Other·February 14, 2024

42 CFR § 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. §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 22 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: (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. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 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 1/17/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation for the Recertification Survey Revisit. The facility failed to provide adequate and sufficient nursing staff to meet the needs of Resident 1. For Resident 1, who had anxiety and difficulty sleeping, there was inadequate availability of nursing services on 1/9/2024 to assure Resident 1’s safety and attainment of the highest practicable mental and psychosocial well-being. This repeated violation of the facility (from 12/2/2023) caused an increased risk in the care of the total resident population (66 residents), effecting resident safety, security, and implementation of policies and procedures necessary to remain in compliance with current laws, regulations and guidelines. As a result, on 1/18/2024, Resident 1, a 76-year-old male, stated he did not receive his 1 AM sleeping medications until 5:30 AM. Resident 1 stated, "I don't feel safe. It makes me feel helpless. I feel dismissed and disregarded." A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/25/2013 with diagnoses including insomnia (trouble falling asleep), anxiety, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Guillain-Barre Syndrome (a rare disorder where the body's immune system damages nerve). A review of Resident 1's History and Physical, dated 6/20/2023 indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/24/2023, indicated the resident never felt lonely or isolated from those around him. The MDS indicated a mood interview should be conducted with Resident 1, and that over the last two weeks, the resident did not express little interest or pleasure in doing things and did not feel down, depressed or hopeless. The MDS further indicated Resident 1 could understand others and make himself understood. According to a review of Resident 1's antidepressant medication care plan, revised on 11/30/2023, Resident 1 received Remeron (a medication that works in the brain, used to treat major depressive disorder) for depression every evening, at 1 AM per resident request. The care plan goal indicated the resident would be free from discomfort or adverse reactions related to antidepressant therapy. The care plan interventions included to give antidepressant medication as ordered by physician and to monitor behavior of depression (sad, irritable, worthlessness, disrupted sleep, fatigue). The care plan indicated Remeron had a Black Box Warning and to closely monitor all antidepressant treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. A review of Resident 1's hypnotic therapy care plan, revised on 12/28/2023 indicated the resident received Trazadone (antidepressant medication) and Vistaril (used to treat anxiety) for insomnia every night, at 1 AM per resident request. The care plan goal indicated the resident would be free from discomfort or adverse reactions related to therapy. The care plan interventions indicated to monitor for insomnia manifested by the inability to sleep by monitoring the number of hours of sleep every shift. The care plan indicated Trazadone had a Black Box Warning and to closely monitor all antidepressant treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. According to a review of the facility's Centers for Medicare and Medicaid Services- Statement of Deficiencies and Plan of Correction (CMS-2576) form with a completion date of 1/3/2024, the facility would determine which shifts present the most issues in terms of call light response. The responses would be relayed to the Director of Staffing Development (DSD) and the Director of Nursing (DON) for further follow up. A review of Resident 1's Medication Administration Record (MAR) dated 1/2024 indicated the resident was to receive two tablets Melatonin 3 mg (for a total of 6 mg) at bedtime for dietary supplement to improve circadian rhythm (a natural oscillation that repeats roughly every 24 hours, plays a large role in your sleep-wake cycle, telling your body when it's time to sleep and wake up for the day). According to a review of the facility's Nursing Staff Assignment and Sign-In Sheet for the 11 PM to 7 AM shift, dated 1/9/2024, Licensed Vocational Nurse 5 (LVN 5) and LVN 6 were working as charge nurses for that shift. The Nursing Staff Assignment sheet indicated there was no supervisor documented and it was not signed by LVN 6 or Registered Nurse 2 (RN 2). A review of Resident 1's Administration History Sheet, dated 1/18/2024, indicated Resident 1 was to receive Trazodone at 1 AM, but received Trazodone on 1/10/2024 at 5:35 AM (three hours and 35 minutes late), on 1/13/2024 at 3:51 AM (1 hour 51 minutes late), and on 1/14/2024 at 3 AM (1 hour late). According to the Nurse's Drug Guide, 2017, when administering Trazadone, to maintain the same schedule for food - drug intake throughout treatment period, to prevent variations in serum concentration. The Drug Guide indicated the adverse effects were light headedness, dizziness, nervousness, headache and agitation. A review of Resident 1's Administration History Sheet, dated 1/18/2024, indicated Resident 1 was to receive Melatonin (a dietary supplement to improve circadian rhythm [a natural oscillation that repeats roughly every 24 hours, plays a large role in your sleep-wake cycle, telling your body when it's time to sleep and wake up for the day] at 1 AM, but received Melatonin on 1/10/2024 at 5:34 AM (three hours and 34 minutes late), on 1/12/2024 at 2:56 AM (56 minutes late), on 1/13/2024 at 3:51 AM (1 hour 51 minutes late), and on 1/14/2024 at 2:59 AM (59 minutes late). A review of Resident 1's Administration History Sheet, dated 1/18/2024, indicated Resident 1 was to receive Vistaril at 1 AM, but received the Vistaril on 1/10/2024 at 5:34 AM (three hours and 34 minutes late), and on 1/14/2024 at 2:59 AM (59 minutes late). During an interview on 1/18/2024 at 11 AM, Resident 1 stated during the month of January 2024 he received his 1 AM sleeping medications very late. Resident 1 stated during an 11 PM - 7 AM shift, after he waited two hours for his 1 AM sleep medications, he was told by a certified nursing assistant (CNA) that there was no charge nurse (a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care) available. Resident 1 stated he did not receive his 1 AM sleeping medications until 5:30 AM. Resident 1 stated, "I don't feel safe. It makes me feel helpless. I feel dismissed and disregarded." During an interview, on 1/18/2024 at 2:40 PM with the Director of Staff Development (DSD), Resident 1's Administration Histories were reviewed. The DSD stated there were no issues with staffing and staff had a window to administer medications which was one hour before to one hour after the prescribed time. For Resident 1's 1 AM medications, staff could administer the medication from 12 AM to 2 AM. The DSD stated administering medications outside of the 1 hour before and after window indicated Resident 1 did not receive the medication timely. The DSD stated that on 1/10, 1/12, 1/13 and 1/14/2024, Resident 1 received his 1 AM medications late. The DSD stated RN 2 administered Resident 1's medication on 1/10/2024 and she may have been covering for someone on break. The DSD further stated a possible outcome of Resident 1 receiving his medications late was that he could become drowsy or unarousable during the day and those medications may interact adversely with his morning medication. During a concurrent interview and record review on 1/18/2024 at 3:25 PM, Resident 1's Administration Histories were reviewed. The DON stated there were no staffing issues and that medications were documented as administered right after the medication was given. The DON stated according to the Administration History, Resident 1 received his 1 AM medications late on several dates. The DON stated this could cause Resident 1 to have side effects of sleeping in the morning. The DON further stated the facility may ask staff to do a double or ask the morning shift to stay over as needed. On 1/18/2024 at 3:44 PM, during an interview, the Administrator stated that on 1/9/2024, for the 11 AM to 7 PM shift, LVN 6 called off work. During an interview on 1/19/2024 at 3:45 PM, when asked about staffing issues, LVN 7 stated, "I don't remember if there were any staffing issues at night." A review of the facility's policy and procedure (P&P) titled, "Administering Medications," revised 4/2019, indicated staffing schedules were arranged to ensure that medications were administered without unnecessary interruptions. It also indicated medication administration times were determined by resident need and benefit, not staff convenience. Factors that were considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions and honoring resident choices and preferences, consistent with his or her care plan. The P&P indicated medications were administered within one hour of their prescribed time, unless otherwise specified and the individual administering medications checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route of administration before giving the medication. A review of the facility's P&P titled, "Staffing, Sufficient and Competent Nursing," revised 8/2022, indicated the facility provided sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. It also indicated licensed nurses and certified nursing assistants were available 24 hours a day, seven days a week to provide competent resident care services including, assuring resident safety, attaining or maintain the highest practicable mental and psychosocial well-being of each resident, assessing, evaluation, planning and implementing resident care plans and responding to resident needs. The facility failed to provide adequate and sufficient nursing staff to meet the needs of Resident 1. For Resident 1, who had anxiety and difficulty sleeping, there was inadequate availability of nursing services on 1/9/2024 to assure Resident 1’s safety and attainment of the highest practicable mental and psychosocial well-being. This repeated violation of the facility (from 12/2/2023) caused an increased risk in the care of the total resident population (66 residents), effecting resident safety, security, and implementation of policies and procedures necessary to remain in compliance with current laws, regulations and guidelines. As a result, on 1/18/2024, Resident 1, a 76-year-old male, stated he did not receive his 1 AM sleeping medications until 5:30 AM. Resident 1 stated, "I don't feel safe. It makes me feel helpless. I feel dismissed and disregarded." The above violation had a direct relationship to the health, safety, and security of Resident 1.