Health inspection·July 5, 2023

F656- §483.21(b) 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.

F658- §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

F580-§483.10(g)(14) Notification 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 life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or T22 CCR § 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. (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (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. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). § 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. D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. 42 CFR § 483.10 (g) (14) Notification of Changes (i) A facility must immediately inform the patient; consult with the patient’s physician; and notify, consistent with his or her authority, the patient representative(s) when there is, (B) A significant change in the patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. 42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices. On 5/16/23 at 9:08 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation regarding patient neglect, quality of care, and quality of life. As a result of the investigation, CDPH determined that the facility failed to: 1. Notify Patient 1’s primary physician (PHY1) to obtain an order to transfer Resident 1 to the GACH and/or obtain an order for a Nurse Practitioner or Physician Assistant to re-insert the GT or obtain an order to contact the GT services in accordance with the facility’s policy after Resident 1’s GT was dislodged. 2. Ensure the Director of Nursing (DON) verified and confirmed with PHY 1 if an indwelling catheter tube (a rubber tube inserted into the bladder to drain urine) may be inserted into the new surgical GT stoma site (opening) after Patient 1’s GT was dislodged in accordance with the professional standards of practice. 3. Ensure the DON did not insert an indwelling catheter in Patient 1’s new GT stoma (opening in the abdomen connected to the stomach or intestine) without sufficient training and competency to reinsert the indwelling catheter on the GT stoma without a physician’s order. 4. Ensure the DON, the Licensed Vocational Nurses (LVN 1 and LVN 2) and Registered Nurse 2 (RN 2) did “not to flush” the patient’s indwelling catheter tube with water/liquid, enteral feeding (a form of nutrition that is delivered into the digestive system/stomach as a liquid) and administer medications to Patient 1 via indwelling catheter after the tube was inserted in accordance with the faiclity’s policy and procedure [TITLE OF PNP AND DATE]. 5. Ensure a plan of care was developed to indicate interventions to be implemented on how to address or handle Patient 1’s GT site in the event the GT becomes dislodged. 6. Ensure the facility’s policy and procedure on “Gastrostomy Tube Re-insertion) was updated based on the current standards of practice regarding GT dislodgement, specifically addressing a newly inserted GT. As a result of these deficient practice, on 4/14/23 at 6:45 AM, (approximately 21 hours after the GT was dislodged) Patient 1 was found unresponsive by facility staff with an oxygen saturation (level of oxygen in the blood) of 40% (normal level 90-100%), and no blood pressure (a pressure of the blood in the circulatory system). CPR (Cardiopulmonary Resuscitation – an emergency procedure consists of chest compression and artificial and artificial ventilation to preserve brain function, breathing and blood circulation to the body) was started by the facility staff and 911 emergency services was called. Patient 1 was pronounced dead by the paramedics at 7:40 AM on 4/14/23. A review of the Death Certificate, indicated Patient 1 expired on 4/14/23, with the cause of death as atherosclerotic heart disease (hardening of the arteries in the heart that results in the narrowing and blockage in the heart). A review of an admission record indicated Patient 1 was a 75 year old male, admitted to the facility on 9/20/1991 and re-admitted on 4/12/2023, with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition (poor food intake), and disability), with GT and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Patient 1’s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/13/2023, indicated Patient 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Patient 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the Physician’s Discharge Summary from the GACH (General Acute Care Hospital) record, indicated Patient 1 was admitted to the GACH on 4/8/23 due to failure to thrive (a condition of having poor appetite, poor nutrition, and fluid intake) and weakness, and was discharged to the facility on 4/12/23. The summary report indicated on 4/11/23 Patient 1 had an EGD (Endo gastroduodenoscopy- a procedure in which a tube is inserted into the mouth to visualize the gastrointestinal tract) and placement of the GT. The GACH Physician Discharge Summary Report, dated 4/12/23, indicated Patient 1 was clinically stable and improved with no signs and symptoms of respiratory distress (difficulty breathing), vital signs (measurement of the heart rate, blood pressure, body temperature) were stable and was cleared for discharge. During a record review on 5/16/23 at 2:50 PM, Patient 1's Baseline Care Plan (initial care plan developed during admission), dated 4/12/2023, indicated Patient 1 had nutritional/fluid impairment (poor nutrition and fluid intake) and was placed on GT feeding. To ensure Patient 1 remained adequately nourished and hydrated (absorption of fluid) without unplanned weight loss, the facility would monitor the patient for aspiration (inhalation of fluid and food in the lungs) and tolerance to GT feeding. In a concurrent interview the DON verified that Patient 1’s care plan did not indicate nursing interventions on how to address or handle the patient’s GT site in the event the GT tube becomes dislodged. A review of Patient 1’s Change of Condition (COC) report, dated 4/13/2023, timed at 9 AM, indicated the Charge Nurse reported to the PHY1 that Patient 1 pulled out his GT. The COC indicated PHY1 ordered to re-insert the GT with an indwelling catheter PRN (as needed) while waiting for the GT to be replaced by the wound specialist. A review of Patient 1’s COC report, dated 4/14/2023, timed at 11AM, indicated (Registered Nurse 1) RN 1 made rounds (tour the facility) at 6:45 AM, and Patient 1 was found unresponsive, without vital signs, oxygen saturation was 40%, and CPR was started by the facility staff. The COC report indicated the paramedics arrived within ten minutes after the 911 emergency services were called, and took over the CPR, and placed telemetry (a heart monitoring by putting wires on the chest to detect the patient's heart activity) without result. Patient 1 was pronounced dead by the paramedics on 4/14/23, at 7:40 AM. During an interview with the DON on 5/16/2023 at 10:04 AM, the DON stated, she inserted an indwelling catheter into Patient 1’s GT stoma site, when the patient’s GT was found dislodged on 4/13/23. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician’s order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with Licensed Vocational Nurse (LVN) 1 on 5/16/2023 at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter when Patient 1’s GT became dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of 4/13/23 to have the Patient 1’s GT replaced after it had been dislodged, however the GT services were unable to see the patient until 4/14/23. During a concurrent interview and record review of the Medication Administration Record (MAR) on 5/16/2023 at 5 PM, LVN 1 stated after the indwelling catheter was inserted by the DON, he signed and confirmed that he started an infusion of Jevity 1.2 (a nutritional formula) 1.2 calorie (unit of energy) bolus feeding (instilling fluid in a fast rate) 400 cc (cubic centimeter-unit of measurement) bolus feeding to Patient 1 and flushed 30cc of water into the indwelling catheter tubing on 4/13/23 at 8 AM. During an interview with the DON and LVN 1 on 5/16/2023 at 5:54 PM and concurrent record review of the Physician’s Order Summary Report, dated from 4/12/23 to 4/14/23, the DON and LVN 1 validated there was no physician’s order to infuse a bolus feeding, nor administer medications, into Patient 1’s tubing after inserting the indwelling catheter into the GT stoma. During an interview with the DON and LVN 1 on 5/16/2023 at 5:55 PM and concurrent record review of the facility’s policy and procedure for reinsertion of a GT, (dated 1/24/2017) indicated the facility does not allow licensed nurses to re-insert gastrostomy tubes that become displaced or removed. The procedure indicated if a GT becomes dislodged, removed, or displaced, the GT site will be covered with a clean dressing. If the physician orders insertion of an indwelling catheter to keep GT orifice (opening) open, this will be done; however, no flushing or enteral feedings will be attempted/provided. During an interview on 5/16/23 at 5:57 PM, the DON stated, “It is a common sense” to continue the feeding without a physician’s order, because Patient 1 “will get hungry.” During an interview on 5/16/2023 at 7:01 PM, the DON stated, she did not have training or certification for inserting an indwelling catheter in the GT site because she has been a nurse for many years. The DON stated “I have been a DON for 20 years; you do not get certification for GT reinsertion. I went to nursing school and had continuous experience.” The DON was asked to demonstrate how to reinsert a GT, the DON refused and replied “That is an insult. I am not a new nurse.” The DON stated she flushed the indwelling catheter with 50 cc of water and aspirated (to draw in or out using a sucking motion) after she inserted the indwelling catheter on 4/13/23 at around 8AM to 9AM, but she does not recall how far she advanced the catheter tubing into Patient 1’s stomach and the placement was not verified by X ray. During an interview on 5/17/2023 at 9AM, PHY 1 stated, he was not notified when Patient 1’s GT was dislodged on 4/13/23. PHY 1 stated he did not place an order on 4/12/23 for the nurses to insert an indwelling catheter into the patient’s stoma, or flush with water/fluid, administer medications and bolus feeding into the tubing after it was dislodged. PHY 1 stated, if the GT was pulled out or became dislodged his standard order to the facility was to transfer the patient to the emergency room so that the patient can be seen by a gastroenterologist (a physician specialized in GT placement) and to have the GT reinserted safely and validate the GT placement by doing an X ray. PHY 1 stated the risk for inserting an indwelling catheter is the tubing could go to a different area of the stomach that could lead to peritonitis. During a telephone interview on 5/23/2023 at 12:17 PM, PHY1 stated he visited the facility to verify the physician’s notes and orders in Patient 1’s records. PHY1 stated the signature on Patient 1’s medical records under physician signature, dated 4/13/23 was not his signature. PHY1 stated the facility did not notify him of any change of condition of Patient 1. PHY 1 stated he has a call forwarding service set up if facility calls his office during early morning or night hours, the calls are forwarded to his number so that he was notified immediately if there was a message or call. During an interview on 5/26/23 at 1:30 PM, and concurrent record review PHY 1’s Order Summary dated 4/12/23-4/14/23, PHY 1 verified he did