Other·May 9, 2024

Villa Rancho Bernardo, 764653 A Citation Title 42 of the Code of Federal Regulations Parts: 483.10 Resident Rights. (g) (14) Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in § 483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in § 483.15(c)(2) is available and provided upon request to the physician. California Code of Regulations, Title 22, Sections: 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 needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. [...] (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). 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. The Department received a complaint on 12/14/21 indicating that Resident 1 had a stroke while at the facility, and no medical action was taken by staff. The complainant documented Resident 1's face was drooping, and he had slurred speech, and he was sent to the General Acute Care Hospital (GACH) where a stroke was declared. On 12/29/21 an unannounced visit was made to the facility to investigate the allegation of nursing staff failing to identify a change of condition (COC, a shift in health status) for Resident 1. Based on interview and record review, Resident 1 was admitted to the facility for fractured ribs. One week later, multiple staff members observed changes in the Resident 1's condition. Specifically, facility staff observed Resident 1 was no longer able to swallow foods and liquids, was less responsive to instructions, did not react to own name, could not hold hands, and could no longer follow cues. Facility staff did not complete a COC Form or perform a complete assessment of the numerous changes observed. Facility staff did not notify the physician of all of the observed changes in Resident 1. The facility failed to: 1. Assess and recognize Resident 1's new inability to swallow foods and liquids, weakness, and other symptoms as a COC. 2. Notify, consult, and provide the physician with all pertinent information about Resident 1's new inability to swallow foods and liquids, weakness, and other COCs. 3. Contact emergency services (9-1-1) and arrange for the immediate transportation and transfer to a hospital for Resident 1 for the COC. 4. Follow its policies and procedures for a Change in a Resident's Condition or Status when nursing staff did not adequately assess Resident 1's COC, did not notify the physician of significant changes in Resident 1's condition and the need to transfer Resident 1 to a hospital. As a result, Resident 1 was not timely transferred to a GACH for evaluation and treatment of a potential stroke. Transportation took five hours to arrive once it was called, which was nearly 11 hours after staff first observed a change in Resident 1's condition. Thus, there was a prolonged delay in providing medical treatment which prevented him from receiving vital clinical therapy for a stroke diagnosed at the hospital. Findings: Resident 1 was admitted to the facility on 11/30/21 with diagnoses to include Multiple Fractures of Ribs, Left Side, Type 2 Diabetes Mellitus with other Diabetic Kidney Complication, Muscle Weakness, Hemothorax, Dysphagia, Oropharyngeal Phase, Unspecified Dementia without Behavioral Disturbance, Essential (Primary) Hypertension, Hyperlipidemia, Fracture of Unspecified part of Scapula, Left Shoulder, History of Falling, Other Acute Kidney Failure, and Long Term Use of Insulin, per the facility Admission Record. On 10/11/22, a record review was conducted. Per Resident 1's Clinical Admission Evaluation dated 11/30/21 at 5:45 P.M., Resident 1 was able to obey commands, and had no signs/symptoms of a swallowing disorder. The same document indicated Resident 1 was able to move all of his arms and legs without problems. Per Resident 1's Baseline Care Plan and Summary dated 12/1/21 at 7:23 P.M., Resident 1 was able to easily communicate with staff. Per Resident 1's Skilled Evaluation Progress Note, dated 12/5/21 at 4:13 P.M., Resident 1 was able to obey commands, and his speech was clear. The document indicated Resident 1 had no signs or symptoms of a swallowing disorder and was able to move all his arms and legs. Per Resident 1's Skilled Evaluation Progress Note, dated 12/6/21 at 4:55 A.M., Resident 1 did not obey commands. Per Resident 1's Change in Condition Progress Note, dated 12/6/21 at 10:24 A.M. and authored by LN 1, Resident 1 was unable to swallow. LN 1 wrote SLP (Speech Language Pathologist) had attempted to feed Resident 1, but he was still unable to swallow. LN 1 indicated the information had been reported to the physician, and she was waiting for orders. An additional call was made to the physician, who then ordered IV fluids. LN 1 documented a family member preferred Resident 1 be sent to the hospital, so she obtained an order from the physician to transfer him to the hospital. LN 1 documented it would take two to three hours for transportation to arrive. Per Resident 1's eINTERACT SBAR (Situation, Background, Appearance, Review) Summary for Providers (a summary of the change in health status used to report to the physician), dated 12/6/21 at 10:28 A.M., Resident 1 had an altered mental status with increased confusion or disorientation, general weakness and swallowing difficulty. The Neurological Evaluation section did not assess speech changes, weakness or hemiparesis (a weakness of one side of the body, a common after-effect of stroke). Per Resident 1's Speech Therapy Treatment Encounter Note, dated 12/6/21 at 4:25 P.M., SLP 1 indicated Resident 1 may have had a COC that day, and documented the need for close monitoring and/or discharge to GACH. Per Resident 1's Occupational Therapy Treatment Encounter Note, dated 12/6/21 at 4:53 P.M., COTA (Certified Occupational Therapy Assistant)1 indicated, "...Observed positioned up in w/c (wheelchair) for visit with daughter in dining room...Afterward patient positioned back to bed, noted with change in cognition and alertness. Pt presenting with incoherent, jumbled verbal responses when asked questions and unable to visual focus and eyes half lidded. Daughter and nursing reporting patient would be going out to hospital in early afternoon due to change in condition...Response to Session Interventions: required extra time to process new information...Complexities/Barriers Impacting Session: Cognitive status, Level of alertness..." Per Resident 1's Nurses Progress Note, dated 12/6/21 at 8:47 P.M., Resident 1 was picked up by the transportation company on 12/6/21 at 3:35 P.M. Per Resident 1's GACH ED (Emergency Department) Provider Note, dated 12/6/21 at 11:41 P.M. "...Clinical picture concerning for altered mental status and CVA (cerebrovascular accident, a stroke)...he was outside of the window for thrombolytics (a medication to treat strokes, optimally given within 4.5 hours of a stroke)...on head CT (computed tomography, a type of x-ray) however there is a large hypodensity...suggestive of ischemic stroke. Feel that this is the likely cause of his altered mental status today...no severe electrolyte (minerals in the blood and body fluids) derangements that would explain patient's presentation today..." Per Resident 1's Neurology Consult Note, dated 12/7/21 at 7:39 A.M., which is prepared by a physician who specializes in treatment of the brain, spinal cord and nerves, indicated, "...Reason for Consultation Stroke...Speech: nonsensical fluent speech...CT head...suggestive of recent infarction (a type of stroke)..." A hospital document dated 12/7/21 at 12:56 P.M. and titled Addendum, Neurology Progress Note, indicated, "MRI (magnetic resonance imaging, a test used to create clear images of medical conditions) brain...Most of these lesions appear to be acute (developed suddenly)..." On 12/29/21 at 1:40 P.M., an interview was conducted with Certified Occupational Therapy Assistant (COTA) 1. COTA 1 stated she had worked with Resident 1 on Friday 12/3/21, and he made eye contact and answered her questions. COTA 1 stated she attempted to get him to hold her hands, but he could not. COTA 1 stated she reported the problems to a nurse but did not recall which nurse. The nurse informed COTA 1 that Resident 1 was being sent out to the hospital, so she assumed they were aware of the extent of his change in abilities. COTA 1 stated she had seen Resident 1 on Friday 12/3/21 for 30 minutes, then on Monday 12/6/21, he was completely different. COTA 1 stated Resident 1 was mumbling and couldn't hold up his head. COTA 1 stated she had spoken to Resident 1's daughter, and to a nurse, although she was not sure which nurse she spoke to. COTA 1 stated she thought nursing staff was aware of the changes Resident 1 was experiencing. On 12/29/21 at 11:10 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was assigned to Resident 1 on 12/6/21. LN 1 stated Resident 1 was able to communicate whether he had pain or not. LN 1 stated Resident 1 had multiple fractured ribs from a fall at home. Resident 1 had been set up for breakfast on 12/6/21 as usual, but that day the Certified Nursing Assistant (CNA) had informed her Resident 1 was not swallowing his breakfast, and the food sat in his mouth. LN 1 stated she placed an order for a Speech Language Pathologist (SLP) to evaluate Resident 1. LN 1 stated Resident 1 looked the same, but his behavior was different than usual. LN 1 stated Resident 1 was less responsive to her instructions than she remembered from previous shifts. LN 1 stated she maybe should have considered a stroke at that point, and when she called Resident 1's name, he just looked at her, yet previously he would have responded with words. LN 1 stated she asked a nursing supervisor, LN 2, to assess Resident 1. LN 1 stated LN 2 went to Resident 1's bedside with her, assessed the resident, then called the physician. LN 1 stated she did not know what LN 2 told the physician, but he ordered intravenous fluids (IV). Per LN 1, LN 2 then spoke to a family member at the bedside, who declined the IV and instead requested a transfer to the hospital. LN 1 stated she called for transportation to the hospital and was informed it would take two to three hours to arrive at the facility. Per LN 1, she called two or three other transportation companies who gave longer arrival times. On 12/29/21 at 2:20 P.M., an interview was conducted with SLP 1. SLP 1 stated she had evaluated Resident 1 on 12/6/21 after breakfast. SLP 1 stated Resident 1 was not responsive and did not follow cues (reminders) regarding swallowing foods or liquids. SLP 1 stated based on her assessment of Resident 1, she downgraded his diet to pureed with close monitoring and reported her concerns to a nurse. SLP 1 was not able to recall which nurse she spoke to. On 12/29/21 at 2:40 P.M., a follow-up interview was conducted with LN 1. LN 1 stated she did not recall COTA 1 reporting concerns regarding Resident 1 to her. LN 1 stated SLP 1 did inform her of her recommendation to change Resident 1's diet, but they had no other discussion about him. LN 1 stated if she had thought it over, she should have called 911. LN 1 stated she did not think it was necessary at the time. On 10/11/22 at 9:44 A.M., an interview was conducted with LN 2. LN 2 stated on 12/6/21, she was the nursing supervisor. LN 2 stated LN 1 asked for help with assessing Resident 1 due to his swallowing problem. LN 2 stated she and LN 1 asked Resident 1 to swallow liquids then cough, and he was able to do so. LN 2 stated she also assessed Resident 1's lung sounds, but she did not assess anything else. LN 2 stated she did not do a head-to-toe assessment, but she should have. LN 2 stated she did not assess Resident 1's arms or legs for weakness and did not evaluate his speech. LN 2 stated Resident 1's problems may have been related to dehydration. LN 2 stated she did not complete a COC form or an SBAR prior to speaking to the physician, but she should have. LN 2 stated the SBAR should be completed prior to calling the physician so the nurse could communicate complete information to the physician. LN 2 stated she recalled reporting the swallowing problem to the physician, but not any other concerns. LN 2 stated she did not consider a stroke at the time, and that a delay in care could worsen Resident 1's condition. LN 1 stated six hours to send Resident 1 to the GACH was not acceptable. On 10/27/22 at 4:14 P.M., an interview was conducted with the physician (MD). The MD stated LN 2 had called him for the primary reason of abnormal lab values. LN 2 had informed the MD of the lab results, as well as Resident 1 not eating well. Per the MD, "There were no red flags from the conversation with (LN 2)." The MD stated although he did not remember much of the conversation, he had the impression the poor intake was for that single day only. The MD stated the lab results combined with a report of not eating well were the reason he ordered IV fluids. When asked about Resident 1's change in mental status, weakness, and new inability to swallow foods and liquids, the MD stated, none of the information had been communicated to him. Per a facility policy, revised 2012 and titled Change in a Resident's Condition or Status, "...1. The nurse supervisor/charge nurse will notify...physician when...d. A significant change in the resident's physical...condition...g. A need to transfer the resident to a hospital...5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. a. Assessment related to the change in condition... The facility failed to: 1. Assess and recognize Resident 1's new inability to swallow foods and liquids, weakness, and other symptoms as a COC. 2. Notify, consult, and provide the physician with all pertinent information about Resident 1's new inability to swallow foods and liquids, weakness, and other COCs. 3. Contact emergency services (9-1-1) and arrange for the immediate transportation and transfer to a hospital for Resident 1 for the COC. 4. Follow its policies and procedures for a Change in a Resident's Condition or Status when nursing staff did not adequately assess Resident 1's COC, did not notify the physician of significant changes in Resident 1's condition and