Health inspection·January 23, 2025

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. 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. 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. 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 12/24/2024 at 11:57 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care/treatment and resident neglect. As a result of the investigation, the CDPH determined the facility failed to monitor the blood sugar levels of Resident 4, who was diabetic (someone with diabetes, also known as diabetes mellitus, a chronic condition that affects how the body uses glucose [sugar] for energy) as indicated in the facility’s policies and procedures (P&P). This deficient practice resulted in Resident 4 being hospitalized on 12/23/2024 for diabetic ketoacidosis (DKA, a serious complication of diabetes in which acids build up in the blood to levels that can be life-threatening) with a critical high blood sugar level of 712 (normal range between 70 milligrams per deciliter (mg/dL, unit of measurement) and 100 mg/dL). A review of Resident 4's "Admission Record," indicated the facility admitted Resident 4, a 77-year-old female, on 12/21/2024. A review of Resident 4’s Discharge to SNF (Skilled Nursing Facility) Summary and Transfer Orders (Transfer Orders),” dated 12/21/2024, the Transfer Orders indicated Resident 4 was a type 1 diabetic (a type of diabetes where the pancreas does not make insulin [hormone that regulates blood sugar levels] or makes very little insulin) who had a past medical history of using an insulin pump (a small, portable device that delivers insulin continuously throughout the day to people with type 1 diabetes). The "Transfer Orders" indicated to continue "OneTouch Delica Plus Lancet (a device which pricks the finger to obtain a drop of blood for testing blood sugar) ... Use 4 times a day as directed to test blood sugar ...” and “OneTouch Verio test strips… Check your blood sugar 4 times a day.” A review of Resident 4's "LTC (Long Term Care) Skilled Admission History & Physical (H&P)," dated 12/22/2024, indicated Resident 4 had diagnoses including type 1 diabetes and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The "H&P" indicated Resident 4 had a history of using an insulin pump to control her blood sugar levels. The H&P indicated Resident 4 had decision making capacity. A review of Resident 4’s “Progress Notes (PN),” dated 12/23/2024, timed at 6:36 p.m., indicated Medical Doctor (MD) 1 called and ordered to check Resident 4’s blood sugar. The “PN” indicated Resident 4’s blood sugar was 420 mg/dL and staff reported blood sugar level and hyponatremia (low blood sodium level) of 127 to MD 1. The “PN” indicated MD 1 ordered to give Resident 4 regular insulin 10 units one time and check Resident 4’s blood sugar after 30 minutes. The “PN” indicated MD 1 ordered to send Resident 4 to General Acute Care Hospital Emergency Department (GACH 1 ED) for evaluation. A review of Resident 4’s “PN,” dated 12/23/2024, timed at 7:10 p.m., indicated Resident 4’s blood sugar was 400 mg/dL when rechecked. The “PN” indicated Resident 4 would be transferred to the hospital (GACH 1). A review of Resident 4’s “ED to Hosp-Admission,” from GACH 1 dated 12/23/2024, timed at 9:47 p.m., indicated Resident 4 presented to GACH 1 ED via ambulance transport for hyperglycemia and abnormal blood test. The “ED to Hosp-Admission” indicated GACH 1 ED provider documented Resident 4 had been admitted to the SNF over the weekend without any insulin orders or blood sugar level checks. The “ED to Hosp-Admission” indicated a provider (unidentified) called the SNF and spoke to the DON to check Resident 4’s blood sugar level and to transfer Resident 4 to GACH ED to rule out DKA. The “ED to Hosp-Admission” indicated Resident 4’s blood sugar level was 420 when the DON checked. A review of Resident 4’s “ED Provider Note (ED PN),” dated 12/23/2024, timed at 11:46 p.m., indicated Resident 4’s blood sugar level was 712 mg/dL at 10:18 p.m. The “ED PN” indicated Resident 4 presented with hyperglycemia (high blood sugar) versus DKA and had not had any insulin in the last 48 hours per records. The “ED PN” indicated Resident 4 was resting comfortably on examination and remained stable. During a concurrent interview and record review on 12/24/2024 at 11:57 a.m. with the Director of Nursing (DON), Resident 4's "Discharge to SNF (Skilled Nursing Facility) Summary and Transfer Orders (Transfer Orders)," dated 12/21/2024 was reviewed. The "Transfer Orders" indicated Resident 4 was a type 1 diabetic who had a history of using an insulin pump. The DON stated Resident 4 did not have an insulin pump while she was residing at the facility. The "Transfer Orders" indicated to continue "OneTouch Delica Plus Lancet... Use 4 times a day as directed to test blood sugar ..." The DON stated the facility staff did not continue the order to check Resident 4's blood sugar 4 times a day as indicated on the "Transfer Orders." The DON stated facility staff were not monitoring Resident 4's blood sugar levels. The DON stated Resident 4’s doctor (unidentified) called the DON on 12/23/2024 because Resident 4’s doctor had been reviewing Resident 4’s laboratory results (unspecified). The DON stated Resident 4’s doctor instructed the DON to check Resident 4’s blood sugar level. The DON stated Resident 4’s blood sugar level was 420 mg/dL at 6:20 p.m. The DON stated Resident 4’s doctor ordered to give 10 units of insulin to Resident 4 and transfer Resident 4 to General Acute Care Hospital (GACH 1). During a telephone interview on 12/24/2024 at 12:55 p.m. with Resident 4's daughter (FM 1), FM 1 stated Resident 4 had been a type 1 diabetic for 57 years. FM 1 stated Resident 4 was currently at GACH 1. FM 1 stated Resident 4's blood sugar level was in the 700s when Resident 4 was transferred from the facility to GACH 1 on 12/23/2024. FM 1 stated the facility was not managing Resident 4's blood sugar. FM 1 stated before Resident 4 was admitted to the facility (on 12/21/2024), GACH staff were checking Resident 4's blood sugar and giving Resident 4 insulin. During a concurrent interview and record review on 12/24/2024 at 2 p.m. with the DON, Resident 4's "Transfer Orders," dated 12/21/2024 was reviewed. The "Transfer Orders" indicated Resident 4 was a type 1 diabetic. The DON stated the DON processed the "Transfer Orders" on 12/21/2024 when Resident 4 was admitted to the facility. The DON stated the DON noticed Resident 4 was a type 1 diabetic. The DON stated all residents with type 1 diabetes needed to have their blood sugar levels monitored. The DON stated the blood sugar levels needed to be checked at least twice a day. The DON stated the DON did not have a discussion with Resident 4's physician to ask the physician for an order to monitor Resident 4's blood sugar levels. The DON stated not monitoring type 1 diabetic residents' blood sugar levels was dangerous to the health of the residents. A review of Resident 4’s “Discharge Summary Note,” dated 12/26/2024 indicated, Resident 4 was admitted to GACH on 12/23/2024 for type 1 diabetes with DKA. The “Discharge Summary Note” indicated following admission, Resident 4 was started on insulin drip DKA protocol (initiating a continuous intravenous insulin infusion, with frequent blood glucose monitoring and adjustments to the infusion rate as needed to achieve a gradual decline in blood glucose levels) and was transitioned to Lantus 10 units subcutaneous injection every night at bedtime. A review of the facility's P&P titled, "Diabetes - Clinical Protocol," revised November 2020, indicated, "For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment ...Resident's blood sugar history over 48 hours ..." The P&P indicated, "For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch and as necessary); monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin ..." A review of the facility's P&P titled, " Admission Assessment and Follow Up: Role of the Nurse," revised September 2012, indicated, "…Reconcile the list of medications from the medication history, admitting orders, the previous MAR (Medication Administration Record) (if available), and the discharge summary from the previous institution, according to established procedures… The P&P indicated, “Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings.” A review of Centers for Disease Control and Prevention (CDC) article titled “Diabetic Ketoacidosis,” dated May 15, 2024, indicated, “DKA is a serious complication of diabetes that can be life-threatening. DKA is most common among people with type 1 diabetes. The article indicated, “DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy… Very high blood sugar and low insulin levels lead to DKA… DKA is a serious condition, but you can take steps to help prevent it: Check your blood sugar often, especially if you're sick. Keep your blood sugar levels in your target range as much as possible… (https://www.cdc.gov/ diabetes/about/diabetic-ketoacidosis.html).” The facility failed to monitor the blood sugar levels of Resident 4, who was diabetic, as indicated in the facility’s policies and procedures. This deficient practice resulted in Resident 4 being hospitalized on 12/23/2024 for DKA with a critical high blood sugar level of 712 mg/dL. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.