Other·January 30, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Complaints CA00873047 and CA00873318 Event # KJGU11 Representing the Department, HFEN 38243 State Citation ___ was written REGULATORY VIOLATION (S): F678 Title 42 §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. FINDINGS: On 12/6/2023, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment. The facility failed to initiate cardiopulmonary resuscitation (CPR, a lifesaving technique consisting of chest compressions and often combined with artificial ventilation used in emergencies to treat persons with ineffective heart pumping/beating and compromised breathing to improve blood perfusion throughout the circulatory system to vital organs, especially to the brain) for Resident 1 when Resident 1 was found unresponsive. This failure left Resident 1 without receiving CPR, which was not in accordance with his choice for full treatment (to prolong life by all medically effective means), as indicated in his POLST (Physician Orders for Life-Sustaining Treatment). Resident 1's Face Sheet (summary of important resident information), Advance Directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity), POLST (Physician Orders for Life-Sustaining Treatment) and Order Summary Report all indicated Resident 1 had opted for Full Treatment or Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Face Sheet (summary of important resident information), dated 12/6/2023, indicated, he was re-admitted to the facility on 7/13/2023, with diagnoses including a sacral (pertaining to the set of fused bones at the base of the spine below the lower back area of the pelvis) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of long-term pressure, or pressure in combination with shear or friction), obstructive reflux uropathy [disorder to which urinary flow is obstructed in the urinary tract (body's drainage system for removing urine)] and hypotension (lower than normal blood pressure). The Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) section of the face sheet indicated: Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/23/2023, indicated a Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 13, which meant he was cognitively intact. (0-7 points = severe cognitive impairment; 8-12 points = moderate cognitive impairment; 13-15 points = cognitively intact). Review of Resident 1's POLST Form, dated 8/2/2023, indicated a box checked for Attempt Resuscitation/CPR and a box checked for Full Treatment. It contains dated signatures of both Physician 1 on 8/3/2023, and Resident 1 on 8/2/2023. Review of Resident 1's Order Summary Report printed on 12/6/23 indicated, "Active orders as of 11/29/2023... FULL CODE, Order Status: Active, Order Date 8/14/2023." Review of Resident 1's Record of Death received on 12/6/2023 indicated, "Date of Death 11/29/23 Hour 0500 (5:00 AM), Nurse present at time of death: name of [LVN A] (Licensed Vocational Nurse), Name of person notified: [name of Physician 1], Relationship to Patient/Resident: Physician, Attending physician notified by: [LVN A], Date and Hour: 11/29/23 0545 (5:45 AM). Remarks: Resident expired peacefully in his sleep at 0500 on November 29, 2023. Notified [Name of Funeral Home] [Phone number of Funeral Home] ... Called by [Signature of LVN A] ... Mortician's Report; Received from [name of LVN D] The remains of: [Name of Resident 1] ... Body released by: [Name of LVN D] at 11/29/23 at 0920... Signed by [Funeral Home Staff]/Mortician, [Name of Mortuary], [Address of Mortuary]." Review of Resident 1's Nurse Notes with effective date: 11/29/2023, at 07:31, indicated, "Late Note: Nursing staff attempted to administer routine medication to resident. Resident was not responding to voice. This nurse tapped on his shoulder with no response. Nurse applied sternum stimulation (rubbing the bone in central part of the chest to test an unconscious person's responsiveness) and no response. Lungs auscultated (listened for airflow in the lungs) with no sounds heard. No heartbeat presented. Capillary refill (pressure applied to a finger to detect blood flow after releasing pressure) was not present. Complexation to the skin was pale and cold to touch. Request 2nd nurse in facility to verify and same results obtained from body. Resident expired at 0500 this morning on 3rd shift. Dr. [Name of Physician 1] primary physician, informed of resident status and aware. Administrator and DON (Director of Nursing) notified as well. Resident is his own responsible family. Friend [name of friend] number dialed but is not able to get a hold of. Orders to release body to mortuary obtained and carried out. [Name of Funeral Home] notified. Spoke to [name of staff]. Informed that mortuary will be at facility to pick up body after 0900 today. Report over to oncoming nurse..." During an interview on 12/6/2023, at 12:04 p.m., with Licensed Vocational Nurse B (LVN B), she stated she knew Resident 1 to be, "alert, oriented, made his own decisions, was his own responsible party... Full Code. He died on 11/29/23... On day shift on 11/28/23... he was fine." Review of a document received 12/6/2023 from Interim DON (INT-DON) regarding Resident 1 titled, "Statement of [LVN A] on 11/29/23 at 1600" indicated, "What happened? I (LVN A) was passing my meds (medications); when I arrived at the resident's room, I announced it was time for his medication. He usually responds to me; so, I went to the side of his bed and started talking to him; I called out his name and he did not respond to me. I then went to the other side of the bed and turned on the light. I touched him and he was cold to the touch. He did not wake up or respond. Then I did the sternum rub. He still did not wake up. I went to listen to his lungs and there were no sounds. I could not find his heartbeat nor his pulse rate. I noticed his capillary refill was not present. Why did you not perform CPR? I did not perform CPR because he was not breathing anymore. No life was in him. Were there any signs of declining during your shift? No, he was fine. When was the last time you interacted with the resident while he was alive? The last time I looked into his room, it was around 0400. I could see the glare from the television on his face; his eyes were open, and he had his remote in his hands - he was putting it on his table. Are you aware where the crash cart (a wheeled container carrying medicines and equipment for emergency resuscitations) is and how to call a Code Blue (used to indicate a patient requiring resuscitation or immediate medical attention)? Yes, I know where those things are, I have never had to do that here. But I know how to do it. Did you know the resident was Full Code? I did not know until after I called the doctor; I assumed he was DNR (do not resuscitate) because of his condition. Is your CPR current? Yes, it is good for 2 years; It expires [expiry date]. Is there anything you would do different next time? I will check the code status... Signed by [LVN A]; DSD and INT-DON." During an interview with the Interim Director of Nursing (INT-DON) on 12/6/2023, at 12:12 p.m., when asked why Resident 1 was not given CPR she stated, "Yes Ma'am, it was not done." When asked what should have been done, the INT-DON stated, "Life saving measures should have been implemented right away... That's a patient's choice, he had the right to be Full Code... he designated that in his POLST." When asked if CPR was not done as per LVN A's statement and if there was a failure, the INT-DON stated, "correct," to both questions. During an interview with LVN C on 12/6/2023, at 1:15 p.m., when asked what she would do if a resident were Full code, LVN C stated, "If I found someone unresponsive, I assess vital signs (V/S, essential body functions like heartbeat, pulse rate, temperature and blood pressure) and call a code on the Intercom so all nurses can come and help me regardless of day and time of incident. So, I will be in-charge since I was the one who found the patient unresponsive. I'll have a CNA (Certified Nursing Assistant) or myself start CPR; when code team (emergency medical response personnel) arrives, we could start oxygen (air we breathe to live), AED (automated external defibrillator, medical device to analyze a heart's rhythm, if necessary, deliver an electric shock to help the heart re-establish an effective rhythm). I would also assign a nurse to call 911 and assign a CNA or Nurse to wait by the door for EMS (emergency medical services staff) so they could come to the patient's room. We continue CPR (chest compressions, AED) until EMS tells us that we are relieved, and they will take over." When asked how to check if the patient is DNR or Full Code, LVN C stated there is "a binder in every unit that has the Code Status, it has their POLST there as well... we also have our laptop on [the] Med Cart, in the EMR [name of electronic medical record] the code status is there... We notify the Provider (Physician), DON, Administrator, and family... this is taught to us usually monthly... we have nurse meetings every 2nd Tuesday of the month where they tell us what the expectations are and if the code status was updated... Station One is Post-Acute unit... every time a new patient comes, the Code Binder is updated. Station Two is Long Term Unit." Review of Facility policy titled "In-Service Training, All Staff" revised August 2022 indicated ... 1) All staff are required to participate in regular in-service education. ... 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. ... 5. Training methods and teaching materials are appropriate to the level of education and expected roles of those attending. During an interview with Physician 1 on 12/6/2023, at 1:30 p.m., he stated, "... if patient was doing okay at 4:00 a.m. and at around 5:00 a.m. was found unresponsive, the nurse should have initiated a Code Blue (code blue or code, used to indicate a patient requiring CPR or to indicate a patient requiring resuscitation or immediate medical attention) ... The reality of the situation, even say patient died say 4 hours ago, she should have initiated a code and called 911. She is not a licensed person that can pronounce death. It's not her place to declare death... I did not pronounce the patient dead at 5:00 a.m. when she called. I wasn't aware it was an issue until... later I found out no code was done, and the patient was a full code." During an interview with the Director of Staff Development (DSD) on 12/6/2023, at 2:07 p.m., she stated all the facility's LVN staff should know how to do CPR and should know whether their assigned residents are full code, or not. Review of Facility's Job Description for Position Title: Licensed Vocational Nurse (LVN), with Date written: November 2021 indicated, ... Purpose: LVNs provide medical support to physicians, registered nurses and patients. They provide routine care, take vital information from patients, provide information about treatments and prescriptions and observe patient health. ... Responsibilities: ... Observe patients under treatment to identify progress, side effects of medications etc. Monitor patients' condition ...Requirements: Familiarity with skilled Nursing, safety and sanitation standards and procedures, ...Current BLS (Basic Life Support - medical care used for patients with life-threatening illnesses or injuries, covers CPR but includes additional life-saving techniques that can help those experiencing cardiac arrest, respiratory distress, or an obstructed airway) Certification Required. According to the California Code of Regulations: Title 16 CCR § 2518.5. Scope of Vocational Nursing Practice. The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan and treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. Title 16 CCR § 2518.6. Performance Standards. ... (b) A licensed vocational nurse shall adhere to standards of the profession and shall incorporate ethical and behavioral standards of professional practice which include but are not limited to the following: (1) Maintaining current knowledge and skills for safe and competent practice... During an interview on 12/6/2023, at 2:23 p.m. with LVN A, she stated, "I was in the hallway passing meds, usually when I go in there, he (meant Resident 1) is alert and he responds. I went in there the TV was on. I called out his name, Mr. [Resident 1 name] here's your meds, usually he would respond, but he did not. I bumped the bed with my hip, my hands were full with meds and drink, no response... I went around the other side of the bed to pull the light, I noticed he was very pale, eyes wide open. So, I touched him, and he was cold. I was feeling the pulse, no pulse. I listened to his lungs with the stethoscope (medical instrument used to listen to sounds produced within the body), there was nothing then I did the sternum rub." LVN A was asked if she knew the code status and she stated, "No, not at that time and that was my mistake, I should have checked that because he was going downhill, he was already weak, he had bedsores. There were times he wouldn't want his drink or care and would say 'leave, me alone, no I don't want that,' I didn't want him to be riled." LVN A was asked if she thought about doing CPR, LVN A stated, "no because he had no more life, he was cold." LVN A was asked if she knew that, as an LVN, she could not pronounce death, LVN A stated, "Now I am aware, I was a home health nurse... I guess it's different than what I thought." When LVN A was asked if she knew there is a Code Binder in the unit, LVN A stated, "Yeah, no I did not look at that time... after the sternum rub, I called the CNA 'hey he passed away,' I let the Doctor (Physician 1) know... I texted him; he got the message, he said okay... I let the Administrator (ADMIN) know, I texted them all and the DON... The ADMIN said/texted, 'Was it expected?' I texted everything was fine during the shift until he was found unresponsive." When asked if the ADMIN asked her if they did CPR, LVN A stated, "No." LVN A further stated, "I called the Mortuary on his chart, informed the mortuary that he died... they did not pick up right away." LVN A was asked who pronounced Resident 1 dead, LVN A stated "It was me I guess, the doctor (Physician 1) said okay on text... At this time the CNAs cleaned him up and prepared him for the mortuary... The body was in the room ready for pick-up for mortuary. I endorsed to the next shift nurse... I left the facility at 8:00 a.m. came back at 2:00 p.m. they (Facility) were telling me I need to redo my statement to make it clearer on my notes to reword it to make it understandable, I reworded it, but it is the same thing, why I didn't do CPR." When LVN A was asked if Physician 1 gave an order to release the body, LVN A stated, "No, he said okay, so I wrote it as an order to send him out to mortuary." When he asked if she assumed it was an order, LVN A stated, "Yes." LVN A confirmed there was no mention of CPR done and 911 was