a towel. The PR indicated facility staff clamped Resident 1's (Permacath) port on Resident 1's right chest near the exit site of Resident 1's Permacath. The PR indicated Resident 1's bleeding was controlled and Resident 1's vital signs were stabilized. The PR indicated Resident 1 was transferred to GACH 1. A review of Resident 1's Progress Notes (PN) dated 5/10/2024, indicated (on 5/10/2024) at 12:30 AM, LVN 3 noted "massive" bleeding from Resident 1's Permacath dialysis site possibly from "ruptured catheter and missing locks (a device designed to bind or constrict or to press two or more parts together so as to hold them firmly)." The PN indicated staff (LVN 3) applied pressure and ice pack on the (catheter's) site. The PN indicated Resident 1's oxygen saturation (O2 sat- a measure of how much oxygen is in the blood) was decreasing. The PN indicated RNS 1 increased Resident 1's supplemental oxygen to 10 to 15 liters per minute (L/min) via non-rebreather mask (a device that gives oxygen, usually in an emergency). The PN indicated staff called 911 and the paramedics arrived after five to seven minutes and took Resident 1 to GACH 1 on 5/10/2024, at 12:45 AM. A review of Resident 1's Change in Condition Evaluation (CICE) dated 5/10/2024, timed at 12:45 AM, indicated on 5/10/2024, untimed, LVN 3 noticed that Resident 1 was acting slightly abnormal. The CICE indicated Resident 1's room light was off, and LVN 3 noticed a dark colored spot near Resident 1's right side. The CICE indicated LVN 3 turned on Resident 1's room light and saw a "large" amount of blood (location not indicated). The CICE indicated LVN 3 called CNA 1 and CNA 1 called 911. The CICE indicated LVN 3 applied pressure (location not indicated) to stop the bleeding. The CICE indicated LVN 3 notified MD 1 on 5/10/2024 at 1:18 AM. A review of Resident 1's GACH 1 Emergency Department Provider Note (EDPN) dated 5/10/2024, timed at 1:14 AM, indicated the ambulance brought in Resident 1 from the facility for bleeding from Resident 1's right chest wall dialysis catheter. The EDPN indicated per the paramedics, Resident 1 was found in a pool of blood, blood-soaked sheets, with approximately 300 ml of blood on the floor. The EDPN indicated per the paramedics, "it was unclear how long or how Resident 1's Permacath opened." The EDPN indicated upon Resident 1's arrival to GACH 1 ED, Resident 1 appeared pale, altered, anxious, and hypotensive (having low blood pressure [BP]) with BP of 84/67 millimeters of mercury (mmHg) (Normal BP= 120/80 mm/hg). The EDPN indicated while in GACH 1 ED, Resident 1 received one (1) unit of packed red blood cells (PRBC- blood transfusions used to improve blood oxygen [the amount of oxygen you have circulating in your blood] carrying capacity and restore blood volume). The EDPN indicated Resident 1 would be admitted to GACH 1's ICU for further evaluation and treatment. A review of Resident 1's GACH 1 Renal Consultation Note (RCN) dated 5/10/2024, timed at 7:29 PM, indicated Resident 1 presented to GACH 1 with significant bleeding from Resident 1's Permacath site. The RCN indicated "apparently the clamp (a device designed to constrict and press two or more parts together to hold them firmly) was opened, and the cap (cover) was not on the catheter." During an interview on 5/17/2024 at 7 AM, RNS 1 stated at approximately 12:30 AM on 5/10/2024, LVN 3 paged RNS 1 to come to Resident 1's room. RNS 1 stated when RNS 1 entered Resident 1's room, RNS 1 observed LVN 3's hands applying pressure on Resident 1's right upper chest where Resident 1's Permacath was located. RNS 1 inspected Resident 1's Permacath and noticed that blood was coming out from the two (2) extension tubing ports (a form of tubing used to add length to an existing infusion tubing) of Resident 1's Permacath. RNS 1 stated RNS 1 manually clamped the tubing above the 2 ports of Resident 1's Permacath and continued to apply pressure on Resident 1's right upper chest. RNS 1 stated RNS 1 observed the clamps and caps were missing from the 2 ports of Resident 1's Permacath. RNS 1 stated RNS 1 asked LVN 3 to get an ice pack and get a clamp from the dialysis kit at Resident 1's bedside. RNS 1 stated RNS 1 clamped Resident 1's Permacath tubing above the 2 ports of the Permacath with an emergency clamp. RNS 1 stated the paramedics came "within a few minutes" and took Resident 1 to the hospital (GACH 1). RNS 1 stated RNS 1 did not see any caps or clamps on Resident 1's bed and RNS 1 did not know why the caps and clamps were missing from Resident 1's Permacath tubing. RNS 1 stated RNS 1 received training for care of Permacath/CVC in October of 2023. RNS 1 stated Resident 1's Permacath needed to be clamped and capped "always" when "it (the Permcath)" was not in use to prevent blood from flowing out of the ports. RNS 1 stated when Resident 1's Permacath was unclamped or uncapped, Resident 1 could be at risk for bleeding from the Permacath ports which could lead to complications such as blood loss and shock (a life-threatening condition that occurred when the body was not getting enough blood flow). During an interview on 5/17/2024 at 9:05 AM, RNS 2 stated on 5/9/2024 at around 2:30 PM, Resident 1 had low blood sugar. RNS 2 stated LVN 4 notified MD 1 and MD 1 ordered to give Dextrose 10 intravenous solution to Resident 1. RNS 2 stated RNS 2 was unable to insert a peripheral IV line on Resident 1. RNS 2 stated LVN 4 notified MD 1 of Resident 1's poor IV access and MD 1 ordered to use Resident 1's Permacath. RNS 2 stated RNS 2 started the Dextrose 10 IV infusion via Resident 1's Permacath (on 5/9/2024) at approximately 3 PM and endorsed the IV infusion to RNS 3 (on 5/9/2024) at approximately 3:40 PM. During an interview on 5/17/2024 at 9:43 AM, RNS 3 stated RNS 3 received report from RNS 2 on 5/9/2024 (unable to recall time) that Resident 1 was receiving IV fluids via Resident 1's Permacath. RNS 3 stated the IV infusion was completed (on 5/9/2024) at 11:30 PM so RNS 3 disconnected the IV tubing from Resident 1's Permacath and flushed Resident 1's Permacath with 10 ml of saline. RNS 3 stated RNS 3 clamped Resident 1's Permacath extension tubing and capped the ports of Resident 1's Permacath. During an interview on 5/17/2024 at 11:25 AM, LVN 3 stated (on 5/10/2024) "at approximately" 12:25 AM, LVN 3 was at Resident 1's room door when LVN 3 saw Resident 1's hands on the headboard of Resident 1's bed. LVN 3 stated LVN 3 noticed a dark spot on the right side of Resident 1's gown while Resident 1's room light was off. LVN 3 stated LVN 3 immediately went inside Resident 1's room, turned on the light, and observed a "big spot" of blood on the right side of Resident 1's body. LVN 3 stated LVN 3 lifted Resident 1's blanket, bedsheet, and gown to see where the blood was coming from. LVN 3 stated Resident 1's Permacath dressing was covered with blood. LVN 3 stated LVN 3 observed drops of blood slowly dripping out from Resident 1's Permacath ports. LVN 3 stated LVN 3 did not see the caps at the end of Resident 1's Permacath extension tubings. LVN 3 stated LVN 3 immediately applied pressure on Resident 1's right chest and yelled out for help. LVN 3 stated CNA 1 came and LVN 3 instructed CNA 1 to call 911. LVN 3 stated RNS 1 came inside Resident 1's room and immediately requested for a bag of ice from another staff to put on Resident 1's Permacath site. LVN 3 stated RNS 1 continued to apply pressure on Resident 1's Permacath site using RNS 1's hands. LVN 3 stated RNS 1 instructed LVN 3 to get a clamp from the dialysis kit. LVN 3 stated RNS 1 clamped the 2 tubes above the 2 ports of Resident 1's Permacath with an emergency clamp then the bleeding stopped. LVN 3 stated the paramedics came within a few minutes, assessed Resident 1, and told LVN 3 that Resident 1's Permacath was still intact. LVN 3 stated the paramedics took Resident 1 to GACH 1. During a follow-up interview and concurrent record review on 5/17/2024 at 2:43 PM, RNS 3 stated (on 5/9/2024, unable to recall time) RNS 3 flushed Resident 1's Permacath with saline and clamped Resident 1's Permacath tubing after the IV infusion completed but did not document the flushing and clamping of Resident 1’s Permacath. During an interview on 5/17/2024 at 4:07 PM, the Director of Nursing (DON) stated licensed nurses (LVNs and RNs) must inspect and monitor the CVC/Permacath site for signs of redness, swelling, bleeding, pain, or any changes in condition. The DON stated "it" was important to clamp and cap Resident 1's CVC/Permacath when it was not in use to prevent bleeding which could cause complications such as hypotension, blood loss, shock, or even death. A review of Resident 1's GACH 1 Discharge Summary (DS) dated 5/18/2024, timed at 9:03 AM, indicated Resident 1 was admitted with hyp