Other·June 30, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint CA 00835079. Representing the Department, HFEN 39111. State Citation A was written. F- 689 42 CFR §483.25(d) Accidents. The Facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate Supervision and assistance devices to prevent accidents. § 72311 (a)(1)(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. § 72329.1 (g)(1) Skilled nursing facilities shall employ and schedule additional staff to ensure patients receive nursing care based on their needs. § 72313 (a)(2) Medications and treatments shall be administered as prescribed. On 4/19/23, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident who was having respiratory issues and was not monitored every 15 minutes. Resident 1 had cognitive impairment and a history of agitation and attempting to pull out her tracheostomy tube (trach, a life sustaining breathing tube that was inserted into the trachea/windpipe). The facility failed to: 1. Provide 1:1 supervision (one staff assigned to the resident to provide continuous supervision) to Resident 1 when having an episode of agitation and pulling on her tracheostomy tube. 2. Evaluate, analyze, and care plan Resident 1's cognitive impairment with resident-specific interventions to meet Resident 1's behavioral and supervision needs. 3. Administer physician prescribed quetiapine (a psychotropic medication used to control mood and behavior) when Resident 1 was attempting to pull out her trach. As a result, Resident 1 removed her trach collar (device used to secure a trach tube) and decannulated herself (tracheostomy tube was removed from the trachea/windpipe) while unsupervised on 3/26/23. Resident 1 had to be reintubated (reinsertion of the tracheostomy tube) at the facility and was transferred to the hospital. Resident 1 experienced an anoxic brain injury (brain death occurring from lack of oxygen) per the hospital record. Resident 1 was placed on comfort care (patient care planned on symptom control, pain relief, and quality of life) and died at the hospital on 3/30/23. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 3/3/23 with diagnoses that include acute and chronic respiratory failure, tracheostomy (opening in the trachea to insert a breathing tube), gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), unspecified severe dementia (condition characterized impaired judgement and memory loss) with behavioral disturbance, and Alzheimer's disease (affects memory and other important mental functions). A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 3/9/23, indicated the brief interview of mental status was not completed due to the resident's severe cognitive impairment. On 4/19/23 at 8:46 A.M., a telephone interview was conducted with Resident 1's family member (FM) 1. FM 1 stated she or another family member regularly spent most of the daytime at the facility supervising Resident 1. FM 1 stated Resident 1 would touch and manipulate her trach and g-tube. FM 1 stated she would have to move the resident's hands away from those areas. FM 1 stated Resident 1 pulled out her intravenous line (IV, used to put medication or fluids into the bloodstream) and had pulled out her g-tube three times. FM 1 stated she had asked nursing staff to place mittens (a restraint device used to prevent fingers from grasping) or to tie the resident's hands down at night when she was not there to watch the resident. FM 1 stated Resident 1 had dementia and was confused. FM 1 stated Resident 1, "Always tried to get up and would stand up." FM 1 stated she had asked nursing staff to place Resident 1 on 1:1 supervision at night and was told there was not enough staff to accommodate the family's request. FM 1 stated she told staff to call her "day or night" and she would come to watch Resident 1. FM 1 stated, "It was my nightmare leaving her [Resident 1] at night that she'd pull the trach out." FM 1 stated she did receive a call (on 3/26/23) that Resident 1 had pulled her trach out and staff had to perform CPR (cardiopulmonary resuscitation-a hands on procedure to revive a person) and send the resident to the hospital via 911. FM 1 stated Resident 1 died four days later at the hospital. On 4/19/23 at 1:55 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she often took care of Resident 1 during the daytime and that the resident was confused and would be, "Moving around too much." CNA 1 stated Resident 1 required close monitoring, but in the daytime the resident's daughters were in the facility to watch her. CNA 1 stated Resident 1's daughters cared for their mom and, "Helped a lot" with taking care of her during the day. CNA 1 stated when Resident 1 was awake and alone in bed, Resident 1 would try to get up and would start grabbing things. A review of Resident 1's progress notes indicated: 3/6/23, a licensed nurse (LN) documented, " ...Gtube was dislodged and replaced ...." 3/7/23 at 6:23 A.M., a LN documented, " ...Resident is alert with bouts of confusion ...Several times tried to get out of bed, found once sitting on the floor ...." 3/21/23, a LN documented, " ...At around 0400H [4 A.M.] pt [patient] was found with her Gtube out ...." 3/25/23 at 9:53 P.M., a respiratory therapist (RT) documented, " ...Pt is restless and refuses to stay in bed. Pt removes trach collar often and needs continuous supervising. RN [registered nurse] is aware ...." 3/26/23, a LN documented, "@ 2042H [At 8:42 P.M.] medication nurse went to give her due medication, nurse noted Pt's skin looked from pale to yellowish but warm. Nurse tried to shake pt on the shoulder to wake her up but there was no response. Upon checking her neck, nurse found out that her tracheostomy was gone ...Pt has no pulse and not breathing ... CPR started...@2050H [At 8:50 P.M.] 911 responders came ...they left the facility with the pt @2109H [9:09 P.M.] ...." 3/26/23, a RT documented, " ...Pt was received on trach collar stable but restless at the beginning of shift ... At around 8:50 pm she was found unresponsive and without a pulse after self decannulation. Immediately trach tube was reinserted and CPR was initiated ...." On 4/19/23 at 2:10 P.M., a joint interview and record review was conducted with licensed nurse (LN) 2. LN 2 stated Resident 1 required the trach and could not adequately breathe on her own without it. LN 2 stated Resident 1 was confused and had dementia. LN 2 stated Resident 1's behavior was manageable in the daytime because the resident's family was present to watch the resident and kept her busy. LN 2 stated Resident 1's hands were always moving, and when the resident's daughter was not there, staff had to sit the resident at the nurses' station for increased supervision. LN 2 stated the resident liked to be in a place where she could see everyone. LN 2 stated staff would give her linens to fold, and it kept her busy. LN 2 stated she would hear from the NOC (night shift from7 P.M. to 7 A.M.) nurses that Resident 1 was difficult to take care of at night and was sometimes combative. LN 2 reviewed Resident 1's clinical record and stated there should have been a written plan of care to address the resident's dementia and behavior "especially" at night. LN 2 stated Resident 1 would pull her life sustaining tubes (g-tube/trach) and that this was a "dangerous behavior" and an immediate safety concern. LN 2 stated Resident 1 could not be redirected in this behavior and did not comprehend the implications of pulling her life sustaining tubes. LN 2 stated Resident 1 pulled out her g-tube on 3/6/23 and 3/21/23, was found sitting on the floor on 3/7/23, and was pulling at her trach collar on 3/25/23, and that these were behaviors that should have been immediately discussed with the interdisciplinary team (IDT) and a plan of care developed to address it. LN 2 stated she did not see any documentation the resident's unsafe behaviors had been addressed by the IDT or care planned. A review of Resident 1's physician's order dated 3/6/23, indicated the resident was to receive quetiapine 50 mg (milligrams) every six hours as needed for pulling at life sustaining tubes. There was also an order dated 3/6/23 to monitor the episodes of this behavior of pulling at the life sustaining tubes. A review of Resident 1's medication administration record (MAR) for March 2023, indicated the resident's behavior of pulling at life sustaining tubes had been observed: 2 times on 3/23/23, 5 times on 3/24/23, 5 times on 3/25/23, 2 times on 3/26/23. The same MAR was blank on 3/23, 3/24, 3/25, and 3/26/23 for quetiapine administration, indicating the medication had not been given to the resident. On 4/19/23 at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 stated she was familiar with Resident 1. LN 4 stated Resident 1 was confused and had dementia. LN 4 reviewed Resident 1's clinical record and stated that Resident 1 pulled out her g-tube on 3/6/23 and 3/21/23, was found sitting on the floor on 3/7/23, and pulled at her trach collar on 3/25/23, and that these were behaviors should have been immediately discussed with the IDT and a plan of care developed to address it. LN 4 stated in the daytime, Resident 1's daughters were in the facility and there were more staff and activities taking place. LN 4 stated there should have been an individualized dementia care plan that addressed Resident 1's supervision and behavioral needs at night. LN 4 stated having a plan of care that addressed Resident 1's behavior and supervision needs may have prevented the resident from pulling out her trach on 3/26/23. LN 4 reviewed Resident 1's quetiapine order dated 3/6/23 and the March 2023 MAR. LN 4 stated the resident should have been administered a dose of quetiapine when the LN first observed Resident 1 pulling at life sustaining tubes. LN 4 stated, "There's a reason for the quetiapine order. It should have been followed." LN 4 reviewed Resident 1's progress note on 3/25/23 at 9:53 P.M. authored by the RT. LN 4 stated she did not see documentation that the RT's concern about Resident 1 needing continuous supervision had been acted upon. LN 4 stated there was no documentation that Resident 1 had been provided increased supervision. LN 4 stated at a minimum, the resident should have been put on Q15 monitoring (checking up on a resident every 15 minutes). LN 4 stated when there was a risk to the airway, Q15 monitoring would not be frequent enough. On 4/19/23 at 3:55 P.M., a joint interview and record review, was conducted with LN 4 and the medical records director (MRD). Resident 1's electronic medical record, paper chart, and the medication cart binders were reviewed. Both LN 4 and the MRD stated there was no documentation Resident 1 had been placed on increased or scheduled supervision such as Q15 monitoring. LN 4 and the MRD stated if Resident 1 had received increased or scheduled supervision it would have been documented in the EMR, paper chart, or medication cart binders. On 4/22/23 at 4:26 A.M., an interview was conducted with RT 1. RT 1 stated she was familiar with Resident 1. RT 1 stated the Resident was confused and would often pull at her trach and the oxygen mask that was applied to it. RT 1 stated if Resident 1 was really agitated or touching and pulling at her trach, then she needed to be placed on 1:1 supervision. RT 1 stated Resident 1 required the trach in order to adequately breathe. On 4/22/23 at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated Resident 1 was confused most of the time. LN 3 stated Resident 1 would become anxious at night after her daughters left. LN 3 stated Resident 1 would pretend to sleep, and as soon as her daughters left, she would start getting up and asking to go home. LN 3 stated she started her shift on 3/26/23 at 7 P.M. and saw Resident 1 sometime between 7 P.M. to 8 P.M. LN 3 stated she had observed Resident 1 to be agitated and pulling at her trach and oxygen mask. LN 3 stated Resident 1 needed 1:1 supervision at that time, but there was no one to do it. LN 3 stated there was not enough staff. LN 3 reviewed Resident 1's clinical record and stated when she went into Resident 1's room at 8:42 P.M., she thought the resident was asleep in bed. LN 3 stated Resident 1 had her blanket pulled up to her chin and could not visualize her trach site. LN 3 stated when Resident 1 did not respond, she pulled the blanket down and found the resident's trach next to her hip on the bed. LN 3 stated Resident 1 was dependent on the trach and could not adequately breathe without it. LN 3 stated, "She needed a sitter [1:1 supervision] at night when agitated." LN 3 stated she could have called Resident 1's daughter to come in but had not done so. LN 3 stated she did not attempt to place mittens on the resident or call the physician. LN 3 stated she was the only LN on the subacute unit on 3/26/23, and she was "just too busy." LN 3 stated there should have been enough staff available to provide the supervision that Resident 1 required on 3/26/23. On 4/22/23 at 5:42 A.M., an interview was conducted with CNA 2. CNA 2 stated, "It was hard taking care of [Resident 1] at night." CNA 2 stated he worked day and NOC shift, and the resident's daughters took care of her needs during the day. CNA 2 stated at night, Resident 1 kept trying to get out of bed and was restless. CNA 2 stated Resident 1 was "quick" and that he had to reapply the resident's oxygen mask several times after the resident removed it from her trach. CNA 2 stated there were a couple times when he worked that he briefly provided 1:1 supervision for Resident 1 when the resident was agitated. CNA 2 stated Resident 1 would calm down when someone was there and responded well to 1:1 supervision. CNA 2 stated Resident 1 needed 1:1 supervision when she was awake at night because she was "impulsive." On 4/22/23 at 6:20 A.M., a joint interview and record review was continued with LN 3. LN 3 reviewed Resident 1's physician order dated 3/6/23, indicating the resident was to receive a dose of quetiapine every six hours as needed for pulling out life sustaining tubes. LN 3 stated when she observed Resident 1 attempting to pull at her trach on 3/26/23, she should have administered a quetiapine dose. LN 3 stated quetiapine would not work immediately but it could have helped, and should have been given. On 4/22/23 at 7:25 A.M., an interview was conducted with LN 5. LN 5 stated Resident 1 had dementia. LN 5 stated Resident 1 would pretend to be asleep sometimes and then start to get up and pull on her g-tube and trach. LN 5 stated, "It's easy in the daytime because [Resident 1's] daughters were here." LN 5 stated Resident 1's behavior at night should have been discussed as IDT and a dementia plan of care developed to help the NOC shift manage the resident's behavior. A review of the facility census, dated 3/26/23, indicated the subacute unit (residents with more acute medical needs and where Resident 1 resided) was at maximum occupancy with 16 residents and one resident listed as a bed hold (out on leave). On 5/10/23 at 10:30 A.M., an interview was conducted with the director of staff services (DSD). The DSD stated, "It was a full house [maximum occupancy]" on the subacute unit on 3/26/23 which was too much for one nurse to manage. The DSD stated if a resident required 1:1 supervision then extra staff should have been provided to meet the resident's needs. On 5/10/23 at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1's clinical record. The DON stated Resident 1's family was present to watch the resident during the day.