Health inspection·December 7, 2023

The following reflects the findings of the California Department of Public Health during the investigation of the complaint CA00843156. Event ID: NESS11 Exit date: 11/29/2023. Representing the Department: Health Facilities Evaluator Nurse, 46552 State Citation AA was written for the following violation: F689 REGULATORY VIOLATIONS: Title 22 CCR § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22 CCR § 72315. Nursing Service--Patient Care. (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. Title 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. On 05/31/2023, an unannounced visit was conducted at the facility to investigate a complaint (CA00843156) during an abbreviated standard survey regarding quality of care. The facility failed to provide required assistance while eating and failed to implement the care plan (care plan: a form summarizes resident's health conditions, specific care needs and current treatments) to provide required assistance for eating for one out of four sampled resident (Resident 1). Resident 1's minimum data assessment (MDS: Clinical and functional assessment tool) dated 3/8/2023 indicated, Resident 1 required "extensive assist (extensive assistance: resident involved in part of the activity and staff provided full assistance with no participation by resident three or more times over the 7 days period) with 1 staff physical assist" with his eating. Resident 1's ADL (ADL: activities of daily living) self-care performance deficit care plan dated 9/10/2021 indicated, Resident 1 required staff's assistance while eating. This failure resulted in Resident 1 to aspirate (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) the food, became unresponsive, with no blood pressure, no pulse, stopped breathing, and physician pronounced Resident 1's death in the facility. FINDINGS: Review of Resident 1's undated face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was initially admitted to facility on 9/9/2021. Resident 1's admission diagnoses included dysphagia (difficulty in swallowing foods or liquids), aneurysm (a bulge and weakness in the wall of the artery) of the iliac artery (a set of two major blood vessels that provide blood to the lower part of the body), chronic respiratory failure (a serious condition that makes it difficult to breathe), diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting to mouth and stomach), morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 1's ADL self-care performance deficit care plan dated on 9/10/2021 indicated, the intervention includes, "Eating: Resident requires limited assistance" (limited assistance: resident highly involved in activity and received staff's physical help in guided maneuvering of hands for eating assistance). Review of Resident 1's physician orders for life-sustaining treatment (POLST) form dated on 11/9/2021 indicated, "Do Not Attempt Resuscitation/Do Not Resuscitate" (DNR: allow natural death when person's heart or breathing stops). Review of Resident 1's speech therapist's (ST: a highly qualified health care professional who diagnoses and treats swallowing problems) discharge summary dated 9/19/2022, indicated, short-term goals: "safe swallow precautions given min (minimal number) cues". Long-term goals: "safe swallow precautions: sitting up for meals. Alternating solids/liquids, small bites given min cues". ST discharge summary document further indicated, discharge status and recommendations for strategies: "Swallow strategies: To facilitate safety and efficiency, it was recommended the patient use the following strategies to increase safety during oral intake: upright position at least 30 minutes after meals, slow rate and alternate liquids and solids". Review of Resident 1's physician's order for diet dated on 2/5/2023 indicated, "Consistent Carbohydrate diet (CCD) (eating same amount of carbohydrates [sugar molecules] every day) Regular Texture, Thin (regular liquids) consistency, Therapeutic Lifestyle changes (TLC: diet plan combines diet, physical activity, and weight management to adopt a heart-healthy eating regimen), No Salt on Tray." Review of Resident 1's MDS assessment dated 3/8/2023, indicated, Resident 1's brief interview for mental status (BIMS) a score of 14 of 15 (13 -15: intact cognition [mental process involved in knowing, learning, and understanding things]). Resident 1's MDS also indicated Resident 1's ADL assistance for eating required "extensive assistance with one-person physical assist." Review of Centers for Medicare & Medicaid Services (CMS)'s Resident Assessment Instrument (RAI: helps facility staff to gather definitive information on a resident's strengths and needs which must be addressed in an individualized care plan) manual 3.0 revised October 2019, the RAI manual indicated, "extensive assistance with one-person physical assist: if resident performed part of the activity over the last 7 days and help of the following types (s) was provided three or more times: ... Full staff performance of activity three or more times during part but not all of the last 7 days." Review of Resident 1's health status note dated 3/19/2023, indicated that at around 7:50 a.m., Resident 2 (who was the roommate of Resident 1) alerted the facility staff to their room. Resident 1's health status also indicated that staff observed Resident 1 was pale and aspirating on food when they arrived at his bedside. Licensed Vocational Nurse A (LVN A) suctioned and was able to remove pieces of food and saliva from resident's mouth. However, Resident 1 continued to desaturate (decreased oxygen level). Oxygen was applied via nasal cannula (a device used to deliver oxygen to person in need of a respiratory help). The document further indicated Resident 1 was noted with no blood pressure, no pulse, was not breathing, had no heart sounds auscultated (listening sounds), and his eyes remained fixed (eyes unresponsive). Physician pronounced Resident 1's death over the phone when notified of the observations noted above by the nursing supervisor. Review of facility's menu on 3/19/2023 for breakfast indicated: baked cheese omelet, oatmeal cereal, toast, milk, coffee or hot tea, and orange juice. During an interview with Resident 2 (Resident 1's roommate) on 7/17/2023, at 10:45 a.m., Resident 2 confirmed there was no staff in the room when Resident 1 was eating breakfast on 3/19/23. Resident 2 stated he saw Resident 1 was holding his throat with both of his hands, was unable to cough or talk, had a pale face, was making wheezing (breathing with a whistling or rattling sound in the chest) sounds, and had dropped his silverware on his plate. Resident 2 stated he shouted for help for Resident 1 and that staff came to help Resident 1. Resident 2 further stated "it was too late my roommate died within few minutes." Review of Resident 2's (Resident 1's roommate) MDS assessment dated 5/3/2023, indicated a BIMS score of 14 of 15 (intact cognition). During an interview with Licensed Vocational Nurse (LVN) A on 7/17/2023, at 12:15 p.m., LVN A confirmed there was no staff in Resident 1's room when he was eating breakfast on 3/19/2023. LVN A stated she went to Resident 1's room, and observed Resident 1's mouth was opened, "mouth was full of food appeared like scrambled egg and his face was looking pale". LVN A also stated she observed Resident 1 was "aspirated on food." LVN A stated she (LVN A) suctioned, removed pieces of scrambled eggs and saliva from his mouth and started oxygen (a treatment that provides extra oxygen to breathe in). LVN A stated Resident 1 became "unresponsive, stopped breathing, and no signs of life" after few minutes. LVN A also stated Resident 1's physician pronounced Resident 1's death over the telephone when called to notify Resident 1's condition. LVN A confirmed Resident 1's diagnoses of dysphagia, and care plan for eating which required staff assistance. LVN A further stated staff should have implemented Resident 1's care plan for eating assistance. LVN A also stated staff should have stayed in the room, provided supervision and assistance for Resident 1 with eating breakfast on 3/19/2023. During an interview with director of nursing (DON) on 7/17/2023, at 1:57 p.m., DON stated staff should have supervised and assisted Resident 1 while he was eating breakfast on 3/19/2023. During a telephone interview with Certified Nursing Assistant B (CNA B) on 7/17/2023, at 3:30 p.m., CNA B stated she was assigned to Resident 1 on 3/19/2023, and CNA B confirmed there was no staff in the room to supervise Resident 1 while he was eating breakfast on 3/19/2023. CNA B stated Resident 2 (Resident 1's roommate) "alerted the staff" to the room. CNA B stated she went to Resident 1's room and found Resident 1 with a "mouthful of scrambled eggs", was holding his throat with his both hands, and coughing with squeaking sounds from his throat. CNA B stated she alerted LVN A. CNA B stated "Resident 1 became unresponsive and stopped breathing" a few minutes after. CNA B also stated Resident 1 needed a staff's supervision and assistance while eating. CNA B further stated staff should have stayed and assisted Resident 1 while he was eating. During a telephone interview with CNA C on 7/17/2023, at 5:20 p.m., CNA C stated Resident 1 needed a staff's supervision and assistance while eating. CNA C stated staff should have stayed and assisted Resident 1 during his mealtime on 3/19/2023. During a telephone interview with Resident 1's primary care physician (PCP) on 7/18/2023, at 1:03 p.m., PCP stated Resident 1 "definitely required staff's supervision and assistance" while he was eating due to his frail medical condition. During a telephone interview and record review with Minimum Data Set Assistant (MDSA) on 7/19/2023, at 12:45 p.m., the MDSA confirmed Resident 1's MDS assessment dated 3/8/2023 indicated, Resident 1 required "extensive assist with 1 staff physical assist" with his (Resident 1) eating. The MDSA stated, "extensive assistance" means, Resident 1 would not be able to perform or complete the activity of eating without nursing staff's physical help. The MDSA also stated staff should have stayed with Resident 1 and assisted with eating as required for Resident 1. During a concurrent interview and record review of Resident 1's ST discharge summary, recommendations for oral intake, and care plan interventions for eating assistance with LVN D on 8/11/2023, at 10:40 a.m., LVN D stated Resident 1 required staff supervision while eating with each meal based on Resident 1's ST's discharge summary recommendations and care plan interventions for eating assistance. LVN D also stated staff should not have allowed Resident 1 to eat on his own. During a telephone interview and record review of ST's discharge summary notes with the facility's ST on 8/11/2023, at 3:46 p.m., the ST stated Resident 1 was "not 100 % safe" to eat on his own without staff supervision during mealtime. The ST further stated staff should have provided supervision and assisted Resident 1 as needed while he was eating. During a concurrent interview and record review of Resident 1's diet order and facility's breakfast menu for 3/19/2023 with the dietary supervisor (DS) on 9/7/2023, at 1:22 p.m., the DS stated Resident 1 was served regular textured scrambled eggs 1/4 cup, oatmeal, toast, 2 % milk, hot tea, and orange juice on 3/19/2023 for breakfast. Review of Resident 1's undated discharge summary indicated, Resident 1's discharge date was 3/19/2023, with diagnoses including dysphagia, chronic respiratory failure, aneurysm of iliac artery, diabetes type 2, and congestive heart failure. Discharge summary also indicated, Resident 1's condition upon discharge was "death" in the facility. Review of Resident 1's undated certificate of death from State of California, indicated, "sudden cardiac death" as the "immediate cause final disease or condition resulting in death". During a telephone interview with Resident 1's PCP on 9/27/2023, at 11:45 a.m., PCP stated lack of oxygen supply to Resident 1's heart and brain after Resident 1 aspirated on food could have caused sudden cardiac death. During a review of the facility's policy and procedure (P&P) titled, "Assistance with Meals," revised March 2022, the P&P indicated, "Residents should receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays and will help residents who require assistance with eating." During a review of facility's P&P titled, "Care Plan Comprehensive," dated 8/25/2021, the P&P indicated, "the facility's Interdisciplinary Team, in coordination with the resident and /or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment." The above violation presented an imminent danger to the resident and was a substantial factor in the death of the resident.