Other·September 25, 2023

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. F693 §483.25(g) Enteral Nutrition (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)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. 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 § 72313. Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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 8/10/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about the quality of care for Resident 1. The facility failed to identify and ensure Resident 1, who had a gastrostomy tube (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication) and was at risk for ostomy site infection, received G-tube care, treatment, and services in accordance with the physician’s orders, Resident 1’s care plan, and the facility's policies and procedures by failing to: - Administer treatments as prescribed in the Physician's Order to clean and treat Resident 1's G-tube site, every day (QD) on 7/2, 7/16 and 7/24/2023, and as needed. -Implement an effective comprehensive person-centered ostomy (surgery to create an opening [stoma] from an area inside the body to the outside) care plan for Resident 1, including to cleanse the G-tube site per Physician's Order to prevent risk of infection. -Review, evaluate and update Resident 1's ostomy care plan as required by regulations and the facility’s policy and procedure titled, "Care plans, Comprehensive Person Centered,” when there was a change in condition (COC) on 8/5/2023, as the resident had redness and a foul smell at the G-tube site. - Implement the facility’s policy and procedure titled, "Prevention and Screening - Clinical Protocol," for identifying and monitoring Resident 1's modifiable risks and complications, by ordering Resident 1’s culture and sensitivity laboratory screening tests (a test to find bacteria, virus, or a fungus [different types of germs] that can cause an infection) after the antibiotic was completed. -Implement the facility's policy and procedure titled, "Antibiotic Stewardship Program," as the Infection Preventionist did not track, collect, and review data on whether appropriate cultures were obtained from Resident 1 before the physician ordered an antibiotic. As a result, Resident 1 developed an infection with redness and a foul smell at the G-tube site on 8/5/2023 requiring antibiotic treatment twice a day for seven days and increased the risk for further complications, including ineffective antibiotic treatment. A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/21/2023 with diagnoses including Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), quadriplegia (paralysis of all four limbs), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the Physician's Order, dated 3/22/2023, indicated to cleanse the G-tube site with normal saline (mixture of salt and water used to clean wounds), pat dry and cover with T-drain dry dressing (a sterile pad applied to a wound to promote healing and protect the wound from further harm) every day (QD) and as needed (PRN) if dressing was soiled or dislodged every shift. A review of Resident 1's Care Plan for at risk for ostomy site infection initiated 3/22/2023, indicated the resident required a feeding tube related to dysphagia (difficulty swallowing). The goal was for the G-tube site to be free from signs and symptoms of redness, excoriation (scratch or wear off the skin resulting in an abrasion), and drainage through the next review date. The interventions included change feeding syringe every 24 hours, change tubing every 24 hours, administer prescribed treatment as ordered, and observe and notify the medical doctor for signs and symptoms of infection on insertion site, and surrounding skin area: redness, excoriation, pain, drainage, local fever, swelling, tenderness. According to a review of the Treatment Administration Record (TAR) for G-tube site, Resident 1 did not receive treatment to the G-tube site on 7/2, 7/16, or 7/24/2023. A review of the nursing assignment sheet for 7/2, 7/16, and 7/24/2023, indicated there was no treatment nurse assigned for these days. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/15/2023 indicated Resident 1 was cognitively (process to think, learn or remember) severely impaired (never/rarely made decisions) with total dependence on staff with one person assist for eating. The MDS indicated Resident 1 had malnutrition, difficulty swallowing, with active diagnoses of encounter for attention to gastrostomy. A review of Resident 1's Care Plan for at risk for ostomy site infection indicated a revision on 8/1/2023, but no changes were made to the care plan on that date. A review of the change of condition (COC) form dated 8/5/2023, indicated Resident 1 developed redness and a foul smell at the G-tube site. There was no revision or update to the Care Plan for at risk for ostomy site infection after Resident 1's COC on 8/5/2023 for development of redness and a foul odor. A review of the Physician's Order, dated 8/7/2023, indicated Resident 1 received Bactrim DS (a type of antibiotic) 800-1600 milligram (mg - a unit of measure) one tablet via G-tube every 12 hours for G-tube site infection for seven days. During an observation on 8/10/2023 at 1:28 PM, in Resident 1's room, the G-tube site was observed with a clean dressing, no foul smell or redness noted. During an interview on 8/10/2023 at 1:35 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had an infection on the G-tube site with redness and foul smell on 8/5/2023. LVN 1 stated Resident 1 was currently receiving Bactrim antibiotics for the infection, that the infection was improving and currently had no foul smell or discoloration. A review of Resident 1's Physician's Orders dated 8/14/2023, indicated Resident 1 was to receive a wound culture for G-tube site infection, which was after the antibiotic treatment was completed. During a record review and concurrent interview on 8/14/2023 at 3:05 PM, with Registered Nurse 2 (RN 2), the nurse staffing assignment and Resident 1's medical record were reviewed. RN 2 stated she has done treatments before, because there was no treatment nurse on some days. RN 2 stated there was no treatment nurse signed in for 7/2, 7/16, and 7/24/2023 on the staff assignment sheet and no treatment was provided to Resident 1. She stated there was a high-risk of infection for residents with G-tube and failing to provide G-tube treatment per physician's order may increase the risk of Resident 1 getting an infection. RN 2 stated according to Resident 1's change of condition dated 8/5/2023, the resident was observed with redness and foul smell at G-tube opening. During an interview on 8/15/2023 at 9:15 AM, the Infection Control Preventionist (ICP) stated she conducted the antibiotic stewardship and assessed Resident 1's infection as it had redness and a foul smell at G-tube site on 8/5/2023. The ICP stated she did not conduct a culture and sensitivity; she did not communicate with Resident 1's physician for culture and sensitivity and did not communicate with the medical director regarding a wound culture for Resident 1. The ICP stated the antibiotic stewardship protocol was to conduct culture and sensitivity for infections and inform the physician of the result to ensure the appropriate antibiotic was used for the specific type of germ of the infection and prevent antibiotic resistance. During an interview on 8/15/2023 at 12:05 PM, RN 2 stated Resident 1 had a G-tube infection on 8/5/2023 and the culture and sensitivity were not ordered and conducted until 8/14/2023. RN 2 stated the culture and sensitivity should be conducted when the antibiotic was ordered on 8/7/2023 due to a risk of antibiotic resistance and potential ineffective treatment for Resident 1's infection. RN 2 stated the facility did not revise Resident 1's Care Plan for at risk for ostomy site infection to include a new intervention for the prevention of G-tube infection on 8/1/2023. On 8/15/2023 at 1:40 PM, during an interview, the Medical Director (MD) stated it was not necessary to order a culture for all wounds, depending on the type of wound and location. The MD stated for a wound with a foul smell and/or purulent exudate (thick fluid may be white, yellow, or pink or green tinged caused by infection), she would normally order a culture but cannot recall if she ordered the culture or not for Resident 1. The MD stated ordering the culture at the time of treatment of a resident's infection for more effective antibiotic treatment, and to prevent spread of the infection to other residents. She stated she was not sure why a culture and sensitivity would be ordered for Resident 1 on 8/14/2023 after the antibiotic treatment was completed. During an interview on 8/15/2023 at 3:07 PM, the Director of Nursing (DON) stated Resident 1's care plan for at risk for ostomy infection initiation 3/22/2023 indicated a revision on 8/1/2023 but there were no changes in the care plan. The DON stated the care plan was not effective and should have been revised. She stated according to the nursing staffing assignment and sign in sheet, there was no treatment nurse assigned for Resident 1 on 7/2, 7/16 or 7/24/2023. The DON stated the TAR indicated Resident 1 did not receive G-tube care per Physician's Orders on 7/2, 7/16, or 7/24/2023. During an interview on 8/28/2023 at 9:05 AM, Family Member 1 (FM 1) stated she spoke with someone at the facility regarding Resident 1's G-tube infection and the facility staff informed her the infection can be from not cleaning the G-tube properly. FM 1 stated the facility staff indicated there were no treatment nurses on some weekends and missed the G-tube cleaning. FM 1 stated she did not believe the facility staff provided good quality cleaning to prevent the infection at the G-tube site for Resident 1 and that the infection could have been prevented if the facility properly cleaned the G-tube. A review of the facility's policy and procedure (P&P) titled, "Enteral Feedings-Safety Precautions," revised January 2023, indicated keep the skin around the exit site clean, dry, and lubricated (as necessary). A review of the facility's P&P titled, "Gastrostomy / Jejunostomy Site Care," revised January 2023, indicated the purpose of this procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown, and infection. The policy indicated to verify that there was a physician's order for this procedure. A review of the facility's P&P titled, "Prevention and Screening - Clinical Protocol," revised 1/2023, indicated the physician will order lab screening tests that are relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications. A review of the facility's P&P titled, "Antibiotic Stewardship Program," revised 1/2023, indicated the infection Preventionist will track, collect, and review data such as whether appropriate cultures were obtained before ordering antibiotic. A review of the facility's P&P titled, "Care plans, Comprehensive Person Centered," reviewed January 2023, indicated assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met. The facility failed to identify and ensure Resident 1, who had a gastrostomy tube and was at risk for infection received G-tube care, treatment, and services in accordance with the physician’s orders, Resident 1’s care plan, and the facility's policies and procedures by failing to: - Administer treatments as prescribed in the Physician's Order to clean and treat Resident 1's G-tube site, every day (QD) on 7/2, 7/16 and 7/24/2023, and as needed. -Implement an effective comprehensive person-centered ostomy care plan for Resident 1, including to cleanse the G-tube site per Physician's Order to prevent risk of infection. -Review, evaluate and update Resident 1's ostomy care plan as required by regulations and the facility’s policy and procedure titled, "Care plans, Comprehensive Person Centered,” when there was a COC on 8/5/2023, as the resident had redness and a foul smell at the G-tube site. - Implement the facility’s policy and procedure titled, "Prevention and Screening - Clinical Protocol," for identifying and monitoring Resident 1's modifiable risks and complications, by ordering Resident 1’s culture and sensitivity laboratory screening tests after the antibiotic was completed. -Implement the facility's policy and procedure titled, "Antibiotic Stewardship Program," as the Infection Preventionist did not track, collect, and review data on whether appropriate cultures were obtained from Resident 1 before the physician ordered an antibiotic. As a result, Resident 1 developed an infection with redness and a foul smell at the G-tube site on 8/5/2023 requiring antibiotic treatment twice a day for seven days and increased the risk for further complications, including ineffective antibiotic treatment. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.