Health inspection·February 25, 2025

The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey Event ID 38KE11. Representing the Department, HFEN # 40583 State Citation B was written. § 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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. California Code of Regulations, Title 22, Section 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 2/6/25, the Department made an unannounced visit to the facility to conduct a Federal Recertification Survey. The department determined the facility provided cardiopulmonary resuscitation (CPR: an emergency lifesaving procedure that involves chest compressions and rescue breathing) to Resident 91 on 12/13/24, against Resident 91's Physician Orders of "Do Not Resuscitate (DNR; a medical order that instructs healthcare providers not to perform performed when the heart stops beating)." This failure resulted in Resident 91 receiving the invasive CPR procedure against Resident 91's wishes to be DNR, with the potential to cause trauma and psychosocial harm to Resident 91. Resident 91's admission diagnoses included atrial fibrillation (a condition where the upper chambers of the heartbeat irregularly and rapidly) and dementia (a brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment). A review of Resident 91's physician's orders, dated 7/21/24, indicated, "...Order Summary: Code Status - FULL CODE (CPR)..." A review of Resident 91's clinical record titled, Physician Orders for Life-Sustaining Treatment (POLST; a medical document that outlines a resident's treatment preferences for when they are seriously ill or dying) dated 7/23/24, indicated, "...Do Not Resuscitate/DNR (Allow Natural Death)..." Resident 91's POLST was signed by Resident 91's Responsible Party (RP), Resident 91's son, and the Physician's Assistant. A review of Resident 91's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) care plan (a list of resident specific problems, goals, and interventions), dated 7/18/24, indicated, "...Focus [Resident 91's name] HAS A POLST - DO NOT ATTEMPT RESUSCITATION/DRN [sic]...Date Initiated: 07/18/2024..." A review of Resident 91's clinical record titled, "Progress Notes," written by Licensed Nurse (LN) 7, dated 12/13/24, at 2:51 AM, indicated, "...CODE BLUE [usually means that someone is experiencing a life-threatening medical emergency such as a cardiac arrest, when the heart stops, or respiratory arrest, when breathing stops]...[Resident 91] was found by CNA [Certified Nursing Assistant] @0139 [1:39 AM]...Code [status] checked and compression [CPR started] on bed...with back board [used to assist in delivering effective chest compressions] in place and Bag-Valve mask [oxygen delivery system] started...by RNs [registered nurse]...EMS [Emergency Medical Services] arrival @0147 [1:47 AM] and taken over CPR...IV [intravenous; insertion of a tube into a vein to deliver fluids and/or medications] insertion 0157 [1:57 AM] (500 ml [milliliters a unit of volume] fluids started) total fluid 1500ml, total epi [epinephrine: an emergency medication administered to increase the chance of restoring a heartbeat] administered [given via] IV (4 [times]) @ (0201 [2:01 AM], 0206 [2:06 AM], 0211 [2:11 AM], 0215 [2:15 AM])...Time of death [the time when a person's vital signs, like breathing and heart, permanently stop] declared by [Medical Doctor (MD) 2] @0221 [2:21 AM]- CPR terminated [stopped]..." During an interview on 2/5/25, at 3:50 PM, LN 3 stated Resident 91's POLST was created on July 13, 2024. LN 3 explained Resident 91's POLST was signed by the physician on 7/23/24. LN 3 further explained, until 7/23/24, Resident 91 was a full code (to provide life saving measures such as CPR), which reflected Resident 91's discharging hospitals records. LN 3 stated when Resident 91's POLST was updated and signed by the Physician's Assistant on 7/23/24, the facility should have updated Resident 91's electronic health record (EHR; an electronic version of a resident's medical history, that is maintained by the provider over time) to reflect the DNR status as indicated on Resident 91's POLST. During an interview on 2/5/25, at 4:19 PM, LN 4 stated to check a resident's code status you would check the binder that has the residents POLST forms and the residents EHR. LN 4 explained he would check both the POLST and the EHR. During an interview on 2/6/25, at 9:13 AM, LN 6 stated a (unidentified) CNA was rounding and found Resident 91 not breathing and called for help [12/13/24]. LN 6 explained Resident 91's code status was checked in Resident 91's EHR, indicating Resident 91 was a full code. LN 6 further explained they started CPR, got the AED (automated external defibrillator; a portable device that delivers an electric shock to a person when their heart suddenly and unexpectedly stops beating), put the backboard in place, and called 911. LN 6 stated she initiated CPR. LN 6 explained the difference between the EHR and the POLST was confusing because Resident 91's POLST said DNR. LN 6 further explained they found out Resident 91's POLST indicated Resident 91 was DNR while EMS was there and informed them, but they had already provided life saving measures to Resident 91 for a few minutes. LN 6 stated the process for finding out a resident's resuscitation status was to look in the EHR. LN 6 stated the risk to performing CPR on someone who was DNR would be trauma to the resident and the resident's family. LN 6 stated they would want to follow the residents, and the families wishes. During an interview on 2/6/25, at 9:23 AM, LN 7 explained they did two to three cycles of CPR on Resident 91, stating they had applied the AED pads at the same time they started compressions. LN 7 stated he was not aware Resident 91 was DNR, stating Resident 91's EHR indicated full code, so CPR was initiated. LN 7 stated the process for determining a resident's code status was by checking the POLST to see what the resident's wishes were, full code or DNR. LN 7 stated he did not check the POLST, only the EHR. LN 7 explained the EHR was usually updated with the most current POLST. LN 7 explained the risk of performing CPR on a resident who was DNR was unnecessary damage and trauma to the resident and the resident's family. During an interview on 2/6/25, at 12:01 PM, the Administrator (ADM) stated the process for determining code status was by the POLST or by what they "tell" us in their care plan conference (a meeting where a resident's care team which typically consists of the resident, their family, and medical personnel from the facility, to discuss and update a resident's plan of care). The ADM explained the importance of knowing the residents code status was to respect the residents' wishes. The ADM further explained not following the residents wishes could cause psychosocial harm. A review of the facility policy titled, "Cardiopulmonary Resuscitation (CPR)," updated September 2017, indicated, "...CPR is initiated for those residents who...Have requested, through advanced directive [a legal document that states your wishes for medical care if you cannot make them yourself] or POLST...to have CPR initiated when cardiac or respiratory arrest occurs..." A review of the facility policy titled, "Advance Directive," revised 1/1/25, indicated, "It is the policy of this facility that residents have the right to request, refuse, and/or discontinue treatment ...and to formulate an advance directive...POLST: This document, signed by an authorized health care professional, is a medical order that records residents' treatment wishes so that emergency personnel know what treatments to provide in the event of a medical emergency..." Therefore, the department determined the facility provided cardiopulmonary resuscitation to Resident 91 on 12/13/24, against Resident 91's Physician Orders of "Do Not Resuscitate." This failure resulted in Resident 91 receiving invasive CPR against Resident 91's wishes to be DNR, with the potential to cause trauma and psychosocial harm to Resident 91. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 91.