Health inspection·March 27, 2025

Code of Federal Regulations, Title 42, Section §483.50(a)(1) Laboratory Services The facility must ensure that- §483.50(a)(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. 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 72301 §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. California Code of Regulations, Title 22, Section 72311 §72311. Nursing Service-General (a) Nursing service shall include, but not limited to, the following: (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. On 1/28/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment. As a result of the investigation, the CDPH determined the facility failed to provide laboratory services (the collection, testing. and analysis of a patient's specimen [such as blood, urine or stool] for health-care professionals to make decisions on the diagnosis and treatment of their patients for Resident 2 as indicated in the facility's policy and procedures (P&P) titled, "Lab and Diagnostic Test Results - Clinical Protocol," The facility failed to: Ensure assigned licensed nurses (LNs) carried out (to do or complete) Resident 2’s Physician Order (PO) by Medical Doctor (MD) 1, dated 1/8/2025, for a urine analysis (UA- test of the urine) with culture and sensitivity (C&S- a laboratory test that identifies the presence of bacteria or other microorganisms in a sample and determines which antibiotics are effective in treating the infection) after the discontinuation of Resident 2's medication ceftazidime-avibactam (Avycaz- antibiotic used to treat a wide variety of bacterial infections). This violation resulted in Resident 2 not receiving the needed antibiotics therapy to treat Resident 2's UTI from 1/8/2025 to 1/12/2025. On 1/13/2025, at 1:40 pm, Resident 2 experienced altered mental status (AMS- change in a person's level of consciousness, awareness, or cognitive function [ability to think, process information and make decisions] and was transferred to the General Acute Care Hospital (GACH) 1 for further evaluation and treatment. A review of Resident 2's Admission Record indicated the facility admitted Resident 2, a 76-year-old man on 1/7/2025, with diagnoses that included UTI and carrier of Carbapenem-resistant Enterobacterales (CRE- a group of bacteria that are resistant to certain antibiotics and can cause serious infections). A review of Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order to discontinue Avycaz intravenous (IV- a method of delivering fluids or medicine directly into a vein using a needle or tube) solution 2.5 gram (gm- unit of measurement) every eight (8) hours on 1/8/2025, and to repeat urinalysis with C&S on 1/9/2025. A review of Resident 2's PO, dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S on 1/9/2025 (indication was not specified). A review of Resident 2's PO dated 1/12/2025, indicated Resident 2 had an order to collect urinalysis due to (Resident 2's) confusion. A review of Resident 2's PO dated 1/13/2025, indicated Resident 2 had an order to transfer Resident 2 to GACH 1 for AMS. A review of Resident 2's Transfer Form (TF- Transfer to Hospital Form) dated 1/13/2025, timed at 11:27 am, the TF indicated Resident 2 was noted with AMS and would be transferred to GACH 1. A review of Resident 2's Progress Notes (PN) dated 1/13/2025, timed at 1:40 pm, the PN indicated Resident 2 was transferred to GACH 1 due to AMS. A review of Resident 2's GACH 1 Emergency Department Provider Note (EDPN) dated 1/13/2025, timed at 2:01 pm, the EDPN indicated Resident 2 was brought in by emergency medical services due to increased confusion and abnormal laboratory test results. The EDPN indicated Resident 2 was sent to GACH 1 to determine alternative antibiotic to treat Resident 2's UTI. The EPDN indicated Resident 2 was started on Avycaz and discharged from GACH 1 on 1/7/2025 to Skilled Nursing Facility (SNF) to continue the antibiotics therapy Avycaz. The EDPN indicated due to the high cost of the antibiotics, SNF 1 had not given Resident 2 Avycaz since Resident 2 was discharged from GACH 1 to SNF 1. The EDPN indicated MD 1 would coordinate with SNF 1 to ensure Resident 2 received the antibiotics Avycaz at SNF 1. A review of Resident 2's GACH 1 Triage (process by which care providers such as medical professionals determine the order of priority for providing treatment) Note ED (TNED), dated 1/13/2025, timed at 2:15 pm, indicated Resident 2 was brought in by ambulance for increased confusion that started yesterday (1/12/2024), with elevated white blood cells (cells in the blood that indicate if an infection is present), and UTI. During a concurrent interview and record review on 1/29/2025 at 1:21 pm with RN 1, Resident 2's PN from 1/8/2025 to 1/12/2025 and active PO dated 1/8/2025 were reviewed. The PO dated 1/8/2025 indicated for facility staff to obtain a urinalysis with C&S for Resident 2 on 1/9/2025. Resident 2's PN from 1/8/2025 to 1/12/2025 indicated no documentation facility staff attempted to carry out Resident 2's physician order to obtain a urinalysis with C&S on 1/9/2025. RN 1 stated Resident 2 was admitted to the facility on 1/7/2025 for IV antibiotics Avycaz therapy. RN 1 stated RN 1 was Resident 2's admitting nurse. RN 1 stated if MD 1 ordered laboratory tests (labs) for Resident 2, the order needed to be carried out "as soon as possible." RN 1 stated there was no documentation in Resident 2's PN indicating Resident 2's urine sample was collected/obtained for the urinalysis with C&S as indicated in Resident 2's physician order. RN 1 stated Resident 2 had a delay in care and services and/or treatment for Resident 2's UTI (from 1/8/2025 to 1/12/2025) when services were not provided as ordered. During a concurrent telephone interview and record review on 1/29/2025 at 3:59 pm with MD 1, Resident 2's PO dated 1/8/2025 was reviewed. MD 1 stated Resident 2 was admitted to the facility for treatment of Pseudomonas-resistant bacteremia (bacteria in the blood). MD 1 stated MD 1 ordered another urinalysis with C&S the day MD 1 discontinued the Avycaz on 1/8/2025 due to the high cost of the medication Avycaz. MD 1 stated MD 1 ordered another urinalysis with C&S on the same day (1/8/2025) to see if another antibiotic would be effective. MD 1 stated Resident 2 did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI from 1/8/2025 through 1/12/2025 and until 1/13/2025, when Resident 2 was transferred to GACH 1 for AMS. MD 1 stated AMS was a symptom of infection. MD 1 stated Resident 2 was readmitted to SNF 1 on 1/13/2025 with another order for Avycaz to be given until 1/16/2025. MD 1 stated if MD 1 ordered labs, the labs needed to be obtained as soon as possible so they (MD 1 and facility staff) could appropriately treat residents. MD 1 stated not obtaining Resident 2's urine sample for urinalysis with C&S as soon as possible caused a delay in Resident 2's care which resulted in Residents 2's rehospitalization (readmitted to the hospital for a second time). During a concurrent interview and record review on 1/30/2025 at 11:10 am with LVN 1, Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. LVN 1 stated Resident 2's care was "not up to par," and Resident 2 did not receive the needed antibiotics Avycaz to treat Resident 2's UTI. During an interview and record review on 1/30/2025 at 11:39 am with the Director of Nursing (DON), Resident 2's PO dated 1/8/2025 was reviewed. Resident 2's PO dated 1/8/2025, indicated Resident 2 had an order for urinalysis with C&S to be obtained on 1/9/2025. The DON stated when MD 1 ordered a urine sample for urinalysis with C&S to be obtained on 1/9/2025, the urine sample needed to be collected that day (1/9/2025), so there was no delay in care. The DON stated Resident 2 experienced a delay in care (did not receive IV antibiotics for 5 days [1/8/25 to1/12/25]) because Resident 2's urinalysis with C&S was not carried out as ordered by MD 1. The DON stated as a result of missing Resident 2's urinalysis with C&S, Resident 2 did not receive any other treatment for Resident 2's UTI. A review of the facility's P&P titled, "Lab and Diagnostic Test Results - Clinical Protocol," revised 11/2018 (most updated), indicated, “The physician will identify and order diagnostic and lab testing on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests”. The P&P indicated, "A nurse will try to determine whether the test was done ...as a routine screen or follow-up ..." The facility failed to: Ensure assigned LNs carried out Resident 2’s PO by MD 1, dated 1/8/2025, for a UA with C&S after the discontinuation of Resident 2's medication Avycaz. This violation resulted in Resident 2 not receiving the needed antibiotics therapy to treat Resident 2's UTI from 1/8/2025 to 1/12/2025. On 1/13/2025, at 1:40 pm, Resident 2 experienced AMS and was transferred to the GACH 1 for further evaluation and treatment. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2.