Health inspection·December 13, 2021

F678 Cardio-Pulmonary Resuscitation (CPR) 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. 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. 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. The following was written as a result of an unannounced investigation for two (2) complaints #CA00606247 and #CA00605866. The complaints were initiated on 10/2/18. The Department determined that the facility failed to ensure Resident 1 was assessed when he had increased blood pressure, declined his medications except for his inhalers for breathing, and when he was unresponsive, cyanotic (bluish discoloration of the skin), had no pulse, and was not breathing. Upon admission, Resident 1 requested CPR (cardiopulmonary resuscitation, a procedure performed on an individual whose heart and breathing have stopped) interventions to prolong his life if he had no pulse and had stopped breathing. According to record review of the admissions record, Resident 1 was admitted to the facility in 2017, at age 67, with a primary diagnosis of myocardial infarction. Additional diagnoses included atrial flutter (a type of heart rhythm disorder (arrhythmia) caused by problems in the heart's electrical system) hypertension (above normal blood pressure), heart failure (the heart can't pump enough blood to meet the body's needs), chronic respiratory failure (usually happens when the airways that carry air to the lungs become narrow and damaged; this limits air movement through the body, which means that less oxygen gets in and less carbon dioxide gets out; this gradually develops over time and requires long-term treatment), and ischemic heart disease (an ongoing condition causing insufficient blood flow to the heart muscle when one or more of the heart arteries (blood vessels that carry oxygenated blood) becomes blocked or narrowed, often resulting in chest pain). The admission record indicated Resident 1 was his own Responsible Party (able to make his/her own decisions). According to record review, a valid Physician Orders for Life-Sustaining Treatment form (POLST, directs individual end of life preferences during a medical emergency), dated 7/6/17, was signed by Resident 1 and his physician. The POLST form indicated Resident 1 had selected, "Attempt Resuscitation/CPR ... Full Treatment-primary goal of prolonging life by all medically effective means." According to clinical record review, a care plan referring to Resident 1 adapting to long-term placement in the facility, revised 3/12/18, indicated Resident 1 chose CPR and full treatment on his POLST. According to record review, Resident 1 had a physician's order, dated 3/13/18, for CPR. According to record review, Resident 1 had a physician's order, dated 5/24/18, for nitroglycerin (a drug that relaxes the blood vessels, so the heart does not need to work as hard and therefore does not need as much oxygen) tablets 0.4 mg (milligrams, a unit of measurement) 1 tablet under the tongue every 5 minutes as needed for chest pain up to 3 doses. If there was no relief, then call the physician. A physician's order, dated 3/13/18, indicated oxygen 1-4 liters by nasal cannula to keep Resident 1's oxygen saturation levels above 90%. Documenting oxygen saturations and liters per minute was ordered for every night shift. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/13/18, was reviewed. The MDS indicated "Attempt resuscitation / CPR." The MDS specified a Brief Interview for Mental Status (BIMS, - a tool to assess understanding) score of 15/15 indicating Resident 1 was cognitively intact. Resident 1's nursing progress note, dated 9/29/18 at 12:16 p.m., was reviewed. The note indicated Licensed Nurse (LN) 3 went into Resident 1's room at 9:20 a.m. to administer his medications. Resident 1 wanted his inhalers to breathe and did not want the rest of his medications. Prior to administering the medication, Resident 1's blood pressure was 150/80 (the BP was abnormal but there was no indication the BP was assessed. Between 9/21/2018 and 9/28/2018, Resident 1's average BP was 114/65). Resident 1 had an irregular heart rate of 96 beats per minute (Between 9/21/2018 and 9/28/2018, Resident 1's average HR was 65). At 9:45 a.m., Resident 1 informed LN 4 he was having chest pain. LN 4 notified LN 3 of Resident 1's chest pain and LN 3 administered one nitroglycerine tablet to Resident 1, "then he laid his head down." LN 3 exited the room and asked Certified Nursing Assistant (CNA 1) to take Resident 1's blood pressure (There was no indication the CNA took Resident 1's BP). LN 4 notified LN 3 that Resident 1 "is blue and unresponsive" (There was no documentation LN 4 assessed the resident when he was blue and unresponsive before notifying LN 3). LN 3 went back into Resident 1's room at 9:50 a.m. Resident 1 "was found cyanotic [bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation] no breathing, no vital signs [blood pressure, pulse]. [LN 3] attempted to arouse [Resident 1] with sternal rubs [vigorous rubbing on the center of the chest] and calling out his name with no response. While in [Resident 1's] room [LN 3] told [LN 4] to call [Resident 1's] MD [medical doctor]. [LN 4] told the MD that [Resident 1] was cyanotic and unresponsive. MD asked what happened he then advised [LN 3] to call [Resident 1's] daughter and explain the situation and what led up to the incident." According to record review, no documented evidence was found in Resident 1's clinical record indicating LN 4 assessed Resident 1 when LN 4 learned Resident 1 was unresponsive. According to record review, no documented evidence was found in Resident 1's clinical record indicating CPR was initiated or 911 was called when Resident 1 was found unresponsive. According to record review, Resident 1's progress notes, dated 9/29/18 at 12:16 p.m., indicated Resident 1 died in the facility on 9/29/18. Review of a copy of the facility's on-line pharmacology resource Epocrates, as provided by the Director of Staff Development (DSD) on 10/16/18 at 10:00 a.m. included, the following concerns related to the possible adverse effects (secondary, unwanted effects that occur due to drug therapy) of nitroglycerine: "May cause hypotension...may cause dizziness...may cause syncope (a loss of conscious)...may cause methemoglobinemia (a serious condition that prevents oxygen from being absorbed in the body resulting in hypoxia [the body becomes deprived of oxygen causing difficulty with breathing] and the skin turning blue in color)." The Epocrates resource also included under "Safety/Monitoring" monitor parameters, BP. Review of Lexi-Comp, an on-line pharmacology resource accessed on 10/16/18 at 10:30 a.m., http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7019 included the following concerns related to the possible adverse effects of nitroglycerine; "May cause hypotension...bradycardia [below normal heart rate]... dizziness...dyspnea [difficulty breathing/ shortness of breath]...diaphoresis [sweaty, cool skin] and fainting. The resource also included, use with caution in the elderly and those with heart conditions/heart failure. Nursing Physical Assessment/ Monitoring; assess cardiac status, monitor blood pressure and heart rate. A review of the Lippincott manual of Nursing Practice, seventh edition, copyright 2001, "Standards of Care Guidelines, Chest Pain", pages 357 through 359, indicate nursing assessment for the patient with chest pain should include: assessing the quality (how the pain feels)...intensity (how strong the pain is)...location (chest, arm)...and duration (when the pain started)...When administering anti-anginal medications, monitor the patient for the progression of the chest pain, the response to drug therapy and any adverse effects and take vital signs every 5 minutes until angina pain subsides or the doctor is called. Document all assessment findings. In an interview with CNA 1 on 10/2/18 at 10:55 a.m., CNA 1 stated, "[On 9/29/18, LN 3] asked me to take [Resident 1's] blood pressure and I found [Resident 1] unresponsive and blue. I went out and told [LN 4] and [LN 4] went out to find [LN 3]...[LN 4] didn't go to check on [Resident 1] first. [LN 3] went in to check on [Resident 1] and [LN 4] went to the nurse's desk. That's where [LN 4] found the shift report form and it said that [Resident 1] was a DNR (Do Not Resuscitate). [LN 4] didn't look at [Resident 1's] POLST; no one looked at [Resident 1's] POLST. The shift report form is a list of the residents with their doctor's name, their diets, and the CNAs put the vital signs on it. The nurses will use it during report. I guess it has their code status on it too. I went to get the crash cart but the Director of Nurses [DON] told us not to touch [Resident 1] because [Resident 1] was a DNR. Then [LN 3] looked in [Resident 1's] chart and saw that [Resident 1] was actually a full code. We're supposed to call for help in an emergency." In an interview with the DON on 10/2/18 at 12:10 p.m., the DON stated, "[On 9/29/18, LN 3] gave [Resident 1] a nitro pill then left [Resident 1] to go use the restroom. Then [CNA 1] found [Resident 1] unresponsive. [LN 3] went to check on [Resident 1] while LN 1 looked on the shift report form for [Resident 1's] code status. [LN 4] said [Resident 1] was a DNR, so no one started CPR. No one looked at his POLST or his orders. I told everyone if [Resident 1] is a DNR not to touch him. [LN 3] should have looked for [Resident 1's] POLST, not relied on that report form. [Resident 1] should have gotten CPR. The nurses are supposed to call 911 and start CPR if a resident is a full code. The nurses don't use that shift report form anymore, I pulled it from all the nurse's stations. I don't have the one from the 29th. I shredded it." The DON acknowledged that Resident 1's POLST, dated 7/6/17, was valid. The DON stated, "This is a valid POLST [dated 7/6/17]; the nurses should have started CPR and called 911." In an interview with the ADON on 10/2/18 at 12:40 p.m., the ADON stated, "I was walking past [Resident 1's] room and [Resident 1] complained to me of having chest pain. I told [LN 4] and [LN 4] went to find [Resident 1's] nurse [LN 3]. [LN 3] gave [Resident 1] a nitro. I left the station and shortly after I heard what happened, that [Resident 1] died. The nurses are supposed to look on the POLST for the resident's code status. We keep a binder at the nurse's station just for that purpose, easy access. The nurses should not have looked on the shift report form. I expect the nurses to start CPR if a resident is a full code, even if they are cyanotic. [LN 3] should have stayed with [Resident 1] to monitor him." In a review of Resident 1's clinical record, the ADON confirmed that Resident 1 had a valid POLST form [dated 7/6/17]. The ADON stated, "The nurses should have called 911 and started CPR." In an interview and concurrent record review with the DSD on 10/2/18 at 1:00 p.m., the DSD stated, "Resident 1 had a valid POLST form [dated 7/6/17] included in the clinical record. The DSD stated, "[Resident 1's] POLST form [dated 7/6/17] was valid, the nurses should have started CPR." In an interview with the facility's Administrator (AD) on 10/2/18 at 1:45 p.m., the AD stated, "I know the nurses are supposed to look at the resident's POLST for their code status, not the shift report form." In a telephone interview with LN 3 on 10/2/18 at 6:00 p.m., LN 3 stated, "Around 9:20 a.m. [on 9/29/18] I took [Resident 1's] meds to him, but he just wanted his inhalers. I left his meds at the bedside. Around 9:45 a.m., the Assistant Director of Nurses [ADON] told [LN 4] that [Resident 1] was having chest pain. [LN 4] told me. I gave [Resident 1] a nitro[glycerin] tablet. I really didn't assess [Resident 1]. I left [Resident 1] and went to the restroom. I asked [CNA 1] to check [Resident 1's] blood pressure and a few minutes later [LN 4] came to the restroom and told me [Resident 1] was unresponsive and blue. I tried to take [Resident 1's] vitals and did a sternal rub, called out his name, but [Resident 1] didn't respond. [Resident 1] wasn't stiff; I was able to get him flat on the bed. Resident 1's medications were still at the bedside. He didn't take them. I asked [LN 4] to see if [Resident 1] was a DNR. [LN 4] looked on the shift report form; it had that [Resident 1] was a DNR. I should have went right to the POLST form for his code status, not the shift report form. Then I read in [Resident 1's] chart that [Resident 1] was a full code. I should have had another nurse watch him when I went to the restroom. I should have called 911 and started CPR." In a telephone interview with LN 4 on 10/3/18 at 2:00 p.m., LN 4 stated, "[On 9/29/18] the ADON came to me and told me [Resident 1] was having chest pain. I went to find [LN 3]. A few minutes later [CNA 1] told me [Resident 1] was unresponsive. I went to the restroom to find [LN 3]. I should have went to check on [Resident 1] first and called for help but I didn't. I went to find [LN 3] first. I didn't look for [Resident 1's] DNR. I thought [LN 3] did because I heard [LN 3] say that [Resident 1] was a DNR. It was [LN 3] that looked at the shift report form. I couldn't tell you where the POLST binder is. We're supposed to look at the POLST. The DON told us not to touch [Resident 1], to leave the room and close the door; [Resident 1] is a coroner's case. A few minutes later [LN 3] read in [Resident 1's] chart that [Resident 1] was a full code, then it was too late to do CPR. We should have called 911 and started CPR. We've been using the shift report form for about a year or two. We just use it to put information on and pass it on for report. The DON took them away. It shouldn't have been used to find the code status." In an interview with the facility's Medical Director on 10/4/18 at 2:00 p.m., the Medical Director stated, "[On 9/29/18, LN 3] called to tell me [Resident 1] wasn't breathing and didn't have any vital signs, and [Resident 1] was a DNR ...I told [LN 3] not to start CPR, don't call 911. It wasn't until the next day [9/30/18] that I found out that [Resident 1] was a full code. Had I known from the start [Resident 1] was a full code I would have told the nurse to start CPR and call 911." Review of the facility's policy titled, "Emergency Procedure-Cardiopulmonary Resuscitation," revised 4/16, indicated, "6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Basic Life Support] shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation [an automated external computerized device used to restart a heart that has stopped beating] exists for that individual...7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR..." According to record review of the Certificate of Death, date of death 9/29/18, indicated Resident 1's immediate cause of death was cardiac arrest (a condition in which the heart malfunctions and suddenly stops beating, resulting in loss of consciousness, pulselessness, and death, without immediate intervention.).