Health inspection·May 30, 2024

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide emergency basic life support, including Cardiopulmonary Resuscitation (CPR, any medical intervention used to restore blood circulation or breathing functions that have ceased) to Resident 1 who was found with no pulse and no spontaneous respiration. This failure resulted in the delayed provision of emergency basic life support for Resident 1. Resident 1 was pronounced deceased by emergency personnel at 5:52 a.m., 42 minutes after Resident 1 was found with no pulse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in [DATE] with diagnoses that included anoxic brain damage (brain injuries that are caused by a complete lack of oxygen to the brain), dependence on respirator status and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 1's Physician Orders for Life Sustaining Treatment form (POLST, a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him/herself), dated [DATE], Section A indicated to Attempt Resuscitation/CPR. During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated Resident 1's code status was FULL CODE (If a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). During a telephone interview on [DATE] at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on [DATE], early morning around 5 a.m., she was in another hallway, away from Resident 1's room when a Certified Nursing Assistant (CNA) called to say Respiratory Therapist (RT) 1 needed help in a Resident 1's room. LVN 1 stated she went to Resident 1's room to find RT 1 alone at Resident 1's bedside, bagging (use of a medical tool, a bag valve mask [BVM] or otherwise known as ambubag, which forces air into the lungs of patients who have either ceased breathing completely or who are struggling to breathe properly and need additional assistance in breathing). LVN 1 stated Resident 1's skin had already turned blue. LVN 1 stated RT 1 asked when LVN 1 had last checked on Resident 1 because RT 1 had been bagging Resident 1 for 15 minutes. LVN 1 stated she asked RT 1 if RT 1 had already called a code (a term used when a patient is in cardiopulmonary arrest [loss of effective heart Page 1 of 3 056327 056327 05/30/2024 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few function, breathing and consciousness] requiring a team of providers, sometimes called a code team, to rush to the specific location and begin immediate resuscitative efforts) but RT 1 did not answer. LVN 1 stated she left the room, called a code, and instructed another staff to call 911 while grabbing the crash cart. LVN 1 stated RT 2, who was the RT assigned to Resident 1, entered Resident 1's room, and stood by RT 1 at the bedside. LVN 1 stated both RT 1 and RT 2 did not start chest compressions on Resident 1. LVN 1 stated after a few seconds, RT 3 and another licensed nurse both entered the room and started chest compressions on Resident 1 while LVN 1 documented the time and sequence of the Code procedure. During a telephone interview on [DATE] at 9:04 p.m. with RT 1, RT 1 stated not knowing who called the code or who called 911. RT 1 stated Resident 1 was breathing fine and was not in respiratory distress, but the ventilator alarms continued to beep so RT 1 called for RT 2 right away. RT 1 could not recall checking if Resident 1 had a pulse. During a telephone interview on [DATE] at 1:11 p.m. with RT 2, RT 2 stated after returning to the unit from break around 5 a.m., RT 1 and LVN 1 were both in Resident 1's room. RT 2 stated being told by RT 1 that Resident 1 had desaturated (oxygen level in the blood is dropped) and had to be given 100% oxygen via BVM. RT 2 stated RT 1 was bagging Resident 1, who did not have a pulse and whose skin color was not good and looked pale. RT 2 stated a Code was called and RT 3 reentered the room and delivered chest compressions with the help of another staff. During a review of Resident 1's Health Status Note, dated [DATE], the Health Status Note indicated the following documentation in the order of the time they were written: 1. Incident Note, dated [DATE] at 6:50 a.m. entered by RT 2, the Incident Note indicated at 5:10 a.m., RT 2 was called into Resident 1's room by RT 1, Resident 1 was pale in color and did not have a pulse. Compressions initiated with AED and code blue announced. Nurse called 911 .Nurse and RT continued compressions with AED. Paramedics arrived at about 5:20 a.m. and took over. Resident 1 was pronounced expired at 5:52 a.m. See nurses [notes] for further information. 2. Health Status Note, dated [DATE] at 7:35 a.m. entered by RT 1, the Health Status Note indicated RT 1 entered Resident 1's room due to ventilator alarms beeping. RT called at 05:10, RT arrived and found with no pulse, Nurse called 911 and compressions /AED initiated with [oxygen] delivery at 100% via bag valve mask .Paramedics arrived around 5:20 and relieved RT and nurses. See nurse notes for more information. 3. Health Status Note, dated [DATE] at 8:25 a.m. entered by LVN 1, the Health Status Note indicated RT 1 called into Resident 1's room by RT 2, Resident 1 Was assessed to have no pulse and pale in color, compressions initiated with AED and code blue announced. Nurse called 911. Nurse and RT continued compressions with AED and oxygen delivery at 100% via bag valve mask. Resident suctioned by RT 2. Began compressions until paramedics arrived at about 05:20, RT's and nurses relieved by paramedics and continued code blue. Family notified. At 5:52 resident pronounced expired by paramedics. During a follow-up telephone interview on [DATE] at 4:07 p.m. with LVN 1, LVN 1 stated the Health Status Note that she entered into Resident 1's clinical record did not include all the important details about the incident on [DATE]. LVN 1 stated RT 1 and RT 2 both told her that her documentation should match RT 1 and RT 2's notes that were already in the clinical record. LVN 1 stated, although LVN 1 wrote down the times and the sequence of the team's efforts when Resident 1 coded, LVN 1 stated not knowing how to document them in the clinical record. LVN 1 stated being told to document only 056327 Page 2 of 3 056327 05/30/2024 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

F 0678 the basics of what happened and the approximate times. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), last revised [DATE], the P&P indicated the following steps: Residents Affected - Few 1. Check the patient for pulse and respirations, if they are absent, attempt to arouse the patient by shaking them or by sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and responsive). If the patient is unresponsive, follow steps 2 through 6. 2. Activate the emergency response team and initiate CPR, call a code and designate a staff person to call 911. 3. Open the airway. 4. Check breathing. 5. Administer rescue breaths. 6. Check for pulse. 7. Give chest compressions. Document the following in the resident's medical record; the condition in which the resident was found, the sequence of resuscitation efforts including approximate times, the resident's response to resuscitation efforts, approximate time EMS team took over, time of death or time the resident was transported. 056327 Page 3 of 3