Health inspection·June 28, 2023

F726 Competent Nursing Staff Section 483.45 Nursing Services 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 Section 483.70(e). Section 483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Section 483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Based on interview and record review, the facility failed to provide safe, competent nurse staffing to one of two sampled residents (Resident 1) experiencing respiratory distress in a sub-acute unit (a unit supporting medically fragile residents who require specialized services and care) when: 1. A ventilator (a machine that mechanically moves air in and out of the lungs) and supplemental oxygen were applied without a physician's order; 2. A respiratory care plan was not developed or implemented; 3. Licensed Nurses (LNs) 1 and 2 did not administer supplemental oxygen via the necessary route when the resident was in respiratory distress; 4. LNs 1 and 2 did not recognize the need for immediate transfer of Resident 1 to a GACH (General Acute Care Hospital); and 5. LNs competency for tracheostomy (trach, a hole that surgeons make through the front of the neck and into the windpipe) and ventilator care was not assessed, demonstrated, or documented as completed. These failures resulted in Resident 1 going into a prolonged hypoxemic (below normal level of oxygen in the blood) state which required transfer to a GACH and placement in an ICU (Intensive Care Unit). Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in the summer of 2022 with diagnoses including dependence on respirator (ventilator), quadriplegia (paralysis of all four limbs) and dysphagia (difficulty in swallowing). 1. A review of an unsigned physician order dated 7/18/22 to 7/22/22 for Resident 1, on 11/23/22 at 7 a.m., indicated Resident 1 did not have any orders related to his ventilator and oxygen administration. In a phone interview, on 11/23/22 at 7 a.m., the Director of Nursing (DON) confirmed there were no physician's orders in place for the resident's ventilator and oxygen administration. The DON stated physician's orders for oxygen and ventilator type and setting should have been in place and failure to have a physician order could result in a negative physical and psychological (mental and emotional) outcome for the resident. A review of the facility's policy titled, "Mechanical Ventilation," undated, indicated, "...Mechanical ventilator may be only applied to a resident, weaned off, or discontinued with a written or verbal physician order." 2. A review of "Care Plan" for Resident 1, on 10/13/22, at 1:40 p.m., indicated a care plan had not been established for Resident 1's ventilator dependency (when a person can't breathe on their own and depends on a ventilator machine to assist in breathing). In a phone interview, on 11/23/22 at 7 a.m., the DON stated a basic care plan should have been developed involving the resident's diagnoses to guide and facilitate his care. The DON acknowledged Resident 1 did not have a respiratory care plan and stated failure to plan a resident's care could result in inconsistencies in care delivery. A review of the facility's policy titled, "Comprehensive Person- Centered Care planning," dated 11/2018, indicated, "To ensure that a comprehensive person-centered care plan is developed for each resident." 3. A review of a nurse's progress note, written on 7/22/22 at 4:53 p.m. by LN 2, indicated Resident 1 was having shortness of breath and his oxygen level was at 88-90% (normal oxygen range approximately 95-100%) on 10 liters (L, a unit of measurement) per minute via oxygen concentrator (oxygen concentrators take in air from the room and filter out nitrogen (a colorless, gaseous element forming 78% of the atmospheric composition), leaving an oxygen enriched gas for use by people requiring medical oxygen due to low oxygen levels in their blood). The note indicated LN 2 called a non-emergent ambulance service to transport Resident 1 to a GACH and did not call emergency services. A review of a nurse's progress note, written on 7/22/22 at 5:30 p.m. by LN 2, indicated, "patient removed from vent by subacute RN to be transported to Sutter hosp." Between the progress note on 7/22/22 at 4:53 p.m., and the progress note written on 7/22/22 at 5:30 p.m., Resident 1 experienced a 37-minute delay of transport from the facility to the GACH. A review of a GACH's ED (Emergency Department) provider note, dated 7/22/22, indicated, "Code critical was alerted ...In ED patient was found to be tachypneic [fast breathing], and hypoxic [low oxygen levels in body tissues] ABG [Arterial blood gases, test measure oxygen and carbon dioxide levels in your blood]. 7.46 PH [a scale used to specify acidity, normal range of PH is 7.35 to 7.45] PO2 [partial pressure of oxygen]- 77 on 100% FIO2 [the fraction of inspired oxygen (Normal atmospheric oxygen at room air is 21%)], aspiration pneumonia [when food or liquid are inhaled into the airway causing inflammation and infection] with mucus plugging [mucus that accumulates in the lungs can plug up, or reduce airflow in, the larger or smaller airways. In the smaller airways, it can collapse the airway and oxygen levels will be negatively impacted over time] ..." A review of a GACH document titled, "07/22/2022 - to Hosp-Admission (Discharged) in [GACH] Intensive Care Unit C FACESHEET," indicated Resident 1 was admitted to the GACH ICU directly from the Emergency Department. In an interview, on 7/22/22 at 11:30 a.m., the Director of Respiratory Therapy (DRT) stated the ventilator dependent patient should have received 100 percent oxygen via an oxygen tank to provide effective oxygenation when the resident was in respiratory distress. The DRT stated an oxygen concentrator would not have provided enough oxygen (an oxygen concentrator can deliver oxygen only up to 10 L/ minute versus an oxygen tank, which can provide up to 25 L/minute when high flow oxygen is needed). A review of the facility's policy titled, "Mechanical Ventilation," undated, indicated, "To facilitate the safe, consistent application and management of positive pressure mechanical ventilation of positive pressure mechanical ventilation for residents requiring the use of positive pressure mechanical ventilation ... to allow for the manual delivery of ventilations and oxygenation to the resident who is unable to maintain their own respirations with their own efforts, either in an emergency or when temporarily disconnected from the mechanical ventilator ... the manual resuscitator bag [A bag used to provide air by hand if your patient is not breathing] is to be used to manually ventilate and oxygenate the resident in the event of a medical emergency." 4. A review of a nurse's progress note, written on 7/22/22 at 5:30 p.m. by LN 2, indicated Resident 1 had been transported to a GACH by non-emergent ambulance services. In an interview, on 7/22/22 at 7 a.m., the DON stated the nursing staff should not have used a non-emergent ambulance to transport the resident to a GACH. She also stated Resident 1 was in respiratory distress which was an emergent situation. The DON stated nurses should have called 911 emergency services and expedited the transfer of the resident in respiratory distress to the GACH. The DON stated a delay in the resident's transfer could have caused hypoxia and negatively impacted the resident. In an interview, on 11/23/22 at 4:45 p.m., the Medical Director (MD) stated when a resident's oxygen levels were low and continued to decline, he expected the resident was to be transferred by 911 emergency services immediately to a GACH. The MD further stated a delay in transfer could cause hypoxia and organ damage due to a lack of oxygenation. 5. In an interview, on 10/13/22 at 1 p.m., the DON stated LNs 1 and 2 should have been trained in tracheostomy and ventilator care and suctioning. In an interview on 10/13/22 at 1:15 p.m., the DON stated nurses should be trained by the RT (Respiratory Therapist) for trach care, responding to alarms and ventilator settings. The DON stated validation of training and competency should be in their employee file. In a concurrent interview and employee personal file and competency review on 10/13/22 at 2 p.m., Director of Staff Development (DSD) stated she was not able to locate or provide any documented evidence if LN 2 received any ventilator or trach training. In a concurrent interview and employee personal file and competency review on 10/13/22 at 2:10 p.m., DSD stated LN 1 was a registry employee she was not able to locate or provide any documented evidence if LN 1 was competent to care for trach and ventilator dependent residents. In a concurrent interview and record review, on 10/13/22 at 3 p.m., the DSD stated she could not provide any documented evidence LNs' 1 and 2 competencies in respiratory care had been assessed and documented. In an interview on 11/21/22 at 11:58 a.m., the LN 2 stated he did not feel safe and comfortable in taking care of ventilator dependent residents without a RT in the building. He also stated he never received any training on managing the residents on ventilators. In an interview on 11/22/22 at 5:01 p.m., the LN 1 stated she was a registry employee, and the facility never provided her any training or competency to care for ventilator dependent residents. She also stated she only knew how to suction the resident through their tracheostomy tube and clean the tracheostomy site. She further stated she was not trained for emergent situations and the supervisor and RT were expected to assist her in any emergency. A review of the facility's policy titled, "SUBACUTE PROGRAM POLICY AND PROCEDURES," undated, indicated, "To assure the provision of skilled subacute care to the residents on the unit ...all licensed nursing staff will have their subacute skill competencies evaluated and validated within thirty days of hire and then on an annual basis at the time of their yearly performance review ..." This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.