Health inspection·January 18, 2024

F689 Title 42, Section 483.25 Free of Accident Hazards/Supervision/Devices Section 483.25(d) Accidents. The facility must ensure that - Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 8/31/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate Complaint CA00856897 regarding quality of care. The department determined the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards when Resident 1, who had an order to not be fed any food or water by mouth ([NPO] nil per os meaning nothing by mouth), was given a meal tray. This failure resulted in Resident 1 to choke evidenced by coughing, labored breathing, and low oxygen levels. He was subsequently transferred to the hospital and passed away. Resident 1 was admitted to the facility on 8/18/23 at 2:12 a.m. Residents 1's "Admission Record" face sheet indicated Resident 1 had diagnoses that included dysphagia (difficulty swallowing) and had a Gastrotomy Tube (G-Tube, a tube inserted through the stomach that brings nutrition, hydration, and medications). A review of Resident 1's "Order Summary Report," dated 8/18/23 revealed a Medical Doctor (MD) ordered Resident 1 to be on a NPO diet. A review of Resident 1's "Nutritional Risk Assessment (Admission/Annual)-V 3.0," dated 8/18/23 at 10:38 a.m., the Registered Dietician (RD) indicated, "Resident is strict NPO-nutrition through G-tube related to dysphagia from throat cancer." A review of Resident 1's "Progress Notes" (PN), dated 8/18/23 at 11:12 a.m., the PNs indicated at 8:30 a.m., Resident 1 was accidently served a breakfast tray "while on NPO status." Resident 1 was observed "coughing while eating the foods on his tray." The food tray was immediately removed. "While continuing to monitor resident's condition, resident noted to be coughing out thick yellow mucus, having labored breathing, desatting [low oxygen level] at 89% on 3.5 L [liters] oxygen, BP [blood pressure] 190/75, HR [heart rate] 103, RR [respiratory rate] 24. Lungs sounds diminished, whooshing sounds noted bil [bilateral]." "Attending physician was notified at 1000 [10 a.m.]" of Resident 1's symptoms and gave an order to transfer Resident 1 to the hospital. Resident 1 was transported out at 10:20 a.m. accompanied by the fire department via gurney. A review of Resident 1's "Hospitalist Admission History & Physical," dated 8/18/23 at 2 p.m., indicated, "Chief Complaint: Cough and shortness of breath patient had an aspiration event today at the skilled nursing facility was sent in for choking.... Patient was sent in by the local skilled facility because of a choking event. Patient does have cough and congestion..." Under the section "Assessment & Plan" indicated "Aspiration pneumonia [a lung infection that develops after you inhale food, liquid, or vomit into your lungs] of both lungs, unspecified aspiration pneumonia type, unspecified part of lung/acute hypoxic [absence of enough oxygen] respiratory failure..." A review of Resident 1's hospital "Discharge Summary," dated 8/23/23 at 3:29 p.m., indicated, "Discharge Diagnosis: Acute on chronic respiratory failure aspiration pneumonia." The "Discharge Summary" indicated, "Patient was treated with antibiotics and diuretics [medicines that help reduce fluid buildup in the body]. He did not improved (sic). Patient started requesting AIM [Advanced Illness Management-hospital based Palliative Care team] consultation...Patient was made DNR [Do Not Resuscitate]. Subsequently to which patient has progressively gotten worse..." Resident 1 expired on 8/23/23 at 2:38 p.m. During an interview on 8/31/23 at 9:48 a.m., with the Director of Nursing (DON), The DON stated Resident 1 was given a breakfast tray by accident by Certified Nursing Assistant (CNA) 1. A nurse was walking by and noticed Resident 1 was coughing while eating his breakfast and immediately removed the tray. The DON confirmed Resident 1 had a diet order of NPO. The DON stated an investigation was conducted and it was determined that Resident 1 was asking for food. CNA 1 proceeded to the kitchen to get Resident 1 a breakfast tray. The DON stated this is not the facility's protocol. If a resident doesn't have a meal tray, the CNA should have informed the nurse. The nurse is then to print out the diet order and bring the printed-out order to the kitchen. The DON stated nurses are to check meal trays before they are to be delivered to the residents. During a telephone interview on, 9/26/23 at 10:15 a.m., with CNA 1, she confirmed she worked the a.m. shift on 8/18/23. CNA 1 stated she noticed Resident 1 did not get a tray. CNA 1 stated she then proceeded to the kitchen to get a meal tray for Resident 1.CNA 1 stated she received a regular diet, meal tray for Resident 1. She took the meal tray to Resident 1 and placed it within reach of Resident 1. CNA 1 stated she didn't take the lid off his plate before leaving his room to help another resident and Resident 1's head of bed was around "45" degrees. CNA 1 confirmed, upon coming onto her shift, she had received report from the night CNA but was not told Resident 1 was NPO. CNA 1 also confirmed the a.m. LN did not inform her Resident 1 was NPO. CNA 1 sated she was not aware of any facility practice that LNs check trays on the floor before CNAs start passing them to the residents. During a review of the facility's policy and procedure (P&P) titled, "NPO Orders," revised April 2007, the P&P indicated, "A resident's food tray shall be held as necessary to perform a test or treatment ordered by the Attending Physician. The Nursing staff will use the diet change notification form to notify Food Services staff when it is necessary to hold a resident's food tray, and also when the tray delivery can resume." During a review of the facility's P&P titled, "Tray Identification," revised April 2007, the P&P indicated, "Nursing staff shall check each food tray for the correct diet before serving the residents." A review of the County, "CERTIFICATE OF DEATH", dated 10/17/23 indicated the cause of death as, "(A) ACUTE RESPIRATORY FAILURE (B) ASPIRATION PNEUMONIA". Therefore, the Department determined the facility failed to ensure Resident 1 was free of accident hazards when Resident 1, who had an order to not be fed any food or water by mouth (NPO), was given a meal tray. This failure resulted in Resident 1 to choke evidenced by coughing, labored breathing, and low oxygen levels. He was subsequently transferred to the hospital and passed away. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.