Other·December 7, 2023

Class B Citation- Quality of Care The following reflects the findings of the California Department of Public Health during investigation of a Complaint CA00834356. Representing the Department, 47205 RN, HFEN. 42 CFR 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 42 CFR 483.12 (a) Freedom from Abuse, Neglect and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms 42 CFR 483.21 (b) (3) (i) Meet Professional Standards of Quality The intent of this regulation is to assure that services being provided meet professional standards of quality. 22 CCR 72311(a)(1)(A) Nursing Services-General 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 based upon an initial written and continuing assessment of the patient's needs. 22 CCR 72311(a)(1)(A)(B) Nursing Services-General 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 based upon an initial written and continuing assessment of the patient's needs. (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. 22 CCR 72517 (a) (10) Ongoing Facility Personnel Educational Program (a)Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not limited to: (10) choking prevention and intervention. On 4/6/2023, an unannounced abbreviated survey was conducted to investigate a complaint of a reported choking incident that required Resident 1 to be transported to the General Acute Care Hospital (GACH) on 4/1/2023 due to the facility's delayed ability to perform timely oral suctioning of Resident 1's secretions. The complainant indicated the facility did not have oral suctioning machines. The facility failed to provide services necessary for Resident 1 to reach his highest practicable physical well-being when Licensed Nurses were aware of Resident 1's diagnosis of dysphagia (trouble swallowing) and Percutaneous Endoscopic Gastrostomy (PEG- a tube inserted through the skin and the stomach wall for the placement of a feeding tube) placement and did not conduct an aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed) risk assessment on admission, and did not ensure Resident 1's head of the bed (HOB) remained elevated in accordance with professional standards and facility policy and procedure (P&P). On 4/1/2023, Resident 1 experienced a choking episode and Licensed Vocational Nurse (LVN) 2 left Resident 1's room to call Emergency Services (EMS)/911 and did not recognize the need to immediately provide emergent care, such as oral suction (removal of mucus, phlegm, saliva from the oral cavity (mouth) or application of oxygen, consistent with nursing professional standards of practice. LVN 2 was unaware the facility had readily available and functional suction machines and provided no emergency nursing interventions until EMS staff arrived, who immediately provided suctioning and oxygen. The facility was unable to provide documentation of staff competency assessment and training for all Licensed Nurses on the use of the portable suctioning machine in the event of an emergency which required Licensed Nurses to perform oral suctioning to clear resident's airway. These failures resulted in Resident 1 to experience an avoidable choking episode, prolonged hospitalization and for Resident 1 to not receive immediate emergent oral suctioning treatment to clear his airway which resulted in a decrease oxygen level. Resident 1 was transferred to the Emergency Department (ED) of a local hospital on 4/1/2023 and was admitted to the General Acute Care Hospital (GACH) Telemetry Unit (a unit of a hospital is reserved for patients who need continuous electronic monitoring of their condition) from 4/1/2023 to 4/21/2023 due to his choking episode. During a review of Resident 1's "Face Sheet" (FS- a document containing resident profile information), dated 11/2/2022, the FS indicated, Resident 1 was initially admitted to the facility on 6/21/2017 and was re-admitted on 11/18/2022 with diagnoses which included anoxic brain injury (harm to the brain due to lack of oxygen), cerebral palsy (CP- a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia, constipation, seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) and a surgical history of a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) with reversal and PEG placement. During a review of Resident 1's "Minimum Data Set" (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment, dated 3/1/2023, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 of 15 points (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). During a concurrent observation and interview, on 4/6/2023 at 9:42 a.m., with Licensed Vocational Nurse (LVN) 1, at nurses' station 3 and 4 (combined nurses' station), LVN 1 stated she was aware there were no suction machines in the residents' room but she was aware of the locations of the portable suction machines. LVN 1 stated she was aware of the choking incident of Resident 1 that occurred on 4/1/2023. LVN 1 stated on 4/3/2023, all Licensed Nurses were in-serviced by the Assistant Director of Nursing (ADON) on oral suction machines. LVN 1 stated resident rooms were not equipped with wall-suctioning. LVN 1 was able to demonstrate each nursing station had a portable suction machine stored in each unit's utility storage room. LVN 1 stated she had not received training on how to use the portable suction machines (they have 3) available at the facility. LVN 1 stated she was not completely comfortable using the portable suction machine but if needed to use it, even during an emergency, she could "figure it out." During an interview on 4/6/2023, at 10:50 a.m., with LVN 2, LVN 2 stated she and CNA 1 responded to Resident 1's room on 4/1/2023 after a report from the Environmental Services (EVS) staff that "white stuff was coming out from [Resident 1's] mouth, possibly choking." LVN 2 stated, " I knew it must be from his Tube Feeding (TF)." LVN 2 stated she and CNA 1 found Resident 1's HOB laying "down more than it should've been." LVN 2 stated the HOB should be higher than "30 degrees." LVN 2 stated, "I heard "gurgling sounds coming from [Resident 1] deep in his chest and white fluid coming from his mouth." LVN 2 stated, "I told [CNA 1] to lift the HOB and [Resident 1] looked like he was choking. He [Resident 1] looked like he needed deep suctioning, outside my scope of practice and all I could do is oral suction." LVN 2 stated she used "nursing judgement" when she determined Resident 1 needed deep suction instead of oral suction because she heard the gurgling "deep in [Resident 1's] lungs." LVN 2 stated she called EMS or 911. LVN 2 stated she and CNA 1 sat Resident 1 up and while LVN 2 "slapped his back," CNA 1 placed a pulse oximeter and blood pressure cuff on Resident 1 to check his blood pressure and oxygen level. LVN 2 stated, "The CNA's have this equipment readily available while waiting for EMS to arrive." LVN 2 stated, "The oxygen reading on the pulse oximeter was 91 or 92%." [documented in the Transfer document completed by LVN 2 and provided to EMS indicated Resident 1's oxygen level was at 90%] (oxygen saturation- a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry. For a healthy individual, the normal O2 should be between 96% to 99%)." LVN 2 stated she did not apply oxygen to Resident 1 for decreased oxygen levels before EMS arrived. LVN 2 stated "I was not sure if [Resident 1] routinely used oxygen. I did not see an oxygen tank in the room." LVN 2 stated the oral suction machine was not used or brought to Resident 1's bedside and she did not ask for help or assistance from any other staff or Licensed Nurses before the EMS staff arrived. LVN 2 stated the ambulance was located "just around the corner" and arrived within minutes of her placing the 911 call. LVN 2 stated she would have "grabbed suction, but EMS showed up quickly." LVN 2 stated while providing EMS staff with a brief report of Resident 1's condition, two other EMS staff were attending to Resident 1 at his bedside. LVN 2 stated an EMS staff asked her if [the facility] had a "suction machine." LVN 2 stated, "I told the EMS worker, no we don't have one, I called you guys [EMS]." LVN 2 stated EMS staff suctioned Resident 1 until he was loaded to the ambulance. LVN 2 stated LVN 3 educated her on where the portable suction machines were kept in the facility. LVN 2 stated she never had to use the portable suction machine but feels "comfortable using it." LVN 2 stated training on the use of the portable suction machine /set-up was done "right after she was hired." LVN 2 stated another in-service was done after Resident 1 was sent to the hospital to make sure everyone knew where the suction "cart" is. During an interview on 4/6/2023, at 11:10 a.m., with LVN 3, LVN 3 stated she was the House Supervisor on 4/1/2023. LVN 3 stated she was told by another staff member, at around 11:30 a.m. that Resident 1 had been "sent out and EMS was wanting to speak with her." LVN 3 stated EMS reported that LVN 2 stated "We don't have suction machines." LVN 3 stated she notified the Director of Nursing (DON) via text message of this event and the statement made by LVN 2 regarding not knowing the location and how to use the oral suction machines. LVN 3 stated she showed LVN 2 the location of where the portable suction machine was kept at the facility at nurse's stations 3 and 4. LVN 3 stated, "[LVN 2] said she didn't know about portable suction machine availability, sorry." During an interview on 4/6/2023, at 11:25 a.m., with CNA 1, CNA 1 stated she entered Resident 1's room and saw Resident 1 lying in bed with the HOB "lower than how it was left after shower". CNA 1 stated LVN 2 told her to raise the HOB to "90 degrees". CNA 1 stated after raising the HOB, she noticed Resident 1 was "trying to cough it up." CNA 1 stated LVN 2 told her "Just let [Resident 1] try to finish coughing it out" and she asked LVN 2 how she could help with the situation. CNA 1 stated LVN 2 did not ask her to bring the portable suction machine to Resident 1's room. CNA 1 stated she had brought the portable suction machine to a Licensed Nurse before and knew where the oral suction machines were located and what supplies are needed to provide oral suction. CNA 1 stated she did not suggest using the portable oral suction machine for Resident 1 to LVN 2 at the time of the emergency. CNA 1 stated she did not know why Resident 1 was lying in bed with his HOB flat. CNA 1 stated she knew it was important for Resident 1 to have his HOB elevated when the TF was connected and/or running to prevent vomiting or aspiration. During an interview on 4/6/2023, at 1:55 p.m., with the DON, the DON stated LVN 3 called her on 4/1/2023, to report Resident 1 was "sent out" to the GACH. The DON stated LVN 3 also informed her that the EMS staff notified LVN 3 that LVN 2 stated the facility did not have suction machines that were readily available for use in an emergent situation. The DON stated she directed LVN 3 to immediately educate LVN 2 about the location and the availability of the portable suction machines. The DON stated she and the ADON discussed the need for immediate training of all Licensed Nurses about the location of the portable oral suction machines, when and how to use it during an emergency such as when a resident was coughing up a lot of secretions. The DON stated the ADON immediately began training the nursing staff on 4/3/2023. The DON stated she was familiar with Resident 1 and his care needs and that her expectation of the Licensed Nurses regarding any report of resident distress would be "immediate assessment, identification of cause for distress, and performance of nursing interventions (such as suction) based on the nurse's clinical assessment of the resident's condition (such as choking)." The DON stated calling 911 was important, but it was her expectation that the Licensed Nurse would stay in the room with the resident during any emergency. The DON stated, "[LVN 2] should have asked for help to call 911, manage resident symptoms, or for someone to get the suction machine." The DON stated it was her expectation LVN 2 would be able to provide oral suctioning as needed and as ordered by the provider especially during an emergency. The DON stated she did not understand why LVN 2 would not have performed a physical assessment such as listening to Resident 1's lung sounds with a stethoscope, provide oral suction, or choking interventions to help clear Resident 1's airway while waiting for EMS staff to arrive. The DON stated she did not know why LVN 2 would state that the facility did not have portable oral suction machines because this was covered and discussed during the new hire orientation. The DON stated LVN 2 and all Licensed Nurses, including CNAs, were required to have a current Cardiopulmonary Resuscitation (CPR) training and certification card (choking interventions are part of this course) to be employed at the facility. During a review of the facility Progress Note (PN) dated 4/1/2023, at 2:28 p.m., the PN indicated, " ...Late Entry Effective Date 4/1/2023 at 9:06 a.m.: " ...Writer and CNA entered room and observed [Resident 1] lying flat and choking. Writer instructed CNA to lift head of bed because a g-tube patient cannot lay flat because they can aspirate. Head of bed was raised, and resident began choking and was unable to clear his mouth or airway. Writer contacted EMS to transfer resident to ED. EMTs entered facility and began to suction resident and transfer him to gurney. EMT asked writer if she had a suction machine and writer stated she did not have the suction machine. It is outside the scope of practice for an LVN to suction so writer immediately contacted EMS [Emergency Medical Services] when resident was observed choking. EMT [Emergency Medical Technician] suctioned resident until they got him into the ambulance, and they turned on lights and sirens as they left. ..." The PN indicated a correction to original PN dated 4/1/2023 at 2:28 p.m. " ... An LVN can suction a resident but cannot deep suction." During a review of the Ambulance Report dated 4/1/2023, the Ambulance Report indicated that the dispatch center received the call for service at "11:02 a.m." ... " ...ambulance enroute at 11:04 a.m. ...", " ...at scene: 11:06 a.m., at patient: 11:08 a.m., Depart: 11:16 a.m. ...." " ...SpO2 83%..." on " ...room air ..." " ...effort labored ...", " ...respirations 24 ..." " ...Activities ...Procedures, 11:11 a.m. Airway suctioning ..." " ...11:14 a.m. oxygen application " ... " ...SpO2 95%..." on " ... ..." " ...