Health inspection·July 24, 2024

F684 Citation A 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, including but not limited to the following: Highest practicable physical, mental, and psychosocial well-being. 22 CCR § 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). 22 CCR § 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. On 5/10/24, an unannounced visit was made to the facility to investigate a complaint. Resident 6 was admitted to the facility on 03/18/24. Resident 6 was diagnosed with the heart conditions of congestive heart failure and ischemic cardiomyopathy. Resident 6 had a change in condition consistent with cardiac (heart) stress on 05/07/24. Upon the change in condition, the facility failed to assess the change in condition by taking vital signs, document the change in condition in patient's health record, and failed to implement required care planning to notify the physician of the change in condition. Specifically, the facility failed to: 1. Document Resident 6's change in condition and provide physician notification of change. 2. Follow policy and procedure regarding notification of physician about change in condition as described in facility's "Change in a Resident's Condition or Status" policy and procedure. As a result of these failures, Resident 6 did not receive proper nursing and physician care, and Resident 6 was pronounced dead on the morning of 5/8/24. Findings: A review of Resident 6's Admission Record was conducted. Resident 6 was admitted to the facility on 3/18/24, with diagnoses including congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) and ischemic cardiomyopathy (damaged heart muscle from lack of blood flow) according to the facility's Admission Record. A review of the facility's progress notes (PN) written by licensed nurse (LN) 3 for Resident 6 was conducted. The PN dated 5/8/24 at 5:20 A.M., indicated the certified nurse assistant (CNA) 3 reported to the CN (charge nurse) that Resident 6 was, "Not responding". The PN indicated cardiopulmonary resuscitation (CPR-a lifesaving technique used when someone's heart was not beating) was initiated for Resident 6 and 911 (emergency telephone number) was called. The PN further indicated, "Paramedics arrived after 5 minutes after the call was made. Paramedics pronounced resident expired" on 5/8/24. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated February 2021 was conducted. The P&P indicated, ".... Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status...Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider..." An interview was conducted on 5/10/24 at 2:50 P.M., with CNA 3. CNA 3 stated she was assigned to Resident 6 on 5/7/24, on the night shift which started at 10:30 P.M. until 7 A.M. CNA 3 stated during rounds at approximately 4 A.M. to 5 A.M., she found Resident 6 unresponsive. CNA 3 stated she called out, "Hello, hello...," then shook Resident 6, but the resident did not wake up. CNA 3 stated she notified licensed nurse (LN) 3 right away. CNA 3 further stated Resident 6 was asleep when she checked Resident 6 at 10:30 P.M., 12 A.M., and at 2 A.M. An interview was conducted on 5/20/24 at 1:52 P.M., with LN 3. LN 3 stated he was assigned to Resident 6 on 5/7/24, on the night shift which started at 11 P.M. LN 3 stated there was no report of any change in condition from the afternoon from the outgoing LN regarding Resident 6. LN 3 stated he saw Resident 6 at approximately 12 A.M. to 1 A.M. and Resident 6 was sitting up at the edge of his bed, watching TV without any changes. LN 3 stated at approximately 5 A.M., the CNA notified him that Resident 6 was unresponsive. LN 3 stated he ran to the room and called another LN. LN 3 stated he and the other LN placed Resident 6 on the floor and initiated CPR until the paramedics (health care professionals who responds to emergency calls) arrived. An interview was conducted on 5/20/24 at 2:06 P.M., with LN 4. LN 4 stated he was assigned to Resident 6 on 5/7/24 from 2:30 P.M. until 11 P.M. LN 4 stated CNA 6 notified him at around 9:30 P.M. to 10 P.M. that Resident 6 refused to take a shower because Resident 6 was not feeling well. LN 4 stated he requested for Resident 6's vital signs (VS- temperature, heart rate, breathing), but CNA 6 did not provide Resident 6's VS. LN 4 stated he did not follow up to take Resident 6's VS or check on Resident 6's condition because he was busy. LN 4 stated he would check on a resident, "Depending on the needs of the resident. If there was a change in condition it would be a priority." During an interview on 5/20/24 at 2:57 P.M., with CNA 6, CNA 6 stated she worked on the 5/7/24 afternoon shift and was assigned to provide a shower for Resident 6. CNA 6 stated CNA 3 was assigned to Resident 6 for the afternoon shift. CNA 6 stated Resident 6 was offered a shower at 3:30 P.M., and Resident 6 refused because he was not feeling well. CNA 6 stated Resident 6 requested to return later. CNA 6 stated she offered a shower again to Resident 6 at 4:30 P.M., and Resident 6 stated he still did not feel well and, "Looked pale and sweaty." CNA 6 stated she reported to LN 4 that Resident 6 refused shower and did not feel well. CNA 6 stated LN 4 instructed her to have the assigned CNA take Resident 6's VS. CNA 6 stated LN 4 got upset because CNA 3 brought the VS machine to LN 4 with Resident 6's VS instead of writing them on a piece of paper. After dinner, CNA 6 stated she offered the shower to Resident 6 again with CNA 3 as the witness, but Resident 6 was still pale and sweaty. CNA 6 stated she notified LN 4 again and LN 4 asked how Resident 6 looked. CNA 6 stated she reported that Resident 6 looked like he had flu symptoms. CNA 6 further stated LN 4 did not check on Resident 6. During a review of the facility's "Weights and Vitals Summary" for Resident 6, there was no documentation of Resident 6's temperature, heart rate and respirations on 5/7/24 morning and afternoon shift. An interview was conducted on 5/22/24 at 3:50 P.M., with the Director of Nurses (DON). The DON confirmed CNA 3 was assigned to Resident 6 on 5/7/24. The DON stated if she was the nurse and a CNA did not take a resident's VS per her instruction, the DON stated she then would take the VS herself and complete an assessment prior to physician notification. An interview was conducted on 5/24/24 at 3:06 P.M., with LN 7 regarding resident change in condition. LN 7 stated she would assess the resident, take the resident's VS, and notify the physician. The facility's Director of Staff Development (DSD- a licensed nurse certified for staff training) was interviewed on 5/24/24 at 3:14 P.M. The DSD stated she had conducted an in-service (training or education) for the facility's licensed nurses regarding resident change in condition. The DSD stated licensed nurses were taught to complete the e-Interact (Interventions to Reduce Acute Care Transfers- an electronic quality improvement program designed to improve identification, evaluation, and communication about changes in resident status) form which triggered physician notification. The DSD further stated assessment of a resident with a change in condition should be performed prior to physician notification. A review of an In-service Attendance Record dated 5/2/24 titled COC (Change of Condition) Documentation and Process was conducted. Per the document, "COC (change of condition) documentation and Processes...," The in-service attendance record did not have LN 4's signature under, "Attendance." Resident 6's physician was interviewed on 5/30/24 at 9 A.M. The physician stated Resident 6 had diagnoses which included CHF, ischemic cardiomyopathy, and a history of myocardial infarction (MI- a heart attack). The physician stated he was not aware that Resident 6 had symptoms of sweating and being pale. The physician stated symptoms of being sweaty and pale were signs of ischemia (lack of blood flow to a part of the body). The physician further stated he expected the facility staff to assess (evaluate) Resident 6 and to notify him of the change in condition. In conclusion, Resident 6 was admitted to the facility on 03/18/24. Resident 6 was diagnosed with the heart conditions of congestive heart failure and ischemic cardiomyopathy. Resident 6 had a change in condition consistent with cardiac (heart) stress on 05/07/24. Upon the change in condition, the facility failed to assess the change in condition by taking vital signs, document the change in condition in patient's health record, and failed to implement required care planning to notify the physician of the change in condition. Specifically, the facility failed to: 1. Document Resident 6's change in condition and provide physician notification of change. 2. Follow policy and procedure regarding notification of physician about change in condition as described in facility's "Change in a Resident's Condition or Status" policy and procedure. As a result of these failures, Resident 6 did not receive proper nursing and physician care, and Resident 6 was pronounced dead on the morning of 5/8/24. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, a result in a Class A Citation.