Health inspection·November 23, 2021

F698 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. Title 22 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. (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. 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 9/1/2021 at 10:40 a.m., the Department of Public Health (Department) conducted an unannounced visit to the facility to investigate a complaint regarding an allegation of quality of care and treatment. The facility failed to ensure Resident 1, who required hemodialysis (HD, process of removing excess water, substances, and waste products from the blood in people whose kidneys could no longer perform these functions), received HD care and services in accordance with the care plan and the facility's policies and procedures by failing to: 1. Notify Resident 1's Primary Care Physician 1 (PCP 1), Resident 1's nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) promptly (with little or no delay) regarding Resident 1's change in condition that started on 8/14/2021 and obtain the necessary orders to meet Resident 1's HD needs. 2. Ensure ongoing communication and collaboration with Dialysis Center 1 (DC 1) to coordinate Resident 1's HD care and services in relation to Resident 1's missed HD and malfunction of HD dialysis catheter (soft tube placed in a large vein to facilitate HD). 3. Implement Resident 1’s plan of care on HD. As a result, Resident 1did not have HD for six days causing increased confusion (inability to clearly think or reason), lethargy (state of sleepiness, deep unresponsiveness, and inactivity) and shortness of breath related to pulmonary congestion (accumulation of fluid in the lungs), requiring hospitalization on 8/17/2021. A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on 6/19/2021 with multiple diagnoses including end-stage renal disease with dependence on HD and atrial fibrillation (irregular, very rapid heart rhythm, causing poor blood flow, blood clots, or stroke). A review of Resident 1's care plan on HD, initiated on 6/20/2021, indicated the following interventions: a. Coordinate the resident's care in collaboration with the dialysis center. b. Monitor/document/report to physician as needed any signs and symptoms of renal insufficiency (poor kidney functions) and changes in the level of consciousness (person's awareness and understanding of what is happening to his/her surroundings). A review of Resident 1's Physician’s Order dated 6/21/2021, indicated for the resident to receive HD every Tuesday, Thursday, and Saturday at 3 pm at Dialysis Center 1 (DC 1). A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 6/23/2021, indicated the resident was able to communicate, understand, and make decisions. A review of DC 1's Nursing - Progress Notes Report for Resident 1, dated 8/11/2021, indicated skilled nursing facility (SNF) called DC 1 to notify them that Resident 1 "accidentally," pulled out his HD catheter (soft plastic tube inserted into a vein). Dialysis Center Nurse 1 (DCN 1) assisted the SNF in arranging for the HD catheter replacement. A review of Resident 1's Health Status Note, dated 8/12/2021, indicated Resident 1 came back to the SNF from the General Acute Care Hospital 3 (GACH 3) with a new HD catheter in place to the left internal jugular vein (IJV, vein in the neck that drains blood from brain, face, and neck) and went to his HD appointment at DC 1 on the same day. A review of Resident 1's Dialysis Communication Record, dated 8/14/2021, indicated DCN 2 was unable to dialyze (treat by means of dialysis) Resident 1. The record indicated Resident 1 needed another replacement of HD central venous catheter (CVC, tube used as a HD catheter placed in a large vein in the neck, chest, groin, or arm). A review of the attached order, dated 8/14/2021, indicated MD 2's order "Nursing Home to arrange HD CVC replacement." A review of Resident 1's Health Status Note, dated 8/14/2021 timed at 5 pm, indicated Licensed Vocational Nurse 1 (LVN 1) received communication from DC 1 regarding inability to dialyze Resident 1 due to the malfunction of HD catheter, which was placed on 8/12/2021. Resident 1's last HD was done on 8/12/2021. The note indicated Primary Care Provider 1 (PCP 1) was aware of the missed dialysis. The note indicated Case Manager 1 (CM 1) was aware of the need to schedule a HD catheter replacement for Resident 1. A review of Resident 1's Change in Condition Evaluation, dated 8/14/2021 timed at 6:46 pm, indicated Resident 1's HD catheter was "not functioning well." The evaluation indicated Registered Nurse 1 (RN 1) documented, "Catheter has gotten worse, which sometimes happen even after it is newly placed." The evaluation indicated RN 1 notified PCP 1 on 8/14/2021 at 7 p.m. The resident's clinical records did not indicate any recommendations from PCP 1. A review of Resident 1's Change in Condition Evaluation, dated 8/16/2021 timed at 2:46 pm, indicated LVN 2 observed Resident 1 with "increased confusion and lethargy" was "unable to complete full sentences," and was "disoriented to time and place." LVN 2 notified PCP 1 on 8/16/2021 at 2 p.m. and obtained PCP 1's recommendation to "send resident to ED (Emergency Department)." A review of the Care Communications (facility's internal electronic communication system used by healthcare workers to communicate any changes in a resident's condition), dated 8/16/2021 timed at 3:06 p.m., indicated LVN 2 paged PCP 1 but was awaiting PCP 1 to return the call with orders. A review of Resident 1's Change in Condition Evaluation, dated 8/17/2021 timed at 4:13 am, indicated LVN 3 observed Resident 1 with increased confusion with other symptoms or signs of delirium (sudden inability to pay attention, disorganized thinking). LVN 3 observed Resident 1 with chills and general weakness. LVN 3 notified PCP 1 on 8/17/2021 at 3:30 am and obtained PCP 1's recommendation to send Resident 1 to a hospital via 911 (emergency services). A review of Resident 1's ED Report from GACH 1, dated 8/17/2021, indicated Resident 1 presented to the ED "due to altered mental status, confusion, shortness of breath." Resident 1 did not have dialysis for five days due to malfunction of the dialysis catheter that was in place in the left IJV. A review of Resident 1's Discharge Summary from GACH 1, dated 8/23/2021, indicated that Resident 1 was transferred to GACH 5 to have HD catheter replacement and resumed HD on 8/19/2021, because the HD catheter replacement at GACH 1 was unsuccessful. During a telephone interview on 9/20/2021 at 1:15 pm, Registered Nurse 1 (RN 1) stated on 8/14/21 (3-11 shift) she was not able to speak with PCP 1 directly to obtain any orders. RN 1 stated she left a message for PCP 1 and endorsed the incident to the next nurse. During a telephone interview on 9/20/2021 at 4:34 pm, RN 2 stated CM 1 was responsible for making arrangements to have the HD catheter replaced. RN 2 stated a missed dialysis session could lead to fluid overload, high blood pressure, electrolyte imbalances (deficiency or overabundance of minerals in the body causing serious problems like seizures or cardiac arrest), difficulty breathing, and possible death. During a telephone interview on 9/20/2021 at 4:51 pm, LVN 2 was unable to recall the reason why Resident 1 was not transferred during her shift even though her documentation indicated she notified PCP 1 on 8/16/2021 at 2 pm with PCP 1's order to "Send resident to ED." During a telephone interview on 9/21/2021 at 4:18 pm, PCP 1 stated he did not receive any notification from the SNF on 8/14/2021 and 8/15/2021 regarding Resident 1's missed dialysis due to the HD catheter malfunction. PCP 1 stated if the SNF staff informed him that Resident 1 did not have HD for at least three days on 8/16/2021, he would have given the order to transfer the resident to the ED immediately. During a telephone interview on 9/23/2021 at 7:53 am, LVN 3 stated when he started his shift on 8/16/2021 (11-7 shift), Resident 1 "did not look good anymore." LVN 3 stated after calling PCP 1's number about two to three times, PCP 1 called back on 8/17/2021 at 3:30 am, and gave LVN 3 an order to send Resident 1 to the hospital via 911. LVN 3 it was not a common facility practice to contact the MedDir to obtain an emergency order to transfer a resident to the hospital. During a telephone interview on 9/28/2021 at 12:15 pm, Director of Nursing (DON) stated if unsuccessful to reach PCP 1, LVN 2 should have called the MedDir. A review of the facility's policy and procedures, titled "Change in a Resident's Condition or Status," dated 5/2017, indicated the facility must promptly notify the resident, the attending physician, and representative of changes in the resident's medical/mental condition. The policy indicated the nurse must notify the attending physician or physician on-call where there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, or a need to transfer the resident to a hospital or treatment center. A review of the facility's policy and procedures, titled "Medical Director," undated, indicated physician services must be under the supervision of the Medical Director. The Medical Director functions included acting as a consultant to the director of nursing services in matters relating to resident care services, helping assure that residents receive adequate services appropriate to meet their needs, and helping assure that the resident care plan accurately reflects the medical regimen. The facility failed to ensure Resident 1, who required hemodialysis, received HD care and services in accordance with the care plan and the facility's policies and procedures by failing to: 1. Notify Resident 1's Primary Care Physician 1 (PCP 1), Resident 1's nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) promptly regarding Resident 1's change in condition that started on 8/14/2021 and obtain the necessary orders to meet Resident 1's HD needs. 2. Ensure ongoing communication and collaboration with Dialysis Center 1 (DC 1) to coordinate Resident 1's HD care and services in relation to Resident 1's missed HD and malfunction of HD dialysis catheter. 3. Implement Resident 1’s plan of care on HD. As a result, Resident 1did not have HD for six days causing increased confusion, lethargy and shortness of breath related to pulmonary congestion, requiring hospitalization on 8/17/2021. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.