Lomita Post-Acute Care Center of Los Angeles County, California was issued a Class AA Citation by the California Department of Public Health (CDPH) on August 14, 2020 after a resident was killed due to sepsis resulting from negligent patient care at the facility.
The Care Center failed to follow its own policies and procedures to ensure that the resident, who had been admitted just 7 days prior, received the care she needed, which started with an accurate assessment of the resident’s change of condition, in combination with urinary catheter care, reporting to the physician the resident’s change of condition in a timely manner, and sending the resident to the hospital only after a family member insisted.
Interviews and Nurses Notes indicated that on several instances there was no documented confirmation that the Resident’s catheter was being examined per physician’s orders. Which likely contributed to the UTI that later caused Sepsis in the Resident.
Family members of the Resident were present and involved throughout the process. Family members (one of which is a nurse themselves) stated that they informed nursing staff at the center that the Resident had a change of condition, including unresponsiveness and facial drooping. Nursing staff denied this and claimed that the Resident was okay because her vital signs looked “normal”. The family member who was a nurse stated that she observed “sediment in the indwelling catheter drainage bag” (which is indicative of an issue). After Family members continually insisted that the Resident was not okay, a physician was contacted and gave orders to transfer the Resident to a nearby acute care hospital. As a result, there was a two-hour delay in diagnosis and care for the Resident after the nurses insisted the resident was stable, with no change of condition, and did not require any interventions.
On 2/13/20 the Resident was transferred to the general acute care hospital after family insisted. The Resident had an altered mental status (which includes general changes in brain function, facial drooping, loss of alertness, and disorientation) and a possible stroke, as documented by the paramedics. The Resident was admitted to the general acute care hospital in an ICU with diagnoses that included “acute encephalopathy (brain damage), possible CVA, suspected aspiration pneumonia (entry of material [food, drink or stomach contents] in to the lungs and choking) and acute UTI complicated with an indwelling catheter.” The Resident was diagnosed with sepsis (infection in the blood) metabolic encephalopathy (brain damage), and UTI. The Resident was hospitalized and died just two days later.
The Facility was issued the AA Citation because it failed to:
- Report Resident’s change of condition of a fall timely to the physician.
- Ensure the Resident was provided with urinary catheter care and that assessment of the urine characteristics were done per the physician’s orders.
- Accurately assess the Resident’s change of condition and transfer the resident to the hospital.
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