Health inspection·October 19, 2022

F 684 Quality of Care Section 483.25 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. The facility failed to provide quality care and services to Resident 1, when Resident 1 had a change in condition and was not sent to the hospital for higher level of care per his wishes, and CPR (Cardiopulmonary Resuscitation: an emergency lifesaving procedure performed when the heart stops beating) was not attempted for Resident 1 per physician order and his wishes. As a result, Resident 1's wishes were not honored, and Resident 1 passed away at the facility. Findings: On 6/2/21, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Resident 1 had a change in condition and no CPR was provided. Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in February 2022 with multiple diagnoses including heart failure (a condition in which the heart does not pump blood as well as it should), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of Resident 1's MDS (Minimum Data Set: a standardized assessment tool that measures health status in nursing home residents) dated 2/28/22, indicated Resident 1 had moderately impaired cognition, was receiving hospice services (care and services provided at the end of life), and indicated to attempt CPR and to provide full treatment (to provide IV fluids [fluids given through a needle inserted into a vein], antibiotics, CPR, and all other intensive medical care including transfer to a hospital). Review of Resident 1's POLST (Physician Orders for Life Sustaining Treatment) dated 1/10/2022, indicated, "...First follow these orders, then contact Physician/NP [nurse practitioner]/PA [physician's assistant]: A copy of the signed POLST form is a legally valid physician order...A...CARDIOPULMONARY RESUSCITATION (CPR): If patient has no pulse and is not breathing...Attempt Resuscitation/CPR...B...MEDICAL INTERVENTIONS ...Full Treatment - primary goal of prolonging life by all medically effective means..." Resident 1's POLST was signed by the physician. Review of Resident 1's nurses' progress notes dated 5/18/22, timed 1:34 a.m., indicated, "...The Change In Condition [CIC] ...Shortness of breath Seizure...Nursing observations, evaluation and recommendations are: resident is twitching and has SOB [Shortness of Breath], O2 [Oxygen] sat. [Saturation of oxygen in the blood] low 74 % [90% and above is normal]. Hospice [Hospice company name] notified with order of PRN [as needed] O2 and to give 1x [1 time] dose of Divalproex [medicine used to treat seizures] 125mg [milligram: unit of measurement] for twitching or seizures..." Further review of Resident 1's nurses' progress notes failed to show continued monitoring of Resident 1's health condition and notification of his CIC to his primary care provider. Review of Resident 1's nurses' progress notes dated 5/18/22, timed 2:30 a.m., indicated, "Resident found unresponsive, no V/S [vital signs: body temperature, pulse rate, respiration rate, blood pressure, O2 sat.] appreciated, pupils fixed and dilated [when the black center of your eyes are larger than normal and unmoving]. Called [hospice company name] hospice nurse...and was here to pronounce expiration..." Further review of nurses' progress notes failed to show CPR was attempted for Resident 1 when he was found unresponsive or was sent to the hospital. Review of Resident 1's care plan dated 3/8/22, indicated," The resident has Heart Failure diagnosis upon admission...Interventions...Notify MD of significant abnormalities..." Review of Resident 1's care plan dated 3/14/22, indicated, " The resident has a terminal prognosis...Interventions...Assess resident...and respect resident wishes..." During an interview on 5/19/22 at 5 p.m., the Administrator (ADM) stated Licensed Nurse (LN) 1 reported to the hospice nurse Resident 1's low O2 sat. of 74% and she found Resident 1 unresponsive on 5/18/22 at 2:30 a.m. The ADM stated the hospice nurse told LN 1 not to send Resident 1 to the hospital. The ADM stated, "[Resident 1] has an order for full code and the hospice nurse has nothing to do with it. The POLST was prepared by Hospice, and [Resident 1] came in with it in February. It states Full Code [Attempt CPR and provided full treatment]." During an interview on 6/1/22 at 2:12 p.m., the ADM verified Resident 1's POLST indicated Resident 1 was full code and CPR was not performed when he was found unresponsive. The ADM stated Resident 1's O2 sat. was in the 70's which was critical, an emergency, and LN 1 should have called 911. The ADM further stated LN 1 should have never left Resident 1 by himself when his O2 sat. was in the 70's. The ADM added LN 1 should have monitored Resident 1 continuously until his O2 sat. was stable, above 90% or until paramedics arrived, and Resident 1 was sent to the hospital. The ADM stated LN 1 should have initiated CPR when Resident 1 was found unresponsive. During an interview on 6/1/22 at 2:40 p.m., the Director of Nursing (DON) stated Resident 1 should have been sent to the hospital when his O2 sat. dropped to 74% since he was a full code. The DON verified Resident 1's primary care provider was not notified of Resident 1's CIC on 5/18/22, of the low 02 sat., or the twitching/seizure. The DON stated, "Nurse should check the POLST and initiate CPR if resident is full code and shouldn't depend on what hospice said." The DON further stated LN 1 should have initiated CPR when Resident 1 was found unresponsive and called 911 to honor his wishes and to save his life. During an interview on 6/1/22 at 3:29 p.m., the ADM stated it was important to follow the POLST to honor the resident's wishes, "It is giving resident a chance... [Resident 1's] chance was taken away." During an interview on 6/22/22 at 11:56 a.m., the hospice nurse stated the call center took the calls from nursing facilities at night and then connected the facility caller to the hospice nurse. The hospice nurse stated the following events happened on the night of 5/18/22 for Resident 1: - He [hospice nurse] received the first call on the night of 5/18/22 from the facility that Resident 1's oxygen level was going below 90% and the facility needed an order for oxygen. He told them to go ahead and apply the oxygen. - Around 2:41 a.m., he received another call from LN 1 who reported Resident 1 passed away at 2:30 a.m. He told LN 1 that he would come to the facility for Resident 1's death visit. - Around 2:45 a.m., he received another call from LN 1 to bring Resident 1's updated POLST that would indicate Resident 1 was DNR (Do Not Resuscitate). He told LN 1 there was no updated POLST, and Resident 1 was full code. At that point LN 1 was panicking and he thought LN 1 did not check Resident 1's POLST until after Resident 1 was expired when it was too late to perform CPR. The hospice nurse stated LN 1 assessed Resident 1 and only asked him for an oxygen order. The hospice nurse further stated a drop in O2 level was common in hospice residents. The hospice nurse added he did not know Resident 1 had a dramatic CIC. The hospice nurse further stated LN 1 only asked him for an O2 order. The hospice nurse stated he did not tell LN 1 not to send Resident 1 to the hospital or not to perform CPR. Review of the hospice call log for Resident 1 dated 5/18/22, indicated the following: " 0115... [LN 1], facility staff nurse, calling from [facility name] to report patient's 02 sat is very low and she is asking if she may have an order for oxygen. Caller also reports patient is "twitching" and patient has an order for DIVALPROEX ... With permission, caller placed on hold to contact the NOC [night shift hospice staff] ... "0118...Call placed to [hospice nurse] License Vocational Nurse. Warm transfer [LN 1 was successfully connected with hospice nurse] successful..." "0241... [LN 1] ...Calling to report the pt [patient] passed at 230 [2:30 a.m.]. Pt is under conservatorship [legal guardian appointed by the court]. Placed caller on hold..." "0245...Called [hospice nurse] License Vocational Nurse, message relayed. [Hospice nurse] states he will send a nurse. Returned to caller to update..." "0248... [LN 1] ...Caller The caller states the patient is a full code. She needs to speak with [hospice nurse] right away. The caller agreed to hold..." "0251... [hospice nurse] License Vocational Nurse warm transfer completed..." Review of a hospice document titled "Statement" dated 5/18/22, indicated, " [hospice nurse] ... On 5/18/2022 I received a call from...facility nurse [LN 1] was requesting for an order of oxygen since his [Resident 1's] oxygen saturation was very low...advised to give oxygen for comfort measures per facility protocol. Nurse verbalized understanding and was informed to call...hospice with any concerns. 5/18/2022 at 0241 am Received a call from...facility nurse [LN 1] who reported that patient passed on at 2:30am. Hospice nurse advised that he will go or send someone. 5/18/2022 at 0245 am Received another call from...nurse [LN 1] asking if Hospice nurse is coming and was advised he was enroute. Before I started my journey, I received another call from [Hospice Call Center] with nurse [LN 1] on hold, she stated she wanted to talk to [hospice nurse], I talked to [LN 1] who stated that patient was a full code and she wanted me to bring updated POLST form. Hospice nurse explained to [LN 1] that even on the Hospice records the patient [Resident 1] is full code and if the patient has already expired, I am still on my way for the death visit..." During an interview on 6/23/22 at 5:42 p.m., LN 2 stated she worked on 5/18/22 alongside LN 1. LN 2 stated LN 1 told her that night that Resident 1's O2 sat. was dropping and she was going to call hospice. LN 2 stated LN 1 started Resident 1 on oxygen. LN 2 stated she was assigned to the South unit at the back and when she came back to the nurses' station from the South unit, "within an hour she told me he expired. She called hospice, when she was on the phone with hospice, she went through his chart. She said he's full code. She looked at me and said he's full code. I was like what?" LN 2 further stated she heard LN 1 telling hospice on the phone, "I have him as full code... Do you have an updated POLST?" LN 2 stated she did not hear what the hospice nurse told LN 1 on the other end of the phone. LN 2 stated CPR was not attempted for Resident 1. LN 2 stated CPR should be initiated right away on a full code resident when found not breathing. LN 2 stated, "It doesn't matter if resident on hospice, when full code, follow the POLST, put O2 on to keep the O2 sat. up, contact the MD [Medical Doctor], let him know of resident condition and send resident out." Multiple attempts were made to interview LN 1 with no success. Review of Resident 1's "CERTIFICATE OF DEATH" issued 7/18/22, indicated immediate cause of death was cardiac arrest (the heart suddenly and unexpectedly stops pumping). Review of the facility procedure titled "Emergency Procedure - Cardiopulmonary Resuscitation" revised April 2016 indicated, "...If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR...Instruct a staff member to activate the emergency response system (code) and call 911....instruct a staff member to verify the DNR or code status of the individual...Continue with CPR... until emergency medical personnel arrive..." Review of the facility policy titled "Change in a Resident's Condition or Status" revised 5/17, indicated, "...The nurse will notify the resident's Attending Physician or physician on call when there has been a... significant change in the resident's physical/emotional/mental condition..." Review of the facility policy titled, "Advance Directives" revised 12/16, indicated, "...The plan of care for each resident will be consistent with his or her documented treatment preferences...A resident will not be treated against his or her own wishes..." In violation of the above cited standards, the facility failed to provide quality care and services in accordance with professional standards of practice for Resident 1, including but not limited to when Resident 1 had a change in condition and was not sent to the hospital for higher level of care per his wishes, and CPR was not attempted for Resident 1 per physician order and his wishes. As a result of this failure, Resident 1's wishes were not honored, and Resident 1 passed away at the facility. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death of a patient or resident.