Other·October 3, 2023

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 839179. The inspection was limited to the specific FRIs investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN #34401 A deficiency was written for FRI # 839179 at F-tag 695/G. 42 Code of Federal Regulations part 483.25 (i) Respiratory care, including tracheostomy care and tracheal suctioning. (i) The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences, and 483.65 of this subpart. The facility failed to provide continuous mechanical ventilation (a life support system; a machine that helps keep the lungs working by pushing air in and out of the lungs via tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe]) as ordered by the physician for one sampled resident (Resident 1). Resident 1 was without oxygen assistance for more than two hours. This failure resulted in Resident 1 experiencing respiratory distress (difficulty breathing), requiring Cardiopulmonary resuscitation (CPR -an emergency lifesaving procedure performed when the heart stops beating), and the need to be transferred to the acute hospital. Findings: On 5/17/23, at 9:45 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an adverse event related to Resident 1's unanticipated sudden respiratory arrest (breathing stops). Resident 1 is a 38-year-old female, admitted to the facility on 3/7/23. Resident 1's diagnoses included stroke (lack of blood flow to the brain), traumatic brain dysfunction (damage to the brain), traumatic spinal cord dysfunction (loss of muscle function and sensation), respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body's vital organs [main organs inside the body such as heart, lungs, and brain]), tracheostomy, and dependence on a respirator [ventilator - machine which replacing breathing of a person]. During a review of Resident 1's "Order Sheet" (OS), dated 3/7/23, the OS indicated, "Ventilator-Volume A/C (assist control-the ventilator delivers a fixed tidal volume [amount of air moved into or out of the lungs] at set intervals of time or when the resident initiates a breath delivers a minimum number of preset mandatory breaths by the ventilator; this mode provides full ventilatory support)" The OS indicated, Resident 1 had an order for mechanical ventilator to be on continuous mode (continuing without a stop). During a review of Resident 1's ventilator machines manual instruction titled, "Instructions for Use" (IFU), dated 4/17/20, the IFU indicated, "Standby-A ventilation feature that suspends (discontinues) ventilation [supply of air to the lungs] and keeps current settings when the clinician wants to temporarily disconnect the patient from the ventilator." During a review of the facility "Incident Report" (IR), dated 4/26/23, the IR indicated, Resident 1 "Was found to be in respiratory distress [difficulty breathing] with a thready [weak] pulse by Nurse Practitioner [NP-works collaboratively with a physician] on 4/26/23 at [7:23 p.m.] [sic]. Code blue [medical emergency] was called and chest compressions [CPR] and ambu-bag [manual self-inflating-bag] ventilation were initiated immediately. During code activation, Nurse Practitioner identified that the ventilator was on "standby" mode and corrected the ventilatory support setting." During an interview on 5/17/23, at 9:45 a.m., with Nurse Manager (NM), NM stated, on 4/26/23, during shift change between 6:30 p.m. to 7:30 p.m., Resident 1 was in her room, lying in bed and noted to be cyanotic (a bluish or purplish discoloration of the skin, lips caused by lack of oxygen) with respiratory distress. NM stated, CPR was initiated, and Resident 1 was transferred to the acute hospital on 4/26/23, for evaluation and returned on 4/27/23. NM stated, NP noted Resident 1's ventilator machine was on a "standby" mode and "was not giving her [Resident 1] the air she needed." During a concurrent interview and record review on 5/17/23, at 10:21 a.m., with Director of Nurses (DON), Resident 1's OS, dated 3/7/23, was reviewed. DON stated, Resident 1 had an order for the ventilator machine to be on continuous mode. DON stated, Resident 1's ventilator machine should never have been placed on a "standby" mode. DON stated, "During the investigation we (management) don't know who put the ventilator on a standby mode." DON stated, Resident 1's code status (full support which includes CPR, if the patient has no heartbeat and is not breathing) was a full code (all procedures will be provided to keep a person alive if the heart stopped beating and/or they stopped breathing). During a concurrent observation and interview on 5/17/23, at 10:52 a.m., with Certified Nursing Assistant (CNA), in Resident 1's room, Resident 1 was lying in bed. A ventilator machine was at Resident 1's bedside with a plastic breathing tube connected from the ventilator machine to Resident 1's neck area. A rhythmic whoosh, pause, whoosh, pause was heard from Resident 1's ventilator machine. CNA stated, Resident 1 was non-verbal and required two staff assistance for turning and repositioning in bed. During an interview on 5/17/23, at 10:58 a.m., with Respiratory Technician (RT) 1 and RT 2, RT 1 stated, "When the power button located in front of the ventilator machines monitor screen is pressed, a 'standby and a power off' question will appear on the monitor screen. When the standby mode is selected, the machine remains on, but it is not giving out any air." RT 1 stated, "The standby mode on a ventilator machine is used when there is an order for weaning (process in decreasing the amount of ventilatory support) a resident off the machine and required an RT to be always at bedside with the resident during the weaning process." RT 2 stated, Resident 1 had an order for the ventilator machine to be on continuously and should not have been placed on a "standby" mode. During a concurrent interview and record review, on 5/17/23, at 12:33 p.m., with DON, Resident 1's ventilator machine alarm and button internal log (ventilator machine had its own memory log that records each event or incident), dated 4/26/23, was reviewed. The log indicated the following: 4/26/23 at 4:59 p.m. the "Start/Stop Key Pressed." 4/26/23 at 4:59 p.m. (1 second later), the "Standby" mode was selected. 4/26/23 at 7:13 p.m. the ventilator machine was turned back on. DON stated, the log indicated Resident 1's ventilator machine was on a "standby" mode for more than two hours (2 hours and 14 minutes). DON confirmed the ventilator machine was on a "standby" mode (4/26/23), which resulted in respiratory distress for Resident 1. During an interview on 5/18/23, at 4:26 p.m., with Registered Nurse (RN) 1, RN 1 stated, on 4/26/23, at 5 p.m. she administered pain medication to Resident 1 in her room. RN 1 stated, at 5:50 p.m., she returned to Resident 1's room to re-assess Resident 1 and noted "her (Resident 1) slight grimacing (frowning)." RN 1 stated, at 6:15 p.m., she gave report to the oncoming nurse (Licensed Vocational Nurse-LVN) inside Resident 1's room. RN 1 stated, she went into Resident 1's room three times (no time given) and did not notice Resident 1's ventilator machine was on a "standby" mode and Resident 1 was not receiving any air. RN 1 stated, Resident 1 "Could not breathe without the ventilator machine." During an interview on 5/18/23, at 9:33 p.m., with RN 2, RN 2 stated, on 4/26/23, at approximately 6:20 p.m., Resident 1 was in her room with the NP. RN 2 stated, NP noted Resident 1 to be uncomfortable (uneasy). At approximately 7 p.m., RN 2 returned to Resident 1's room with the NP and found Resident 1 was "dusky [grayish] color" and had a faint (weak) pulse. RN 2 stated, CPR was immediately started. RN 2 stated, the NP noted Resident 1's ventilator machine was on a "standby" mode (4/26/23). RN 2 stated, Resident 1 "needed the ventilator machine to help with breathing." During an interview on 5/22/23, at 12:39 p.m., with RT 3, RT 3 stated, "When a ventilator machine is placed on a standby mode, the machine is on, but it is not giving breath to the resident, not ventilating, not working." RT 3 stated, Resident 1 was dependent on the ventilator machine, "was not ready for any type of weaning," the ventilator machine should never have been placed on a "standby" mode. During an interview on 5/22/23, at 2:03 p.m., with NP, NP stated, on 4/26/23, she assessed Resident 1 two times (no time given). NP stated, Resident 1 looked uncomfortable, and she ordered pain medication to be given and a bladder scan (procedure used to detect how much urine is in the bladder). NP stated, she returned to Resident 1's room and noted Resident 1's "skin color" was different and noted the ventilator machine was on a "standby" mode. NP stated, she re-started Resident 1's ventilator machine and initiated the CPR. NP stated, Resident 1 had an order for the ventilator machine to be on continuously, "There is no reason for her [Resident 1] to be on standby mode." During an interview on 5/23/23, at 7:23 a.m., with LVN, LVN stated, on 4/26/23, at approximately 6:20 p.m., RN 1 was giving a verbal report of all her patients (this is done when one nurse is checking out and another nurse will be taking care of the patients/residents) to LVN. LVN stated, at 6:50 p.m., he went back in Resident 1's room with RN 3 to perform the bladder scan and he noted the lights on Resident 1's ventilator machine was on "but was not making any noise". LVN stated, he did not take a closer look at Resident 1's ventilator machine because he thought it was on. LVN stated, Resident 1 had always been on the ventilator since she was admitted (3/7/23). During an interview on 5/25/23, at 10:08 p.m., with RN 3, RN 3 stated, on 4/26/23, at approximately 6:50 p.m., she went to Resident 1's room to help with the bladder scan procedure. RN 3 stated, she did not notice Resident 1's ventilator machine was on a "standby" mode. RN 3 stated, Resident 1 had an order "to be on the ventilator machine continuously." RN 3 stated, "She [Resident 1] would not be able to tolerate without it [ventilator machine]." During a review of Resident 1's "Nursing Narrative Note" (NNN), dated 4/26/23 at 8:23 p.m., the NNN indicated, "Approximately [7:23 p.m.] [sic] NP decided to go back and follow up on [Resident 1] and noticed that [Resident 1] was gray/dusky in color and was unresponsive [not reacting or responding] with faint [weak] pulse. . . [Resident 1] was in respiratory distress and CPR was initiated. . . " During a review of Resident 1's "Critical Care Progress Note" (CCPN), dated 4/26/23 at 7:40 p.m., written by the NP, the CCPN indicated "Significant Findings: Respiratory arrest (medical emergency where the ability of a resident to breathe stops). CPR started. . . send to [acute hospital] for evaluation." During a review of Resident 1's EMS (Emergency Medical Services- is a system that provides emergency medical care) narrative note, date 4/26/23, at 7:25 p.m., the note indicated, "RN at scene states she was doing her normal evening rounds, and when she came to this patient [Resident 1], noticed that her ventilator was turned off. . .Continuously monitored patient during transport and arrived [acute hospital]." During a review of the acute hospital Emergency Documentation (ED), dated 4/26/23, at 10:30 p.m., the ED indicated, "ED Course: 38-year-old female. . . presents to our facility status post [after] CPR. Staff found patient somewhat uncomfortable and realized that her ventilator has been turned off. They turned the ventilator back on, checked her pulse which was reported to be thready [weak]. CPR was initiated and maintained for approximately 10 minutes . . . Critical Care Note: There was an acute [sudden] impairment of an organ system (a group of organs in the body that work together to perform a specific function) with a high probability of imminent or life-threatening deterioration (a critical illness or injury acutely impairs one or more vital organ systems) in the patient's condition. . ." During a review of the facility's policy and procedure (P&P) titled, "Orders: Processing & Notation of Non-Medication Orders," dated 5/3/23, the P&P indicated, "Licensed staff ensure Practitioner orders are followed when delivering care to patients." During a review of the facility's P&P titled, "Mechanical Ventilation," dated 3/17/21, the P&P indicated, "Respiratory Care practitioners will safely establish and maintain mechanical ventilatory support resulting in respiratory homeostasis [state of balance] . . . Procedures: XIII. Automatic Stop Order: Not applicable." This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is a Class A citation.