Other·February 28, 2022

§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. The facility failed to assess Resident 1's medical emergency in a timely manner when he was found face down on the floor while the upper part of his body was resting over a waste basket, and provide Basic Life Support (BLS, generally refers to the type of care that first-responders, healthcare providers, and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress, or an obstructed airway), including CPR (Cardiopulmonary Resuscitation is an emergency lifesaving procedure performed when the heart stops beating. CPR can double or triple the chances of survival after a cardiac arrest) prior to the arrival of emergency medical personnel, subject to accepted professional guidelines, and the facility's policy and procedure for CPR. This failure resulted in Resident 1 not surviving his medical emergency. On 1/11/2021, at 12:06 p.m., the California Department of Public Health, Licensing and Certification (CDPH L&C), received a Facility-Reported Incident (FRI) from the Administrator of a facility regarding an unusual occurrence, the resident named in the "Intake Information" report was Resident 1. The intake details of the FRI indicated, "Date of alleged event: 1/10/2021", no time was specified. "UNUSUAL OCCURRENCE-DEATH. CLEANING WOMAN FOUND RESIDENT UNRESPONSIVE CALLED LVN (Licensed Vocational Nurse). LVN ASSESSED & PERFORMED CPR. CALLED 911. PARAMEDIC RESUMED CPR. REPORT FILED WITH POLICE." On 1/11/2021, at 12:22 p.m., a complaint was called in to CDPH L&C, indicating that CPR was not performed on Resident 1 prior to the arrival of emergency medical personnel. During a review of Resident 1's "Discharge Summary Notes," dated, 12/7/2020, at 1:58 p.m., from the acute care hospital, the Discharge Summary Notes indicated, Resident 1 was WDWN (Well Developed, Well Nourished, with no acute distress. During this hospitalization, Resident 1 was treated for Chronic Kidney Disease Stage 5, Metabolic Encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), and Septic Shock (Septic shock is when you experience a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death). Resident 1's vital signs (Vital signs are a group of the four to six most important medical signs that indicate the status of the body's vital (life-sustaining) functions) at discharge were stable. Resident 1's condition at discharge was fair. Resident 1's code status was FULL CODE (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Resident 1 was admitted to this facility on 12/7/2020. During an interview on 1/14/2021, at 11:35 a.m., with Housekeeping Staff A, Housekeeping Staff A stated she saw Resident 1 face down inside his room and she called LVN (Licensed Vocational Nurse) B. Housekeeping Staff A stated LVN B came to Resident 1's room and started CPR. During an interview on 1/14/2021, at 12 p.m., with LVN B, he stated that he was called to Resident 1's room by a housekeeper and saw him in a prone position (face down) and stated Resident 1's upper chest was resting over a waste basket and he was not moving. LVN B stated Resident 1 was unresponsive when he assessed his LOC (level of consciousness). LVN B stated he could not feel Resident 1's pulses and he was not breathing. LVN B stated he started CPR because he knew that Resident 1 was a full code. LVN B stated CNA C helped him to lay Resident 1 on his back on the floor so he could start CPR. LVN B stated RN (Registered Nurse) D came and took over the CPR so he, (LVN B), could call 911. LVN B stated he performed chest compressions for 30 seconds before RN D took over. LVN B stated he did not give recue breathing (first aid technique that's done when someone has stopped breathing (also known as respiratory arrest). Rescue breathing is also referred to as mouth-to-mouth resuscitation. LVN B stated he had already stopped providing CPR when the EMT's (Emergency Medical Technicians) arrived. During an interview on 1/14/2021, at 1:51 p.m., with CNA C, CNA C stated he responded to the emergency in Resident 1's room and saw RN D performing CPR on Resident 1.When CNA C was asked if he helped LVN B place Resident 1 on his back before starting CPR, he stated, "No", CNA C stated he did not see LVN B perform CPR on Resident 1. During a review of Resident 1's "Progress Notes", dated 1/10/2021, at 10:47 p.m., authored by LVN B, the progress notes indicated,"1/10/21 @ 1140 am inside resident's (Resident 1's) room. Resident (Resident 1) is found to have fallen forward on the floor, face down, with upper chest area resting on top of waste basket. Upon assessment, BLS was immediately initiated and performed. After visually & verbally confirming no responses from the resident, cheyne-stokes (Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea) breathing is being observed, pulse was neither unable to be determined nor present, CPR was applied until EMT arrives outside resident's (Resident 1's) room." During a review of the facility document titled, "Witness Statement Incident Reporting," (no date and time provided), handwritten by LVN B, stated, "My attention was called by the housekeeping of the resident's (Resident 1's) situation. As I enter the room, I found him on the floor, w/c (which) looked like he has fallen forward, face down, upper half of chest was resting over the waste basket. Upon assessment with no response, I continue to perform BLS, CPR included. Once the other Charge Nurse (RN D) comes inside, we switched so I can call 911, as she (RN D) continues CPR. I go back and forth the room as I was talking with the 911 dispatch. Once 911 arrives, I went to switch with the nurse (RN D) to apply CPR, and she (RN D) opens up the door for them (EMT). CPR is finally interrupted as soon as EMT arrives (I see them outside the resident's (Resident 1's) room, inside the facility)." On the same document, RN D's handwritten note stated, "I was called by a staff member (housekeeper) because the other nurse (LVN B) needs help at room xx. When I arrived (LVN B) and the resident (Resident 1) was on the floor. LVN B is giving a CPR. He (LVN B) told to call 911, we twitch (switch) so he can call 911, then I continue doing CPR while he was on the phone. When he came back into the room after two to three minutes or more, again we twitch (switch), and he told me to let the EMT inside. After letting them in, I gave one of the EMT the POLST (Physician Orders for Life Sustaining Treatment) & history of the resident (Resident 1)." During an interview on 2/4/2021, at 3:55 p.m., with RN D, stated she did not hear LVN B calling a facility code for medical emergency which was a "Code Blue." RN D stated she was called to Resident 1's room by a female housekeeper because LVN B needed help. RN D stated LVN B was on the floor starting CPR. RN D stated she switched with LVN B because she did not know what happened to Resident 1 and may not provide the correct information to the 911 dispatcher. RN D stated she checked for Resident 1's pulse and breathing, and when these were absent, she continued to perform CPR. RN D stated she did two to three cycles of CPR. RN D stated she performed CPR on Resident 1 for about three to five minutes. RN D stated she did not give Resident 1 with rescue breaths during the CPR. RN D stated she opened the door for the EMT and handed over Resident 1's POLST and History to one of the EMT. RN D stated Resident 1 was a full code. During a review of the 911 dispatch call between the dispatcher (911 is the national number in the United States to dial when emergency help is needed, and 911 dispatchers are the people who take those calls and send fire, police, or ambulance services where needed) and LVN B that was recorded on 1/10/2021, at 11:56 a.m. the call indicated the following: 911 Dispatcher: "Medical 911, what's the address of the emergency?" LVN B: Responded by stating the name of the facility and the address. 911 Dispatcher: "In what city?" LVN B: Responded by stating the name of the city. 911 Dispatcher: "What number are you calling from in case we get disconnected?" LVN B: Responded by stating the facility's phone number. 911 Dispatcher: "Ok, is there a room number or a unit number there?" LVN B: Responded, "Yes", and stated the room and bed numbers. 911 Dispatcher: Verified the room and bed numbers and asked, "What's happening today?" LVN B: "I'm sorry?" 911 Dispatcher: "Tell me exactly what is happening?" LVN B: "He is face down on the floor" 911 Dispatcher: "Did he fall?" LVN B: "I would say so, but he is uh, he is uh, I just went here and told the nurse that, that uh, that, that about his condition and I'm not quite sure if he is breathing or not." 911 Dispatcher: "You don't know if he is breathing or not?" LVN B: "Yeah." 911 Dispatcher: "Can you roll him over and check his breathing?" LVN B: "Um, I have to go over there, can you give me a second?" 911 Dispatcher: "Yes." LVN B: "Ok." After 43 seconds, LVN B: "Yes, he is breathing but he is stiff as a rock right now." 911 Dispatcher: "Ok, but he is breathing right?" LVN B: "He is, he is." 911 Dispatcher: "How old is he?" LVN B: "Um, I would say" 911 Dispatcher: "About how old is he?" LVN B: "Forty-six." 911 Dispatcher: "He is forty-six?' LVN B: "1946." 911 Dispatcher: "1946, ok. "Is he awake?" LVN B: "No, I would say no." 911 Dispatcher: "No, ok, is his breathing completely normal?" LVN B: "Um, I couldn't, I couldn't, yeah it is but um, I'm concerned because he is stiff but he is breathing, he is as stiff and I couldn't even get to turn him." 911 Dispatcher: "Ok, is he still unconscious?" LVN B: "Yes, he is actually, yes," 911 Dispatcher: "Ok, we have everyone on the way, are you able to go check on him and check his breathing for me again?" LVN B: "Ok, let me go." 911 Dispatcher: "Oh my God, this guy is ..." After two minutes and two seconds, 911 Dispatcher: "Hello, Hello, forgot about me." End of recording. During an interview on 2/19/2021, at 11:11 a.m., with Paramedic 1, Paramedic 1 stated that on 1/10/2021, at about 11:57 a.m., he received a 911 call regarding a fall victim, patient was unresponsive but breathing. Paramedic 1 stated that he and his crew, (four other paramedics), arrived at the facility at around 12:03 p.m. Paramedic 1 stated that when they arrived in the patient's (Resident 1's) room, there were four staff members inside the room, all were standing and nobody was performing CPR. Paramedic 1 stated he asked the staff if CPR was performed and nobody gave him an answer. Paramedic 1 stated his crew started accessing the patient (Resident 1) but he was deceased of cardiac arrest. Paramedic 1 stated that all four facility staff members in the room were stunned to know the patient (Resident 1) was dead. Paramedic 1 stated that there was absolutely no evidence that CPR was performed on the patient (Resident 1). Paramedic 1 stated that there was no evidence that the staff attempted to open the patient's (Resident 1's) airway. Paramedic 1 stated that his crew would attest to his assessment that there was no evidence that the patient (Resident 1) received emergency medical attention prior to their arrival. Paramedic 1 provided the names of the other four paramedics who responded to the emergency. During a review of certifications provided by the facility titled, "Basic Life Support," these documents indicated that LVN B and RN D are certified BLS providers. During an interview on 2/23/2021, at 2:30 p.m., with Administrative Staff E, Administrative Staff E stated that Resident 1 does not have a POLST form filed on his medical record. Administrative Staff E stated that Resident 1 will automatically be a Full Code at the facility until a POLST form was prepared for him. During an interview on 2/23/2021, at 3 p.m., the DON was asked to clarify a progress note she wrote on 1/10/2021, at 2:22 p.m. stating that Resident 1's death was "expected." The DON stated she already made a correction and clarified it by stating that Resident 1's death was "unexpected" because otherwise the facility would not have reported it as an unusual occurrence. During an interview on 2/23/2021, at 3:40 p.m., with Resident 1's Attending Physician, Physician F, Physician F was reminded of his patient Resident 1, he acknowledged that Resident 1 was his patient. Physician F briefly talked about Resident 1's discharge summary which indicated that Resident 1 expired on 1/10/2021, and cause of death was CVA (Cerebrovascular Accident or Stroke) most likely ischemic (Ischemic strokes occur when blood flow is blocked). Physician F stated that during medical emergencies such as Resident 1's, he expects the facility staff to provide CPR. Per the 2015 updated AHA (American Heart Association) ECC (Emergency Cardiovascular Care) Guidelines, the BLS for Healthcare Professionals Steps for CPR for Adults and Older Child are as follows: NOTE: non-relevant guidelines were intentionally omitted. 1. Verify Scene Safety- Don't enter an unsafe environment. Call 911. 2. Activate 911- If you are alone and do not have a mobile device, leave the victim to call 911 first, Return to perform CPR. 3. Determine if the victim is breathing and has a pulse- Simultaneously check for breathing and pulse for no more than 10 seconds. Note: Agonal breaths are not considered signs of breathing. Check carotid artery on your side of the victim's neck. 4. Rescue Breathing, if victim has a DEFINITE detectable pulse, but is not breathing- one breath every five to six seconds. Check pulse every 2 minutes. 5. If victim has no detectable pulse: Begin CPR, minimize interruptions- 1 Rescuer: 30 compressions: 2 breaths, 2+ Rescuers: 30 compressions: 2 breaths 6. Compression rate- 100-120 compressions per minute 7. Hand placement- two hands on lower half of breastbone 8. Compression depth: 2 to 2.4 inches (5-6 cm) 9. Chest recoil- Allow for full chest after each compression 10. Minimize interruptions- Limit interruptions in chest compressions to no more than 10 seconds. During a review of the facility's Policy and Procedure (P&P) titled, "Cardiopulmonary Resuscitation," dated, 8/1/2015, provided by the facility Administrator on 1/14/2021, at 1:50 p.m., the P&P indicated the Purpose: Cardiopulmonary Resuscitation (CPR) is instituted in cases of recognized cardiac and/or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. Policy: Cardiopulmonary Resuscitation is instituted on all residents except those designated as "No Code" or "No CPR." ... Procedure: 1. Responding to CPR Emergency A. Call for Help and send someone to contact the EMS (Emergency Medical Services) for emergency medical assistance. Announce your facility code for medical emergencies. Send someone for the emergency cart and supplies. B. Assess the resident to determine if conscious. Gently shake the resident's shoulders and shout, "Are you okay?" This helps ensure that you don't start CPR on a person who's conscious. C. Open the resident's airway, check for breathing, assess for circulation, and begin cardiopulmonary resuscitation using one person or two person rescue (whichever is appropriate). D. If alone, activate the call light and start one person rescue. If call light is not available, continue one person rescue for one minute before leaving resident to call for help. (If you suspect a head or neck injury, move the resident as little as possible to reduce the risk of paralysis). E. Continue CPR until EMS arrives and assumes care of the resid