Health inspection·December 9, 2024

Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notifications 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— (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 lifethreatening conditions or clinical complications) Code of Federal Regulations, Title 42, Section 483.21(b)(1), 483.10(c)(3)(i) 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) 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 Code of Federal Regulations, Title 42, Section 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: California Code of Regulations, Title 22, 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. California Code of Regulations, Title 22, Section 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 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 11/5/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment, resident rights, and administration/personnel. As a result of the investigation, CDPH determined that the facility failed to provide the care and services for Resident 2 according to the facility’s policies and procedures (P&Ps) titled, “Resident Care, Monitoring of,” “Change of Condition Reporting,” and “Significant Change of Condition, Response.” The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2’s Primary Care Provider/Medical Doctor (MD) 1 promptly when LVN 1 noted a lump in Resident 2’s left breast on 4/17/2024 at 12:15 pm.     2. Ensure LVN 1 and/or assigned licensed nurses (LVNs or Registered Nurses [RNs]) developed a plan of care and implemented interventions to address Resident 2’s left breast lump. 3. Ensure LVNs 1, 4, 5, 6, 8, 9, 10, and 11 communicated with MD 1 and clarified MD 1’s recommendation to order a mammogram to Resident 2’s both breasts as documented on Resident 2’s eINTERACT Change in Condition (CIC) Evaluation dated 4/17/2024, timed at 12:15 pm. 4. Ensure the assigned licensed nurses reassessed the condition of Resident 2’s left breast lump after 72 hours (on 4/21/2024) and followed-up with MD 1 to obtain the necessary orders to care and/or treat Resident 2’s unresolved left breast lump. 5. Ensure MD 1’s order for mammogram to Resident 2’s breasts dated 4/25/2024 was carried out as MD 1 ordered. As the result of these failures, Resident 2 did not receive the care and services for Resident 2’s left breast lump from 4/17/2024 to 7/1/2024. On 7/1/2024 at 3:15 am, Resident 2 complained of severe and uncontrolled pain under Resident 2’s left breast and left rib cage. On 7/1/2024 at 8:50 am, Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation of the left breast lump. Resident 2 was found with a 1.8 centimeter (cm) by 2.4 cm by 1.3 cm mass suspicious for malignancy (cancer) on Resident 2’s left breast at GACH 1. On 7/31/2024, Resident 2 had an ultrasound guided biopsy at GACH 1 which showed infiltrating ductal carcinoma (a type of breast cancer that originates in the milk ducts of the breast and then spreads into surrounding tissue) of the left breast. A review of Resident 2’s Admission Record, indicated Resident 2, a 68-year-old female, was initially admitted to the facility on 12/2/2016, and readmitted on 10/4/2022, with diagnoses that included multiple sclerosis (long standing disease that affects the brain, spinal cord, optic nerves, and blocks messages between the brain and body), hydronephrosis (condition where one or both kidneys become stretched and swollen as a result of build-up of urine), and cerebral palsy (disorder of movement, muscle tone, or posture).     A review of Resident 2’s eINTERACT CIC Evaluation dated 4/17/2024, timed at 12:50 pm, indicated Resident 2 was noted with a lump on the left breast after showering. The CIC Evaluation indicated LVN 1 notified MD 1 on 4/17/2024 at 12:15 pm and MD 1 recommended to order a mammogram to both breasts for Resident 2.   A review of Resident 2’s physician order (PO) dated 4/25/2024, transcribed by LVN 6, indicated an order for a mammogram to both breasts for Resident 2.   A review of Resident 2’s CIC Evaluation dated 7/1/2024, timed at 3:05 am, indicated Resident 2 complained of uncontrolled and severe pain under Resident 2’s left breast and left rib cage. The CIC Evaluation indicated Resident 2 requested to be transferred to GACH 1. A review of Resident 2’s Progress Notes (PN) dated 7/1/2024, timed at 3:15 am, indicated MD 1 was notified regarding Resident 2’s complaint of severe pain under Resident 2’s left breast and left rib cage not relieved with pain medication. The PN indicated MD 1 ordered to transfer Resident 2 to GACH 1 Emergency Department (GACH 1 ED) for further evaluation. The PN indicated the facility transferred Resident 2 to GACH 1 ED on 7/1/2024 at 8:50 am.     A review of Resident 2’s GACH 1 ED General Note, dated 7/1/2024, timed at 9:05 am, indicated Resident 2 was brought to GACH 1 for severe pain on the left ribs unrelieved by pain medication. The GACH 1 ED General Note indicated Resident 2 had a mass on the left breast that was noted three months ago (4/17/2024) and Resident 2 had not had a mammogram.     A review of Resident 2’s GACH 1 Ultrasound (US) Report of Resident 2’s left breast dated 7/1/2024, timed at 12:48 pm, indicated Resident 2 had a 1.8 cm by 2.4 cm by 1.3 cm mass in the left breast, highly suspicious for malignancy. The US Report indicated a recommendation for a mammogram and US-guided biopsy of Resident 2’s left breast to ensure appropriate care.     A review of Resident 2’s GACH 1 ED Assuming Care Note (EDACN), dated 7/1/2024, timed at 2:03 pm, indicated (on 7/1/2024) at 3:36 pm, Resident 2 was unable to get into position to perform a mammogram and the mammogram was cancelled. The EDACN indicated (on 7/1/2024) at 3:42 pm, Resident 2’s breast US showed a category four (indicates likelihood for malignancy) suspicious breast lesion (mass), and a US-guided biopsy was recommended. The EDACN indicated (on 7/1/2024) at 3:47 pm, Resident 2’s breast US showed concerning malignancy and required further workup from a specialist. The EDACN indicated Resident 2 would follow-up with MD 1 with a referral for a breast cancer specialist.  A review of Resident 2’s Minimum Data Set (MDS, a resident assessment tool), dated 10/3/2024, indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was dependent on staff for showering/bathing self, putting on/taking off footwear, sitting to lying (in bed), sitting to standing, chair/bed-to-chair transfers, and toilet transfers. The MDS indicated Resident 2 required substantial/maximal assistance with oral hygiene, toileting, personal hygiene, upper and lower body dressing, and rolling left and right (in bed). A review of Resident 2’s GACH 1 Hematology Oncology Progress Note (HOPN) dated 10/25/2024, indicated Resident 2’s US-guided biopsy dated 7/31/2024 showed Resident 2 had infiltrating ductal carcinoma (breast cancer). During a telephone interview on 11/4/2024 at 12:07 pm, Resident 2 stated in later part of April 2024 (unable to specify date), the facility nurses (unable to identify) found a lump in her left breast. Resident 2 stated the facility “was not doing anything.” Resident 2 stated she expressed to the facility that she was stressed and concerned about the lump, but she was dismissed by facility staff. Resident 2 stated she had asked facility staff more than three times to call MD 1 to inform MD 1 regarding Resident 2’s left breast lump and pain in her left breast but was dismissed by facility staff. Resident 2 stated she was not seen by MD 1 nor taken to the hospital until 7/1/2024, when she had a lot of pain in her chest and ribs. Resident 2 stated the only reason her left breast lump was assessed at GACH 1 on 7/1/2024 was because she advocated for herself and told the ED physician she had a lump. Resident 2 stated MD 1 did not assess her for a left breast lump until 7/2/2024, when GACH 1 informed MD 1 that she needed to be referred to a specialist for breast cancer.  Resident 2 stated she cried every day and tried to keep a positive attitude about the diagnosis, but it was hard because she was struggling “to not give up.” Resident 2 stated she felt like a “death sentence” had been given to her. Resident 2 stated she felt so unseen and dismissed because facility staff did not listen to her.    During a telephone interview on 11/5/2024 at 1:38 pm, the hematologist/oncologist /MD 2 stated she was Resident 2’s primary oncologist. MD 2 stated Resident 2 was diagnosed with infiltrating ductal carcinoma with metastasis (process by which cancer cells spread from their original location to other parts of the body) to the bone. MD 2 stated it was important for Resident’s 2 left breast lump to be assessed as soon as it was found and get a biopsy to investigate if the lump was cancerous. MD 2 stated a biopsy was needed to be done as soon as possible to determine the best course of treatment for Resident 2. MD 2 stated a delay in assessment and treatment could affect Resident 2’s cancer prognosis. MD 2 stated with cancer, the faster the diagnosis was made, the faster [the oncologist] can treat cancer symptoms and hope to reduce the size of the tumor. MD 2 stated at this time, Resident 2’s cancer was not curable.   During an interview on 11/5/2024 at 3:08 pm, the Director of Nursing (DON) stated LVN 1 was on maternity leave and could not be reached for an interview.   During a telephone interview on 11/6/2024 at 8:12 am, LVN 5 stated (in general) when a resident had a change in condition, LVN 5 needed to notify the resident’s physician (MD 1) to see if any orders were needed. LVN 5 stated if he was unable to speak to the physician (MD 1), he needed to follow-up and speak with the physician to obtain orders. LVN 5 stated when there was a change in resident’s (Resident 2’s) condition licensed staff needed to monitor a resident for at least 72 hours. LVN 5 stated when the condition was still present after 72 hours, the licensed nurses needed to inform the resident’s physician to see if new orders such as a referral or hospital transfer for further evaluation was needed. LVN 5 stated when a resident’s physician could not be reached, it could be fatal and could endanger the resident’s health in a negative way. LVN 5 stated Resident 2’s left breast lump needed to be followed-up on in April 2024 because the lump turned out to be cancerous and could metastasize. LVN 5 stated when Resident 2’s cancer metastasized, the cancer could spread to other organs, be harder to treat, and could be fatal. LVN 5 stated Resident 2’s left breast lump required reassessment by the licensed nurses. LVN 5 stated the assigned licensed nurses to Resident 2 needed to call MD 1 to report Resident 2’s left breast lump and obtain the necessary orders to care and/or treat Resident 2’s left breast lump.      During a telephone interview on 11/6/2024 at 9:08 am, LVN 6 stated (in general) when completing change in resident condition monitoring, when he did not see any new orders or progress notes indicating new orders from the resident’s physician, he would need to follow-up and call the physician immediately to see if orders were needed to ensure appropriate care and treatment were provided and the best possible prognosis of the change in condition was possible. LVN 6 stated Resident 2 complained that the Resident 2’s left breast lump hurt (unable to specify date and time). LVN 6 stated it was important for staff to communicate and follow-up with MD 1 regarding Resident 2’s left breast lump so orders and referrals could have been made for Resident 2. LVN 6 stated Resident 2 could have been assessed by MD 1 in April 2024 and there would have been no delay in care.     During a concurrent telephone interview and record review on 11/6/2024 at 12:03 pm, LVN 6 reviewed Resident 2’s PO dated 4/17/2024 to 4/20/2024 and 4/25/2024. Resident 2’s PO dated 4/17/2024 to 4/20/2024, indicated no transcribed telephone order from MD 1 for Resident 2’s mammogram to both breasts as indicated on Resident 2’s CIC Evaluation dated 4/17/2024. LVN 6 stated he documented a telephone order from MD 1 on 4/25/2024 at 12:31 pm, for Resident 2 to have a mammogram to both breasts. LVN 6 stated LVN 1 instructed him to transcribe the mammogram order because MD 1 requested the mammogram, so LVN 6 made the physician order. LVN 6 stated he could not remember if he notified the Social Services Director (SSD) to arrange and schedule Resident 2’s mammogram appointment. LVN 6 stated notifying the SSD regarding Resident 2’s mammogram order was important so the SSD could arrange and schedule an appointment for Resident 2. LVN 6 stated he did not notify MD 1 regarding Resident 2’s left breast lump and did not obtain the mammogram order directly from MD 1 on 4/25/2024.      During a concurrent interview and record review on 11/6/2024 at 12:55 pm, MD 1 reviewed Resident 2’s Physici