Other·January 12, 2024

Code of Federal Regulations, Title 22, Section § 72301. Required Services. (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. (g) The facility shall make arrangements for a physician or physicians to be available to furnish emergency medical care if the attending physician, or designee, is unavailable. The telephone numbers of those physicians shall be posted in a conspicuous place in the facility. Code of Federal 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. Code of Federal Regulations, Title 22, Section 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. F684 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. On 11/28/2024 at 11:45 a.m., The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality care and treatment services. As a result of the investigation, the Department determined the facility failed to provide nursing care and services for Resident 1 by failing to: 1. Ensure Registered Nurse (RN) 2 "reconciled (comparing a resident's medication orders to the medications he/she has been taking to avoid medication errors) Resident 1's insulin [medication used to help the body turn food into energy and control blood-sugar/glucose (BS) levels] and tacrolimus (medication used to prevent the body from rejection organ-transplant/replacement) per Resident 1's physician orders when Resident 1 was readmitted from General Acute Care Hospital (GACH) 1 to the facility on 11/22/2023. 2. Ensure Resident 1's Primary Care Physician (MD) 1 and Nurse Practitioner (NP) 1 reviewed Resident 1's Discharge Summary for medications ordered from GACH 1 on 11/22/2023. As a result of these failures, Resident 1 did not receive insulin aspart (rapid-acting insulin that helps lower mealtime blood-sugar spikes) per sliding scale (varies the dose of insulin based on the BS level prior to insulin administration, the higher the BS level, the higher the insulin dose) nor tacrolimus from 11/22/2023 to 11/29/2023 (eight days) and Resident 1 had light-headedness. a. A review of Resident 1’s Admission Record indicated the facility admitted a 59-year-old female on 3/28/2022 and readmitted on 11/22/2023 with diagnoses including type 2 diabetes mellitus (DM 2, a chronic condition that affects the way the body processes blood sugar [glucose]), kidney transplant status, and pancreas transplant status. A review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 9/26/2023, the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required supervision with bed mobility and eating. The MDS indicated Resident 1 required limited assistance with transfers, locomotion, dressing, toilet use, and personal hygiene. A review of Resident 1’s telephone order dated 11/16/2023 at 4:35 pm indicated to transfer Resident 1 to GACH 1 for evaluation and treatment of back pain and burning upon urination. A review of Resident 1's Patient Visit Information (Discharge Summary [D/C Summary, a clinical report prepared by a health professional at the conclusion of a hospital stay]) from GACH 1, dated 11/22/2023, indicated Resident 1 was discharged from GACH 1 back to the facility on 11/22/2023 and the discharge action plan included to continue insulin aspart U-100 sliding scale. The D/C Summary indicated blood-sugar level would be obtained prior to insulin dose (if needed) by finger stick (prick on the side of the finger with a needle to test blood-sugar levels). The D/C Summary indicated insulin would be administered per the sliding scale based on Resident 1's BS level. The D/C Summary indicated the amount of insulin to be given to Resident 1 was based on Resident 1's BS at the time of finger stick. The D/C Summary indicated to continue tacrolimus 1 mg (daily) and tacrolimus 2 mg (daily at bedtime). A review of Resident 1's Admission Assessment (AA), dated 11/22/2023 at 11:58 pm, indicated Resident 1 was admitted back to the facility on 11/22/2023 at 8 pm. The AA indicated RN 2 signed the AA. During an interview on 11/29/2023 at 11:55 am, with Resident 1, Resident 1 stated Resident 1 had not received insulin medication for a week. Resident 1 stated it was possible Resident 1 had not received other medications. Resident 1 stated insulin had not been given to Resident 1 and Resident 1's BS had not been checked since Resident 1 was readmitted to the facility on 11/22/2023. Resident 1 stated Resident 1 asked nursing staff (unable to identify) about Resident 1's insulin but staff told Resident 1 the insulin order was discontinued. Resident 1 stated it was confusing because Resident 1 was receiving insulin before being hospitalized and Resident 1 had DM 2. Resident 1 stated Resident 1 got lightheaded a few days prior to today (11/29/2023). Resident 1 stated staff gave Resident 1 juice but did not check Resident 1's BS level. Resident 1 stated Resident 1 felt "brushed off" by staff when asking about not receiving insulin or BS checks. Resident 1 stated "it felt like staff were not taking Resident 1's concerns seriously." Resident 1 stated Resident 1 was "worried something bad would happen" to Resident 1 because Resident 1's BS was not being monitored. During a concurrent interview and record review on 11/29/2023 at 12:47 pm, with the MDS Nurse (MDSN), Resident 1's Order Summary Report (OSR), dated 11/29/2023 was reviewed. The D/C Summary indicated to continue insulin aspart U-100 sliding scale and tacrolimus 1 mg (daily) and tacrolimus 2 mg (daily at bedtime). The MDSN stated Resident 1 did not have an active order for insulin per sliding scale and tacrolimus. The MDSN stated Resident 1's physician’s order for insulin per sliding scale and tacrolimus 1 mg daily plus tacrolimus 2 mg at bedtime were discontinued (unable to provide the MD order who discontinued the insulin per sliding scale order) on 11/22/2023. During a concurrent interview and record review on 11/29/2023 at 1 pm, with RN 1, Resident 1's D/C Summary, dated 11/22/2023 and the Medication Administration Record (MAR), dated November 2023 were reviewed. Resident 1's D/C Summary indicated for Resident 1 to continue to receive the insulin aspart per sliding scale: Inject as per sliding scale: 0 - 150 millimoles per liter (mmol/L, a unit of measurement)= 0 unit (no coverage), if BS is less than 70, give 8 ounces (OZ, unit of volume) of orange juice and notify the MD. 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. If BS is above 400, give 12 units and notify MD and tacrolimus 1 mg daily and 2 mg at bedtime. RN 1 stated when Resident 1 was readmitted to the facility on 11/22/2023 Resident 1's GACH 1 D/C Summary indicated to continue insulin aspart per sliding scale. RN 1 stated Resident 1's MAR did not indicate insulin aspart was administered per sliding scale to Resident 1 from 11/22/2023 to 11/29/2023 (eight days). RN 1 stated Resident 1 was currently not on any insulin medication since being readmitted to the facility on 11/22/2023 as indicated by the "x" marks on Resident 1's MAR. RN 1 stated Resident 1 had not been monitored for Resident 1's BS since Resident 1 was readmitted to the facility on 11/22/2023, as indicated by the "x" marks on Resident 1's MAR. The D/C Summary indicated to continue tacrolimus 1 mg (daily) and tacrolimus 2 mg (daily at bedtime). RN 1 stated tacrolimus was a transplant anti-rejection medication. RN 1 stated tacrolimus was a vital medication to Resident 1's medical condition. RN 1 stated tacrolimus stopped Resident 1's body from rejecting Resident 1's transplanted organs. RN 1 stated Resident 1's MAR did not indicate tacrolimus was administered to Resident 1 from dates 11/22/2023 to 11/29/2023 (eight days). During a concurrent telephone interview and record review on 11/29/2023 at 4:40 pm, with NP 1, NP 1 reviewed Resident 1's GACH 1 D/C Summary, dated 11/22/2023. NP 1 stated NP 1 took (accepted) Resident 1's admitting orders on 11/22/2023. NP 1 stated NP 1 was not aware Resident 1 was taking insulin nor tacrolimus. During a concurrent interview and record review on 11/29/2023 at 5:30 pm, with Medical Records Staff (MRS), MRS stated Resident 1 did not have any new orders for insulin aspart per sliding scale nor tacrolimus since Resident 1's readmission to the facility on 11/22/2023. During an interview on 11/29/2023 at 6:10 pm, with the Director of Nursing (DON), the DON stated when residents (in general) return from GACH, the nurses need to look at the residents' D/C Summary. RN 1 stated Resident 1's nurse should have called MD 1 to reconcile medications that needed to be restarted based on the GACH 1's D/C Summary list. The DON stated if medications are not reconciled with MD 1, it was possible RN 2 missed the reconciliation. The DON stated, if Resident 1 told Resident 1's nurse that Resident 1 did not receive certain medications, Resident 1’s nurse should have reviewed the D/C Summary and compared the D/C Summary to Resident 1's OSR, MAR, and called MD 1 to ask about the missing medication. During a telephone interview on 11/30/2023 at 9:02 am, with RN 2, RN 2 stated RN 2 readmitted Resident 1 back to the facility and completed the AA. RN 2 stated the MDSN assisted RN 2 with Resident 1's readmission by taking report from GACH 1. RN 2 stated RN 2 did not see sliding scale parameters for the insulin order. RN 2 stated not receiving tacrolimus was life-threatening to Resident 1. b. A review of Resident 1's AA, dated 11/22/2023 at 11:58 pm, indicated RN 2 notified MD 1 at 9 pm that Resident 1 was readmitted back to the facility. The AA indicated RN 2 signed Resident 1's AA. During a concurrent telephone interview and record review on 11/29/2023 at 4:40 pm, with MD 1 and NP 1, MD 1 and NP 1 reviewed Resident 1's GACH 1 D/C Summary, dated 11/22/2023. NP 1 stated NP 1 was not aware Resident 1 was not taking insulin nor tacrolimus. NP 1 stated NP 1 informed the facility nurse (unable to identify) to resume Resident 1's previous medications. NP 1 stated there were communications with the facility nurses about tacrolimus and insulin, but NP 1 did not have evidence of such communications. NP 1 stated Resident 1 was assessed by NP 1 on 11/23/2023, but NP 1 did not review Resident 1's MAR nor GACH 1’s D/C Summary. MD 1 stated MD 1 had too many "patients" to keep track of and expected the facility to continue all medications indicated in the "hospital" D/C Summary. A review of the facility's policy and procedure (PP) titled, "Reconciliation of Medications on Admission," revised 7/2017, the PP indicated the facility would ensure medication safety by accurately accounting for the resident's medications routes and dosages upon admission or readmission to the facility. The PP indicated to prepare by gathering the approved medication reconciliation form, D/C Summary from the referring hospital, and most recent MAR if the resident was being readmitted. The general guidelines in the PP indicated that medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care, and medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. The PP indicated to review the list carefully to determine if there were discrepancies/conflicts. The PP indicated if there was a discrepancy or conflict in medications to contact the nurse or physician from the referring facility, discuss with the resident or family, and contact the admitting physician. The PP indicated to document the medication discrepancy on the medication reconciliation form, document what actions were taken by the nurse to resolve the discrepancy and how the discrepancy was communicated to the charge nurse, physician, pharmacy and/or next shift. During a review of the facility's PP titled, "Admission Assessment and Follow Up: Role of the Nurse," revised 9/2012, the PP indicated to reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution. During a review of the facility's PP titled, "Admission Criteria," revised 3/2023, the PP indicated the facility admits residents who had medical and nursing care needs can be met. The PP indicated prior or at the time of admission, the resident's attending physician provide the facility with information needed for the immediate care of the resident, including orders covering medication orders. As a result of the investigation, the Department determined the facility failed to provide nursing care and services for Resident 1 by failing to: 1. Ensure RN 2 reconciled Resident 1's insulin and tacrolimus per Resident 1's physician orders when Resident 1 was readmitted from GACH 1 to the facility on 11/22/2023. 2. Ensure MD 1 and NP 1 reviewed Resident 1's Discharge Summary for medications ordered from GACH 1 on 11/22/2023. As a result of these failures, Resident 1 did not receive insulin aspart per sliding scale nor tacrolimus from 11/22/2023 to 11/29/2023 and Resident 1 had light-headedness. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.