Health inspection·July 30, 2024

Code of Federal Regulations, Title 42, Section 483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident— §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; California Code of Regulations, Title 22, Section 72315. Nursing Service – Patient Care. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. California Code of Regulations, Title 22, Section 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (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 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 6/14/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment. As a result of the investigation, CPDH determined that the facility failed to provide adequate hydration for Resident 1 as indicated in Resident 1's untitled Care Plan (CP) dated 5/16/2024, and the facility's policy and procedure (P&P) titled, "Hydration Management," and "Intake and Output." The facility failed to: 1. Ensure Resident 1's assigned Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) provided Resident 1 with adequate fluids to meet Resident 1's estimated fluid requirement of 1950 milliliters (mL) to 2040 mL per day as assessed by Registered Dietician (RD) 1 from 5/21/2024 to 6/1/2024. 2. Ensure CNA 1, LVN 1, and LVN 2 monitored Resident 1's intake and output. 3. Ensure LVN 1 notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 2) promptly when LVN 1 noted Resident 1 "struggled” to drink fluids on his own and needed encouragement with drinking fluids. 4. Ensure LVN 1 and LVN 2 communicated with MD 2 to obtain a physician's order for monitoring Resident 1's intake and output. These violations resulted in Resident 1 experiencing altered level of consciousness (ALOC) and difficulty to arouse on 6/1/2024 at 4 pm. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 6/1/2024 at 5:55 pm for further evaluation/treatment and was diagnosed with hypernatremia (high concentration of sodium in the blood and occurs with inadequate fluid intake and or increased water loss) most likely from dehydration (a harmful reduction in the amount of water in the body), uremia (a condition involving abnormally high levels of waste products in the blood), and Acute Kidney Injury (AKI- when kidneys suddenly stop working properly). A review of Resident 1's Admission Record, indicated the facility initially admitted Resident 1, a 74-year-old male, on 4/18/2024, and readmitted Resident 1 on 5/16/2024, with diagnoses that included dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), unspecified chronic kidney disease (damage to the kidneys resulting to the inability of the kidneys to filter blood the way the kidneys should), and abnormalities of gait and other mobility. A review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 4/22/2024, indicated Resident 1 had severely impaired cognition. The MDS indicated, Resident 1 was independent with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance with upper body dressing, putting and taking off footwear, rolling left and right in bed, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. The MDS indicated Resident 1 required partial/moderate assistance with toileting hygiene and showering/bathing self. A review of Resident 1's General Chemistry laboratory results dated 5/15/2024, indicated Resident 1's serum (blood) sodium (Na- amount of sodium [a mineral needed by the body to keep body fluids in balance] in the blood) level was 151 milliequivalents per liter (mEq/L) (Normal Na level is 135 mEq/L to 145 mEq/L). A review of Resident 1's Comprehensive Resident Assessment (CRA) dated 5/16/2024, indicated Resident 1 needed assistance with eating/nutrition and was dependent on staff for oral hygiene. A review of Resident 1's first untitled Care Plan (CP) dated 5/16/2024, indicated Resident 1 was at risk for dehydration. The first CP goal indicated facility staff would identify signs and symptoms (s/s) of dehydration such as dry eyes or mouth, fever, vomiting, urinary tract infection (UTI - infection in any part of the urinary tract, the system of organs that makes urine), poor skin turgor, change in mental status, and increased confusion. The first CP interventions indicated for staff to provide Resident 1's diet as ordered, assist Resident 1 at mealtime and with all food and fluid offerings, offer fluids during activities, and monitor Resident 1 for s/s of dehydration. A review of Resident 1's second untitled CP dated 5/16/2024, indicated Resident 1 had the potential for fluid-electrolyte imbalance related to hypernatremia. The second CP goal indicated Resident 1 would have no signs or symptoms of hypernatremia. The CP interventions for this goal indicated for staff to ensure adequate fluid intake, monitor intake and output, and give diet as ordered. A review of Resident 1's Physician Order dated 5/19/2024, contained an order for No Added Salt (NAS) diet, pureed texture, and nectar/mildly thick liquid consistency. A review of Resident 1's Registered Dietician Nutrition Risk Assessment (RDNRA) completed by RD 1 dated 5/21/2024, indicated Resident 1 was on nectar thick liquid consistency and drank 400 mL to 900 mL of fluids per day plus the water pitcher at bedside (specific amount not indicated). The RDNRA indicated Resident 1's estimated fluid needs per day were between 1950 mL to 2040 mL of fluids per day. The RDNRA indicated Resident 1's oral intake appeared adequate to meet Resident 1's estimated needs. The RDNRA further indicated RD 1's recommendation was to continue the current plan. A review of Resident 1's Order Summary Report (OSR) active as of 6/1/2024, indicated there was no order to monitor Resident 1's intake and output. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) dated 6/1/2024, untimed, documented Resident 1 had an altered level of consciousness. The SBAR further documented that Resident 1 had a heart rate of 28 beats per minute (bpm) (Normal heart rate is 60 bpm to 100 bpm) and his oxygen saturation (O2 sat- a measurement of oxygen level carried in the blood) was 72% (Normal oxygen saturation is 96 percent [%] to 100 %). The facility staff called 911 and Resident 1 was transferred to GACH 1. A review of Resident 1's GACH 1 Emergency Department Provider Note (EDPN) dated 6/1/2024, timed at 6:33 pm, indicated Resident 1 was brought in by ambulance with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and ALOC. The EDPN indicated Resident 1 had a serum Na level of 169 millimoles per liter (mmol/L). The EDPN indicated Resident 1 would be admitted to GACH 1 for diagnoses of hypernatremia most likely from dehydration, uremia, and acute kidney injury. During a telephone interview on 6/14/2024 at 11:22 am, Resident 1's Medical Doctor from GACH 1 (MD 1) stated Resident 1 was MD 1's patient while at GACH 1. MD 1 stated normal Na level was between 135 and 145 mmol/L. MD 1 stated when Resident 1 was admitted to GACH 1, Resident 1's Na level was 169 mmol/L. MD 1 stated, "that kind of Na level was a dangerously high level of Na" in Resident 1's blood. MD 1 stated Resident 1 was dehydrated, emaciated, unable to answer questions, and had altered mental status. MD 1 stated Resident 1 required aggressive intravenous (IV- soft, flexible tube placed inside a vein to administer fluids and medication directly into the bloodstream) fluid hydration. MD 1 stated Resident 1's Na level indicated to MD 1 that Resident 1 had not received adequate hydration and nutrition for at least a week. During a concurrent interview and record review on 6/14/2024 at 4:30 pm, the Director of Nursing (DON) reviewed Resident 1's second CP dated 5/16/2024, and the OSR with active date of 6/1/2024. The second CP's interventions required staff to ensure Resident 1 received adequate fluid intake, and to monitor Resident 1's intake and output. The OSR indicated there was no MD order to monitor Resident 1's intake and output. The DON stated when Resident 1's untitled CP indicated for staff to monitor intake and output, the staff needed to notify Resident 1's PP/MD 2 to obtain a physician order for "it (monitoring Resident 1's intake and output)." The DON stated there was no physician order to monitor Resident 1's intake and output. During a concurrent telephone interview and record review on 6/17/2024 at 11:27 am, RD 1 reviewed Resident 1's RD Nutrition Risk Assessment (RDNRA) dated 5/21/2024. The RDNRA indicated Resident 1 required 1950 mL to 2040 mL per day of fluids to maintain adequate hydration. RD 1 stated normal Na level was between 135-145 mmol/L. RD 1 stated when Resident 1's Na level was above 145 mmol/L, "it (the high level of Na)" could indicate Resident 1 was dehydrated. RD 1 stated based on Resident 1's RDNRA, Resident 1 required 1950 mL to 2040 mL per day of fluids to maintain adequate hydration. RD 1 stated when Resident 1 was not drinking Resident 1's estimated fluid needs, Resident 1 could become dehydrated and require hospitalization. RD 1 stated when Resident 1 was not meeting his estimated fluid needs, "it (the fact that Resident 1 did not drink 1950 mL to 2040 mL of fluid per day)" should be reported to the licensed nurses daily and reported to RD 1 and MD 2. RD 1 stated facility staff (CNAs and LVNs in general) did not inform RD 1 that Resident 1 was not drinking Resident 1's estimated fluid needs (1950 mL to 2040 mL of liquid) per day. During a follow-up and concurrent telephone interview and record review on 6/17/2024 at 12 pm, RD 1 reviewed Resident 1's medical record document titled, "Task: Nutrition - Fluids," dated 5/16/2024 to 6/1/2024. The "Task: Nutrition -Fluids," under "how much did the Resident drink in ml?" indicated the following: 1. On 5/16/2024: 120 mL. 2. On 5/17/2024: 350 mL. 3. On 5/18/2024: 440 mL. 4. On 5/19/2024: 930 mL. 5. On 5/20/2024: 840 mL. 6. On 5/21/2024: 360 mL. 7. On 5/22/2024: 360 mL. 8. On 5/23/2024: 420 mL. 9. On 5/24/2024: 180 mL. 10. On 5/25/2024: 340 mL. 11. On 5/26/2024: 500 mL. 12. On 5/27/2024: 530 mL. 13. On 5/28/2024: 360 mL. 14. On 5/29/2024: 200 mL. 15. On 5/30/2024: 700 mL. 16. On 5/31/2024: 280 mL. 17. On 6/1/2024: 600 mL. During a concurrent telephone interview and record review on 6/17/2024 at 12 pm, RD 1 stated according to Resident 1's documented "total fluid intake per day," Resident 1 did not meet Resident 1's required estimated fluid needs per day from 5/16/2024 to 6/1/2024. RD 1 stated RD 1 did not review Resident 1's documented fluid intake from 5/16/2024 to 5/21/2024 when RD 1 completed Resident 1's RDNRA on 5/21/2024. RD 1 stated RD 1 could have caught that Resident 1 was not drinking enough fluids and talked to the nursing staff and informed Resident 1's physician about "it (regarding Resident 1 did not consume enough fluid per day)." RD 1 stated dehydration could perpetuate conditions like urinary tract infection, sepsis (a life-threatening complication of an infection), and hypernatremia and could further damage Resident 1's kidneys. During an interview on 6/17/2024 at 1:36 pm, LVN 1 stated LVN 1 was unaware Resident 1 had a history of hypernatremia. LVN 1 stated Resident 1 needed encouragement to drink fluids because Resident 1 would "struggle" at times to drink on his (Resident 1's) own. LVN 1 stated LVN 1 was unaware of Resident 1's estimated fluid needs per day (between 1950 mL to 2040 mL of fluids per day) to maintain adequate hydration. LVN 1 stated LVN 1 did not notify RD 1 or MD 2 that Resident 1 needed encouragement and "struggled" to drink liquid at times. LVN 1 stated the CNAs were supposed to inform the LVNs when Resident 1 was not drinking enough or was having issues with drinking fluids. LVN 1 stated licensed nurses were supposed to ensure Resident 1 was drinking enough fluids before the end of their shift and report any issues to the on-coming shift. LVN 1 stated LVN 1 did not receive any reports from any CNAs about Resident 1 not drinking enough fluids to meet Resident 1's estimated fluid needs per day. During an interview on 6/17/2024 at 1:53 pm, LVN 2 stated LVN 2 was not aware Resident 1 had a history of hypernatremia. LVN 2 stated Resident 1 was "good at drinking fluids." LVN 2 stated CNAs documented Resident 1's total fluid intake per shift and not the LVNs. LVN 2 stated Resident 1 drank "well" but could not state how much Resident 1 usually drank in a day. LVN 2 stated LVN 2 did not remember Resident 1's estimated fluid needs per day. LVN 2 stated when Resident 1 was not meeting Resident 1's estimated fluid needs per day (between 1950 mL to 2040 mL of fluids per day), LVN 2 needed to encourage Resident 1 to drink fluids and document any hydration issues in Resident 1's medical record. LVN 2 stated LVN 2 did not receive any report that Resident 1 was not drinking enough fluids. LVN 2 stated when Resident 1 was not meeting Resident 1's estimated fluid needs per day as assessed by RD 1, LVN 2 needed to notify Resident 1's PP/MD 2 because that was considered a change of condition (COC) and LVN 2 needed to obtain new orders from MD 2 for laboratory tests for Resident 1. LVN 2 stated LVN 2 did not notify MD 2 at any point between 5/21/2024 and 6/1/2024 that Resident 1 had not drank Resident 1's estimated fluid needs per day. LVN 2 stated "it was possible" that Resident 1 could have elevated Na levels from not drinking enough fluids and become dehydrated. During an interview and a concurrent record review on 6/17/2024 at 3:17 pm, Resident 1's CRA dated 5/16/2024, indicated Resident 1 needed assistance with eating/nutrition. CNA 1 stated Resident 1 required a lot of encouragement to drink fluids. CNA 1 stated Resident 1 was unable to drink fluids by himself because Resident 1 did not have balance in his hands. CNA 1 stated when Resident 1 was not drinking enough, CNA 1 was supposed to report it to the assigned licensed nurse. CNA 1 stated CNA 1 did not report any fluid intake issues to the licensed nurses because Resident 1 usually drank fluids with encouragement. CNA 1 stated she was not sure if Resident 1 drank enough fluids during her) shift and did not know where to find out how much fluids Resident 1 needed to drink during her shift. During an interview on 6/17/2024 at 4:29 pm, the DON stated licensed nurses (LVNs in general) were supposed to evaluate fluid intake weekly for each resident, including Resident 1. The DON stated licensed nurses needed to ensure residents drank their estimated fluid needs per day. The DON stated nursing staff (CNAs and LVNs) could find Resident 1's assessed estimated fluid needs in Resident 1's RD notes and assessments. The DON stated CNAs needed to immediately report to the licensed nurses when Resident 1 was not drinking enough, and the licensed nurses needed to notify the Resident 1's physician (MD 2). The DON stated not drinking enough fluids was con