Health inspection·March 28, 2025

CCR 22 § 72311 - Nursing Service-General (a) Nursing service shall include, but not be limited to, 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. CCR 22 § 72523 - Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. 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 resident's choices. The facility failed to: 1) Ensure Licensed Nurse 1 (LN 1) notifies facility physician of Resident 1's change in condition (decrease in blood pressure). 2) Implement facility policy and procedure "Change in a Resident's Condition or Status", including "promptly" notifying Resident 1's attending physician after Resident 1's change in condition. 3) Ensure LN 1 provides Resident 1 treatment and care in accordance with their professional standards of practice, including but not limited to notifying physician after change in condition. Following these failures, Resident 1 was found with cold, pale skin and without pulse approximately four hours after the decreased blood pressure (measurement of the force exerted by blood against the walls of the arteries as the heart pumps) was first identified. An hour later, Resident 1 was pronounced dead. A review of Resident 1's medical record was conducted on 1/22/25. Per the Admission Record, Resident 1 was admitted to the facility on 12/27/24 with diagnoses that included urinary tract infection (infection in the system of organs that makes urine). A review of Resident 1's Weights and Vitals Summary log was conducted. Resident 1 had the following BP (Blood Pressure) readings and HR (Heart Rate) during the night shift: 12/28/24 at 12:21 A.M., 189/86 and 88 bpm 12/29/24 at 2:47 A.M., 156/75 and 81 bpm 12/30/24 at 5:35 A.M., 132/61 and 63 bpm 12/31/24 at 1:27 A.M., 116/62 and 63 bpm 1/1/25 at 4:01 A.M., 134/64 and 82 bpm 1/2/25 at 2:09 A.M., 60/39 and 71 bpm 1/2/25 at 2:33 A.M., 92/58 and 67 bpm 1/2/25 at 2:37 A.M., 95/41 A review of Resident 1's Nursing Progress Notes, documented by LN 1, indicated the following events: On 1/1/25 at 11:30 P.M., Resident 1 requested for water and rested. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 12:30 A.M., Resident 1 was seen resting with eyes closed. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 2:09 A.M., Resident 1's vital signs (measurements to show how well the body functions) were BP (blood pressure) 60/39 mmHg (millimeters of mercury), HR (heart rate) 71 bpm (beats per minute), and the O2 sat (oxygen saturation - measure of how well the body is oxygenating the blood with normal range of 95-100%) was 87 %. LN 1 applied four liters of oxygen via nasal (nose) cannula (thin plastic tube) to Resident 1. LN 1 gave Resident 1 water, and Resident 1 drank 240 milliliters. LN 1 left the pulse oximeter (an electronic device measuring oxygen saturation) on Resident 1's finger. On 1/2/25 at 2:33 A.M., Resident 1's vital sign was assessed. BP was 92/58 mmHg, HR 67 bpm, and O2 sat of 90%. On 1/2/25 at 2:37 A.M., Resident 1's BP was rechecked and was 95/41 mmHg. On 1/2/25 at 3 A.M., a Certified Nursing Assistant (CNA) checked Resident 1, and the O2 sat was 90%. On 1/2/25 at 3:30 A.M., LN 1 checked on Resident 1 and offered fluids, but Resident 1 refused. On 1/2/25 at 4 A.M., a CNA notified LN 1 that Resident 1's O2 sat was 95%. Resident 1 had no discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 4:30 A.M., LN 1 checked Resident 1. Resident 1 was resting. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 4:45 A.M., a CNA checked on Resident 1, and there was no labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 5 A.M., LN 1 checked Resident 1, and the O2 sat was 93% with oxygen at four lpm of oxygen. On 1/2/25 at 5:15 A.M., a CNA checked on Resident 1, and there was no labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 5:30 A.M., LN 1 checked Resident 1, and the "pulse oximeter read that O2 saturation was stable..." No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 6:05 A.M., a CNA checked Resident 1. Resident 1 was resting. No labored breathing or distress. No discoloration from lack of oxygen or changes noticed in skin color. On 1/2/25 at 6:15 A.M., LN 1 checked Resident 1. Resident 1's skin was pale, and the body was cold. LN 1 instructed CNA to call 911 (emergency responder). Resident 1 had no pulse, and CPR (Cardiopulmonary Resuscitation- life-saving procedure) was performed. The emergency responder came to the facility and provided CPR. Resident 1 was pronounced dead at 7 A.M. On 2/4/25 at 2:29 P.M., LN 1 was interviewed. LN 1 stated Resident 1 had low BP readings ranging from 60/40 mmHg to 90/60 mmHg on 1/2/25. LN 1 stated he offered Resident 1 fluids, elevated the resident's head of the bed, provided oxygen, and elevated Resident 1's feet. LN 1 stated Resident 1's vital sign on 1/2/25 were not within Resident 1's normal range. LN 1 stated Resident 1 experienced a change of condition. LN 1 stated he should have immediately notified Resident 1's physician regarding the resident's change of condition. On 2/4/25 at 4 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated LN 1 should have assessed Resident 1 thoroughly when the resident's oxygen level and blood pressure suddenly went down. The DON also stated that LN 1 should have immediately notified Resident 1's physician when the resident experienced a change of condition. On 3/5/25 at 1:45 P.M., an interview was conducted with Resident 1's physician (PH). The PH stated he expected the nurses to inform him when a resident experience a change of condition. The PH stated the license nurse should have notified him when Resident 1 experienced a change of condition. A review of the facility's policy and procedure, titled Change in a Resident's Condition or Status, dated 2/21, was conducted. The policy 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..." The facility failed to: 1) Ensure Licensed Nurse 1 (LN 1) notifies facility physician of Resident 1's change in condition (decrease in blood pressure). 2) Implement facility policy and procedure "Change in a Resident's Condition or Status", including "promptly" notifying Resident 1's attending physician after Resident 1's change in condition. 3) Ensure LN 1 provides Resident 1 treatment and care in accordance with their professional standards of practice, including but not limited to notifying physician after change in condition. Following these failures, Resident 1 was found with cold, pale skin and without pulse approximately four hours after the decreased blood pressure (measurement of the force exerted by blood against the walls of the arteries as the heart pumps) was first identified. An hour later, Resident 1 was pronounced dead. These violations, whether jointly, separately, or in any combination, presented either an imminent danger of death or serious harm, or a substantial probability that death or serious physical harm would result. Therefore, a Class A Citation is warranted.