Health inspection·January 18, 2024

F678, Section 483.24, Cardiopulmonary Resuscitation (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. Title 22, Section 72301, Required Services (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. Title 22, Section 72523, Patient Care Policies and Procedures (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/29/23 at 11:56 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding concerns of patient neglect and death. On 9/10/23 at approximately 9:58 a.m. Patient 1 was found pulseless and not breathing in the facility by a Respiratory Therapist (RT) who then alerted two Licensed Nurses (LNs). The LNs did not perform Cardiopulmonary Resuscitation (CPR, an emergency procedure conducted to manually preserve intact brain function until further measures are taken to restore blood circulation and breathing in a person whose heart has stopped beating) even though Patient 1's Physician Orders for Life-Sustaining Treatment (POLST) indicated Patient 1 was to receive CPR. The department determined the licensed facility staff failed to provide basic life support, including CPR, to Patient 1 and failed to execute a physician's order to call an emergency medical care team to provide necessary medically effective means to prolong Patient 1's life. These failures led to Patient 1 having been deprived of the possibility of a prolonged life. A review of LN 2's Basic Life Support Provider document, dated 1/28/22, indicated LN 2 successfully completed the cognitive and skills evaluations for certification in CPR and automated external defibrillator (AED, a medical device used to analyze the heart's rhythm and, if necessary, deliver an electrical shock to help the heart re-establish an effective rhythm) program. This document also indicated an expiration date of January 2024. A review of LN 1's Healthcare Provider card, dated 3/2/22, indicated LN 1 successfully completed the requirements for certification in adult CPR and AED program. This card also indicated an expiration date of 3/2/24. A review of Patient 1's admission record indicated admission to the facility on 9/2/23, with diagnoses which included respiratory failure with hypoxia (a condition in which a person's respiratory system is unable to provide oxygen to tissues in the body in order to function) and congestive heart failure (a condition in which the heart is unable to pump blood adequately throughout the body). This admission record also indicated Patient 1's family member was her Responsible Party (RP, a person who is appointed to make healthcare decisions if or when Patient 1 was unable to). A review of Patient 1's POLST, dated 9/2/23, indicated licensed staff were to, "Attempt Resuscitation/ CPR ...[provide] Full Treatment- primary goal of prolonging life by all medically effective means...In addition...use intubation, advanced airway intervention, mechanical ventilation, and cardioversion as indicated..." This POLST was signed by a physician on 9/4/23 and, "verbal consent obtain [sic] by phone at [3:50 p.m.] 9/2/23 from RP with 2 nurses ..." A review of a facility document titled "Consent to Treatment", dated 9/2/23, indicated, "The [Patient] hereby consents to routine nursing care provided by this Facility as well as emergency care that may be required ..." This consent was signed by a facility representative and, "verbal consent obtain [sic] by phone from RP with 2 nurses at [5:30 p.m. on] 9/2/23..." A review of a Minimum Data Set (MDS, an assessment tool), dated 9/2/23, indicated, "Does [patient] have a California POLST form in chart?...Yes ...Item selected in California POLST Section A ...Attempt resuscitation/ CPR ...Item selected in California POLST Section B ... 'Full Treatment' is the only box checked ...POLST Section D- Signature of Physician ...Yes ...POLST Section D- Signature by ...Decision Maker ...Yes ..." A review of a MDS, dated 9/4/23, indicated Patient 1 had an ostomy (a surgically placed opening from the digestive or urinary system which allows the body to uncontrollably expel waste). The MDS also indicated Patient 1 was, "...always incontinent [of urine]" and Patient 1 was not on a, "...toileting program currently being used to manage...bowel continence..." A review of an order summary report, dated 9/5/23, indicated Patient 1 had a physician's order which indicated her POLST was, "Full Code [licensed staff was to provide care with the primary goal of prolonging life by all medically effective means] ...Order date ...9/5/23 ..." A review of a physician's note, dated 9/9/23 at 1 p.m., indicated, "...The [RP] has been approached by Palliative Care [staff who specialize in medical care for people with serious illness] people at the facility where thepatient [sic] came from ...however has insisted with continued aggressive care ...pt [Patient 1] is full code ..." A review of Patient 1's Medication Administration Record (MAR), dated September 2023, indicated, "POLST: Full Code ..." This MAR also indicated LN 1 administered medication to Patient 1 via Gastrostomy tube (G-tube, a tube surgically inserted through the abdomen that brings nutrition and medication directly to the stomach) between 8 a.m. and approximately 9:58 a.m. on 9/10/23. A review of a nurse progress note, dated 9/10/23 at 10:12 a.m. indicated, "Upon making nursing round approximal at [9:58 a.m.] RT and nurse observed [patient] with out [sic] color, no pulse was noted, not breathing. [Patient] lost bladder and bowel function. RT noted no breath sounds and no O2 [oxygen] saturations were present, no any [sic] pulses were present, no heartbeat detected. RN on unit at this times [sic] confirm death at 10:02 [a.m.] MD [Medical Director/physician] notified at 10:04 [a.m.], RP son notified at 10:09 [a.m.]. social [sic] services notified at 10:06 [a.m.]. DON [Director of Nursing] notified at 10:10 [a.m.]. Mortuary pick body at [1:45 p.m.]." A review of a nurse progress note, dated 9/10/23 at 12:41 p.m. indicated, "[Patient 1] expired at [10:02 a.m.]." A review of Patient 1's medical chart on 9/29/23, indicated no documented evidence CPR was attempted or performed when licensed staff found Patient 1 pulseless and not breathing on 9/10/23. There was also no documented evidence emergency medical personnel were called to assist the facility to provide Patient 1 care to prolong her life by all medically effective means on 9/10/23. In an interview on 10/6/23 at 12:48 p.m., the MD 1 confirmed Patient 1's code status was "full code" and staff did not initiate CPR for Patient 1. The MD 1 also stated, "When there was no pulse nothing can be done for the [patient]..." In an interview on 10/6/23 at 2:55 p.m., the Respiratory Therapy Supervisor (RTS) confirmed RT 1 was present when Patient 1 was found pulseless and not breathing. The RTS also confirmed no CPR had been initiated on Patient 1 at the time she was found. In an interview on 10/6/23 at 3:27 p.m., the RT 1 stated during his second visit to check on Patient 1, he saw Patient 1 was pale, the pulse oximeter monitor was not connected to Patient 1, and when he connected the pulse oximeter monitor to Patient 1 it was unable to get a reading. The RT 1 stated two nurses came to check on Patient 1 for a pulse, chest rise, and obtain vital signs, but were unable to get any vital signs. The RT 1 stated nobody started CPR on Patient 1. The RT 1 also stated the nurses called both the DON and the MD and were instructed not to do CPR. In an interview on 10/10/23 at 11:35 a.m., the LN 2 stated on 9/10/23 at 9:58 a.m., the RT 1 had told her he wanted LN 2 to check on Patient 1. The LN 2 stated when she assessed Patient 1, Patient 1 was cold with her mouth open, her hands were clenched, there was no heart rate, and no respirations. In an interview on 10/10/23 at 3:23 p.m., the LN 1 stated the LN 2 called her into Patient 1's room at approximately 10 a.m. on 9/10/23. The LN 1 stated upon assessment, Patient 1 had no pulse and no respiration. The LN 1 stated the Unit Manager called the MD and the DON and was instructed not to perform CPR for Patient 1. In an interview on 12/14/23 at 10:31 a.m., the MD 2 stated he expected licensed staff to start CPR on a patient with a full code order who was found pulseless and not breathing because no one would know how long the patient had been in that situation unless the staff observed the moment the patient had a change in condition. The MD 2 also stated he expected emergency services to be called because the facility does not have the capability to perform advanced cardiac life support. The MD 2 further stated it would be difficult for a physician to pronounce death without assessing the patient's heart, lungs, and pupils. In an interview on 12/14/23 at 11 a.m., the DON (who is also a licensed nurse) stated any licensed nurse who was certified to perform CPR could perform CPR. When asked if she was able to pronounce death of a patient, the DON stated she was not a physician; therefore, she was unable to determine the death of a patient. A review of Patient 1's POLST, dated 9/2/23, indicated, "First follow these orders, then contact Physician...A copy of the signed POLST form is a legally valid physician order...If patient has no pulse and is not breathing...Attempt Resuscitation/ CPR...To be a valid POLST form must be signed by (1) a physician...and (2) the patient or decisionmaker...Using POLST...Section A...If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen 'Do Not Attempt Resuscitation.' " A review of the facility's policy and procedure titled "Physician Orders for Life-Sustaining Treatment ...", updated 4/8/22, indicated, " ...The POLST will be honored if received on admission and signed by both the patient and a physician in accordance with the guidelines ...Because the POLST form is a physician order, emergency medical personnel are required to adhere to its instructions regarding CPR ...The POLST form is printed on bright pink paper so it will be easily recognizable by all health care personnel..." A review of the Uniform Determination of Death Act, approved by the American Medical Association on 10/19/80 and approved by the American Bar Association on 2/10/81, indicated, " ...Determination of Death...An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards." Therefore, the department determined the facility failed to provide basic life support, including CPR, to Patient 1, including but not limited to failing to execute a physician's order to call an emergency medical care team to provide necessary medically effective means to prolong Patient 1's life. These failures led to Patient 1 having been deprived of the possibility of a prolonged life. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1.