Other·December 1, 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. 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 10/16/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the recertification survey. The facility failed to provide care and services for Residents 22, 27, 33, and 54 in accordance with the facility's policies and procedures (P&P) titled, "Nursing Care of The Resident with Diabetes Mellitus," dated 2020, "Condition Changes - Clinical Protocol," dated 3/2023 and "Nutritional Assessment," dated 4/2023, by failing to: -Notify a physician if the blood sugar (BS) consistently remained above 200 milligrams per deciliter (mg/dL - unit of measurement [normal range for a diabetic according to the American Diabetes Association: 80 -130mg/dL]) for Residents 22, 27, 33, and 54. -Enter the Physician's Order for a dietary consult on the medical charts of Residents 22, 27, 33, and 54. -Develop a system to ensure a Registered Dietician (RD) was aware of the Physician's Order for a dietary consultation for Residents 22, 27, 33 and 54. -Document and communicate with a RD regarding the Physician's Order for dietary consultation and the consistent elevated blood sugar for Residents 22, 27, 33, and 54. -Implement the diabetic care plan for nutritional regimen and ongoing monitoring per RD for Residents 22, 27, 33, and 54. The facility was aware Residents 22, 27, 33, and 54 had diabetes. -Resident 22's Hemoglobin A1C (HgA1C - is a blood test that shows the average BS level over the past two to three months, reference range [RR] value of 5.7 % to 6.4 %) on 6/29/2023 was 13% and on 8/28/2023 was 12.9%. -Resident 27's HgA1C level increased from 11.1% to 12.5%. -Resident 33's HgA1C was 8.2 %. -Resident 54's was HgA1C was 9.8 %. As a result, Residents 22, 27, 33, and 54 were placed at an increased risk of complications related to prolonged and uncontrolled elevated blood sugar, not limited to neuropathy (permanent nerve damage), retinopathy (damage to the nerves in the eyes), diabetic ketoacidosis (DKA: life threatening complication of diabetes), heart attack, sepsis (a life-threatening medical emergency because the body's extreme response to infection), and death. a. A review of Resident 27's admission record indicated the resident was initially admitted to the facility on 2/1/2022 and was readmitted on 4/9/2023 with diagnoses including heart failure, diabetes (an impairment in the way the body regulates and uses sugar as a fuel), kidney failure, and high blood pressure. A review of the Physician's Order dated 7/6/2022, indicated Resident 27 was to receive regular human insulin (a natural hormone [a chemical substance produced in the body that controls and regulates the activity of certain cells or organs] in the body that helps control BS) per sliding scale (dosage dependent on BS level). A review of the Physician's Order dated 8/21/2022, indicated Resident 27 was to have a controlled carbohydrate no added salt, mechanical soft texture (diet designed for people who have trouble chewing and swallowing), regular consistency diet. The order indicated the resident may have peanut butter and jelly sandwiches. According to a review of the Physician's Order dated 3/4/2023, Resident 27 was to receive metformin (medication used to treat diabetes by reducing the amount of sugar the liver produces) 1000 mg with meals. A review of the situation background assessment and recommendation (SBAR) form dated 3/21/2023 at 4:40 PM, indicated Resident 27's BS was elevated at 518 mg/dL. The SBAR indicated a physician was notified and no new orders were received. A review of the Physician's Order dated 3/21/2023, progress notes dated 3/21/2023, and the SBAR forms dated 3/21/2023, indicated no further action was taken for Resident 27's BS of 518 mg/dL. A review of Resident 27's care plan for "Hyperglycemia (elevated BS) related to diabetes meal consumption," dated 3/22/2023, indicated for RD to consult for nutritional regimen and ongoing monitoring of Resident 27. A review of Resident 27's Nutritional Assessment dated 4/11/2023 at 9:15 AM, indicated "Recent RD consult note addressing trend of high sugars. Nursing to inform family on risk of elevated BS when providing additional outside foods.” The note indicated dietary intervention included to recommend an evening / night diabetic snack to support stable blood sugars. According to a review of the Medication Administration Record (MAR), Resident 27's BS levels consistently remained above 130 mg/dL for the following months: On 5/1/2023 to 5/31/2023, blood sugar levels ranged from 142 mg/dL to 395 mg/dL. 106 out of 126 entries were above 200 mg/dL. On 6/1/2023 to 6/30/2023, blood sugar levels ranged from 173 mg/dL to 399 mg/dL. 117 out of 123 entries were above 200 mg/dL. A review of Resident 27's SBAR form dated 6/29/2023 at 4:35 PM, indicated Resident 27's Hemoglobin A1C level was elevated at 11.1% (Reference range [RR] value of 5.7 % to 6.4 %). A review of Resident 27's MAR indicated from 7/1/2023 to 7/31/2023, blood sugar levels ranged from 206 mg/dL to 399 mg/dL and 120 out of 121 entries were above 200mg/dL. A review of the Physician's Order dated 7/21/2023, indicated Resident 27 to receive Lantus (long-acting insulin) subcutaneous (SQ- under the skin) 12 units at bedtime. A review of the Minimum Data Set (MDS – a standardized assessment and care planning tool) dated 8/8/2023, indicated Resident 27 had severe cognitive impairment (ability to acquire and understand knowledge). The MDS indicated the resident was dependent on facility staff for all care and needs. -anything about diabetes? According to a review of Resident 27's care conference Interdisciplinary team notes (IDT, a team of health care professions, who work together to establish plans of care for residents) dated 8/9/2023 at 11:02 AM, the IDT team did not discuss or make recommendations for Resident 27's consistently having elevated BS for the past three months. A review of Resident 27's SBAR form dated 8/24/2023 at 10:39 AM, indicated "Elevated blood sugar reading despite DM regimen.” The SBAR form did not indicate Resident 27's actual BS reading. A review of Resident 27's care plan for "Elevated Blood Sugar Result Despite Diabetic Management," dated 8/24/2023, indicated the RD to consult for nutritional regimen and ongoing monitoring for Resident 27. A review of the Physician's Order dated 8/24/2023, indicated Resident 27 to receive Lantus 12 units SQ every morning. The Physician's Order indicated there was no documented evidence regarding the dietary consult as indicated in the "Resident has Elevated Blood Sugar Results Despite Diabetic Regimen (orders put in place by physician to control blood sugar levels)" per care plan dated 8/24/2023. A review of the MAR indicated Resident 27's BS levels consistently remained above 130 mg/dL for the following months: -On 8/1/2023 to 8/31/2023, blood sugar levels ranged from 183 mg/dL to 400 mg/dL. 114 out of 116 entries were above 200mg/dL. -On 9/1/2023 to 9/20/2023, blood sugar levels ranged from 186 mg/dL to 390 mg/dL. 99 out of 116 entries were above 200mg/dL. According to a review of all Resident 27's nutritional notes dated from 8/24/2023 to 10/18/2023, the RD had not consulted or visited with Resident 27, per the care plan. A review of Resident 27's IDT notes dated from 8/24/2023 to 10/18/2023, indicated the IDT team had not met to discuss Resident 27's consistently elevated blood sugar. The most recent meeting was 8/9/2023. A review of Resident 27's Laboratory Results Report dated 8/26/2023, indicated Resident 27' s HbA1C level was 12.5 % mg/dL up from 11.1% on 6/29/2023. A review of Resident 27's MAR indicated the BS level from 10/1/2023 to 10/18/2023 were all above 130 mg/dL. The BS level ranged from 187 mg/dL to 400 mg/dL. 69 out of 72 entries were above 200 mg/dL. A review of Resident 27's "Blood Sugar Summary" for October 2023, indicated Resident 27's BS levels on: -10/9/2023 were 325mg/dL at 6:11 AM, 299 mg/dL at 12:16 PM, 303 mg/dL at 4:42 PM, and 364mg/dL at 9:43 PM. -10/10/2023 were 216mg/dL at 6:59 AM, 256 mg/dL at 12:22 PM, 325 mg/dL at 4:49 PM, and 398mg/dL at 8:29 PM. -10/11/2023 were 400 mg/dL at 6:30 AM, 306 mg/dL at 12:29 PM, 344 mg/dL at 5:26 PM, and 352 mg/dL at 8:40 PM. -10/12/2023 were 366 mg/dL at 6:34 AM, 323 mg/dL at 11:45 AM, 364 mg/dL at 5:37 PM, and 341 mg/dL at 9:22 PM. -10/13/2023 were 398 mg/dL at 6:19 AM, 234 mg/dL at 12:24 PM, 307 mg/dL at 4:08 PM, and 311 mg/dL at 8:12 PM. -10/14/2023 were 314 mg/dL at 5:37 AM, 303 mg/dL at 11:39 AM, 369 mg/dL at 5:25 PM, and 328 mg/dL at 9:23 PM. -10/15/2023 were 399 mg/dL at 5:59 AM, 261 mg/dL at 12:14 PM, 388 mg/dL at 4:11 PM, and 327 mg/dL at 8:31 PM. -10/16/2023 were 387 mg/dL at 6:14 AM, 305 mg/dL at 11:08 AM, 364 mg/dL at 4:31 PM, and 385 mg/dL at 9:10 PM. A review of Resident 27's progress notes for 10/9/2023 to 10/17/2023 did not indicate that the physician was notified for the four or more consecutive readings of BS above 130 mg/dL. During an interview on 10/19/2023 at 2:57 PM, the RD stated the facility never notified the RD of a Physician's Order for dietary consultation for Resident 27. The RD stated an RD had not seen or visited Resident 27 since 4/12/2023 and further stated the facility allowed Resident 27, "to eat whatever the resident [Resident 27] wanted.” The RD stated the facility had not changed Resident 27's diet to manage the resident's high BS levels. During an interview on 10/20/2023 at 7:08 AM, the Assistant Director of Nursing (ADON) stated if a resident had a Change of Condition (COC) the ADON would assist with assessing the resident, notify the physician, and carry out physician's orders. The ADON stated she would update the resident's care plan and notify RD if RD consult was ordered. The ADON stated the ADON would verbally notify the RD if RD consultations were ordered. The ADON stated she did not document anywhere nor on residents' medical chart for notification requests and or physician's order for RD consult notifications needed for residents. The ADON stated she would remember (make a mental note) which residents had dietary consultation. The ADON stated if she was off duty, "I would assume the Director of Nursing (DON) would contact the RD for any dietary consults." The ADON confirmed and stated the facility did not have a specific method of communicating with the DON or anyone on pending/ordered RD consults for the residents. The ADON stated, "All communications are verbal.” The ADON confirmed she never entered the RD consult orders in residents' electronic health record and that it was important to maintain BS within normal limits to avoid hypoglycemia (low BS) or hyperglycemia (high BS). The ADON stated adverse effects for hyperglycemia included diabetic coma (a life-threatening complication that can result from hyperglycemia or hypoglycemia) and shock (a critical condition brought on by the sudden drop in blood flow through the body). The ADON stated prolonged elevated blood sugars could lead to arteriosclerosis (hardening of blood vessels), heart attack, stroke, neuropathy (nerve damage), retinopathy (damage to nerve in eyes), stroke, and death. During an interview and record review on 10/20/2023 at 7:09 AM, Resident 27's medical chart was reviewed. The ADON stated Resident 27's blood sugar had not been managed appropriately. The ADON reviewed the resident's blood sugar from 1/26/2023 to 10/20/2023 and stated the blood sugars were uncontrolled since 1/26/2023. The ADON stated complications of uncontrolled high BS included, "death, kidney failure, everything.” The ADON stated and confirmed the facility did not notify the RD of ordered dietary consults for Resident 27. The ADON reviewed the Physician's Orders for Resident 27 to confirm, then stated the Physician's Orders were not entered for dietary consult for Resident 27. During an interview on 10/20/2023 at 2 PM, the facility's Medical Director 1 (MD1) stated it was expected that the facility staff tried to control BS levels as much as possible for diabetic residents. MD1 stated it was important to identify residents who were compliant and noncompliant with diabetic regimen. MD1 stated for residents with BS difficult to manage, they needed to be transferred to a general acute care hospital (GACH). MD1 stated BS levels were considered uncontrolled if the BS was above the normal range (130 mg/dL) for four or more consecutive readings. MD1 stated a physician must be notified and an endocrinologist consultation ordered for residents with uncontrolled blood sugar. MD1 stated it was expected the RD consults/visits with the resident to avoid complications of prolonged high BS levels which included neuropathy, retinopathy, and DKA. MD1 stated the complications were elevated (risk increased) when a resident had other health problems. MD1 stated he was not aware that Residents 22, 27, 33, and 54 had consistently elevated blood sugar. MD1 further stated Residents 22, 27, 33, and 54 consistent elevated blood sugar was an important concern that needed to be addressed immediately to avoid life threatening complications. During an interview on 10/20/2023 at 4:12 PM, the DON defined COC as any change from a resident's baseline such as abnormal lab results, a change in mental status, and reaction to medication. The DON stated if a resident developed a COC, the facility completes a head-to-toe assessment and SBAR form. The DON stated the SBAR should paint a clear picture of what happened to the resident and the reason why. The DON stated a physician was to be notified of a COC. The DON stated the RD was notified of dietary consult verbally. When asked how the RD notification was tracked to ensure the residents were seen, the DON replied, "You inform them [RD], so they have to respond.” When asked about the facility's process of verifying that the RD dietary consultation request was completed, the DON confirmed and stated the facility did not have a system in place to verify if RD consultations were communicated and completed. The DON then stated, “This isn't just the one resident error this is something bigger.” The DON stated acceptable BS levels for diabetic residents range from 100-130mg/dL. The DON defined uncontrolled diabetes as BS levels above 200mg/dL for three or more readings. The DON stated if the BS levels remained elevated for three to four consecutive readings, a physician must be informed. The DON stated continued elevated BS levels could lead to new onset or worsening of renal disease, cardiac disease, a heart attack, DKA, sepsis, and death. b. A review of Resident 22's admission record indicated the facility initially admitted the resident on 2/13/2020 and readmitted on 9/25/2021 with diagnoses that included Diabetes, peripheral vascular