Health inspection·April 30, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 928031. The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint number 928031 at F tag 693/G. 42 Code of Federal Regulations part 483.25 (g) Assisted nutrition and hydration. Based on a resident's comprehensive assessment, the facility must ensure that a resident- (5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. 72311. Nursing Service--General. (1) 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. On 11/12/24, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident's death due to delay in care. Resident 1 was a 71-year-old male, admitted on 7/9/24 with diagnoses of acute (symptoms or signs that begin and worsen quickly) and chronic (continuing or occurring again and again for a long time) respiratory failure (a serious lung condition which makes it difficult to breathe on your own) with hypoxia (a medical condition that occurs when there's not enough oxygen in the body's tissues), paraplegia (paralysis of the legs and lower body, typically caused by spinal cord [part of the body that connects the brain and the body]injury or disease) dysphagia (swallowing problems occurring in the mouth and/or the throat), disorders of diaphragm (diaphragm- is a muscular barrier between the chest and the abdominal cavity; disorders of the diaphragm often interfere with breathing), and gastrostomy status (the presence of a surgical opening into the stomach). Based on interview and record review, the facility failed follow their policy and procedure (P&P) titled, "Enteral Feedings (a method of delivering nutrients and fluids to the body for patients who cannot safely chew or swallow) - Safety Precautions," for one of three sampled residents (Resident 1) who was on gastrostomy tube (G- tube- a tube which delivers liquid, nutrition, and medications through a flexible tube that goes directly into the stomach) feeding when G-tube placement was not checked, gastric residual volume (measures the amount of fluid or contents remaining in the stomach after feeding) was not checked, and signs and symptoms of complications were not reported timely to the physician. These failures resulted in Resident 1 being transferred to the acute hospital and being diagnosed with aspiration pneumonia (a lung infection that occurs when something other than air, like food, liquid, saliva, or vomit, is inhaled into the lungs). Findings: During a review of Resident 1's quarterly "Minimum Data Set," (MDS- an assessment tool) dated 10/8/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- test to evaluate cognitive [how well a person thinks, remembers, and learns] function) score was 12 out of 15 (a score of 8 to 12 indicates moderately impaired cognition). During a review of Resident 1's "Order Summary Report," (OSR- physicians' orders) undated, indicated, continuous feeding via G- tube Glucerna 1.2 (specialized source of nutrition) 90 ml (millimeter- unit of measure per hour) x (times) 20 hours. "Enteral Feed (G- tube feeding- delivers liquid nutrition through a flexible tube that goes directly into your stomach) Order every shift Enteral: Assess for any s/sx (signs and symptoms) of aspiration (when food or drink are breathed into the lungs). . . crackles (abnormal breath sounds that occur when fluid builds up in the airways of the lungs) in lungs, . . . SOB (shortness of breath) regurgitation (vomiting), drooling (excess saliva flows out of the mouth involuntarily), wheezing (a high-pitched whistling sound that occurs when breathing due to narrowed or obstructed airways, noisy breathing QS (every shift) and notify MD (Medical Doctor)- Start Date- 07/09/2024 0600 (6 a.m.)" and "Enteral Feed Order every shift Enteral: Assess for formula intolerance QS- NV (nausea [uneasiness in the stomach] and vomiting), . . . and notify MD if any- Start Date- 07/09/2024 0600". During a review of Resident 1's "SBAR," (situation, background, appearance, and review- a communication form) dated 10/25/24 documented by Licensed Vocational Nurse (LVN) 2, the SBAR indicated, "Upon on coming [sic] of my shift (LVN 2 shift started at 6 p.m. on 10/25/24) the (Resident 1) had noted N/V (nausea and vomiting), looked pale and had a noted wheeze (a high-pitched whistling sound that occurs when the airways in the lungs become blocked, making it difficult to breathe) . . .later (between 7 p.m. and 8 p.m.) due meds (medications) were given (via G-tube) without A/R (adverse result- negative or harmful results). During rounding per shift change (10:30 p.m.) for the CNA'S (certified nursing assistant) the (Resident 1) was found Diaphoretic (excessive sweating due to a secondary condition), labored breathing (increase in effort to breathing) with noted crackles while sitting in high fowlers position (seated upright) and on 2L (liters- unit of measure) O2 (oxygen) via NC (nasal cannula- thin plastic tube placed in nostrils to deliver oxygen). The (Resident 1) looked cyanotic (having a bluish or purplish discoloration of the skin or mucous membranes (moist tissues that line the inside of your mouth and nose) due to low oxygen levels in the blood). . .Blood sugar was assessed and recorded at 151 mg/dl (milliliter per deciliter- unit of measure [normal blood sugar between 70-100]) O2 sat (saturation-oxygen absorb in blood) @ (at) 88 (percent [unit of measure] a normal oxygen saturation level is between 95 percent and 100 percent). (Resident 1's physician) notified at 10:47 (10:47 p.m.), order given to send out (to the acute hospital). (Ambulance) arrived at 10;58 [sic] (10:58 p.m.)." During an interview on 11/24/24 at 1:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 10/25/24 (10:30 p.m. to 6 a.m.) she was assigned to Resident 1. CNA 1 stated she checked Resident 1 at approximately 10:30 p.m. CNA 1 touched Resident 1 and noticed he was damp and sweaty. Resident 1 did not verbally respond when she greeted him. CNA 1 stated Resident 1 moaned which was "unlike him." CNA 1 stated Licensed Vocational Nurse (LVN) 2 and Registered Nurse (RN) were notified of Resident 1's condition (damp and sweaty) and LVN 2 and RN came into the room with a crash cart (a cart stocked with emergency supplies, used for cardiac [relating to the heart] and respiratory [made up of your lungs, airways, throat, nose, and mouth] emergencies). CNA 1 stated Resident 1 was sent out (acute hospital) via ambulance at approximately 11 p.m. (10/25/24). During an interview on 11/26/24 at 10:03 a.m. with LVN 2, LVN 2 stated on 10/25/24 she came to work at 6 p.m. and noted Resident 1 was vomiting and wheezing. She stated she waited 45 minutes and administered Resident 1's due medications via G- tube at approximately 6:45 p.m. LVN 2 stated Resident 1 had vomited several times from 6 p.m. to 10:30 p.m. and she stopped the G- tube feeding (no time given), "Every time I tried to connect (Resident 1) to his feeding tube (Resident 1) would vomit to the point of projectile vomiting (a type of severe vomiting that involves the forceful expulsion of stomach contents)." LVN 2 stated, "As soon as the CNA would get him cleaned up (Resident 1) would vomit again." LVN 2 stated she did not immediately report Resident 1's vomiting and wheezing to the MD on 10/25/24 at 6 p.m. LVN 2 stated, "I felt it was necessary to get (Resident 1) out to the hospital." During a concurrent interview and record review on 12/11/24 at 3:30 p.m. with Director of Nursing (DON), Resident 1's SBAR dated 10/25/24 was reviewed. DON stated LVN 2 noted Resident 1 had vomiting and wheezing episodes between 6 p.m. and 6:30 p.m. DON confirmed the MD was not notified until 10:47 p.m. (approximately 4 hours and 30 minutes after the first episode of vomiting was noted). Resident 1's medical record was reviewed. DON confirmed no documentation the G- tube placement and/or residuals were checked prior to LVN 2 administration of medication to Resident 1 at 8 p.m. (10/25/24). DON stated the MD should have been notified immediately (after the first episode of vomiting and wheezing were noted between 6:15 p.m. to 6:30 p.m.). During a review of Resident 1's "Pre-hospital Care Report," (PCR- paramedic's documentation) dated 10/25/24 the PCR indicated dispatch was notified at 11:01 p.m., the unit arrived at the facility at 11:06 p.m., and arrived at the hospital at 11:25 p.m. The PCR indicated, "(Resident 1) is presenting with respiratory distress (difficulty breathing, rapid breathing, and low blood oxygen levels). Staff stated patient had been in the current condition for close to thirty minutes into her shift (6:30 p.m.). Staff stated that the earlier shift had reported (Resident 1) was presenting in the same condition . . . (Resident 1) has rhonchi (a low-pitched, loud, continuous lung sounds that resemble snoring or gurgling (growling); usually means a blockage or an increased mucus in the airways) on all pulmonary (lungs) fields. (Resident 1) has partial airway obstruction (blockage) due to phlegm (thick mucus produced by the lungs) build up. (Resident 1) has an increased respiratory rate and effort . . . (Resident 1) has cool, moist, and pale skin signs." During a review of Resident 1's "ED (emergency department) Physician Note," (EDPN) dated 10/25/24 at 11:38 p.m. the EDPN indicated, "Medical Decision Making . . . have ordered Rocephin (medications used to treat bacterial infections- no route indicated) and clindamycin (medications used to treat bacterial infections) to cover aspiration pneumonia . . . (Resident 1) chest x-ray (generate images of tissues and structures inside the body) shows elevation of right hemi (half) diaphragm (is the major muscle of respiration, located below the lungs) is along with what I suspect are infiltrates (a substance that is denser than air and is present in the lung tissue, such as fluid) in the right lung. . .This chest x-ray was interpreted by myself (ED physician)." During a review of the facility's policy and procedure (P&P) titled, "Enteral Feedings-Safety Precautions," November 2018, the P&P indicated, "To ensure the safe administration of enteral nutrition. . .Preventing aspiration 1. Check enteral tube placement prior to feeding or administration of medication. 2. Check gastric residual volume as ordered. . . 4. Monitor the resident for signs and symptoms of respiratory distress during enteral feedings and medication administration. . . Recognizing and reporting other complications 1. . . g. Nausea; . . . i. c. Difficulty breathing. Documentation Document all assessments, findings, and interventions in the medical record. Reporting Report unusual findings and/or signs of complications to the Physician." In violation of the above cited standards, the facility failed to follow their P&P titled, "Enteral Feedings - Safety Precautions," when G-tube placement was not checked, gastric residual volume was not checked, and signs and symptoms of complications were not reported timely to the physician, resulted in Resident 1 being transferred to the acute hospital and was diagnosed with aspiration pneumonia . This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm to Resident 1 would result and constitutes to a Class A citation.