Other·October 22, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey of a facility reported incident. Facility reported incident: 595805 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the Department: 06855 HFEN A deficiency was issued for facility reported incident 595805 at F 695.

F695 SS=G Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/27/2018 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. 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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow physician orders and failed to use professional standards of practice and follow facility policy when changing one of three sampled resident's (Resident 1's) tracheostomy tube (a tube going in to a surgically created hole in the neck) on 7/15/18. After the nurse and respiratory therapist LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZGV11 Facility ID: CA230000044 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555151 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOWS POST ACUTE 320 N Crawford St Willows, CA 95988 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE removed Resident 1's tracheostomy tube, they were unable to get the new tube into the tracheostomy passage. Resident 1 died due to lack of oxygen. Findings: A visit was made to the facility on 7/25/18 to investigate the facility reported death of Resident 1 during a monthly tracheostomy tube change. Resident 1's record was reviewed. Resident 1 was 56 years of age, admitted to the facility on 8/14/17, after a intracerebral and intracranial hemorrhage (bleeding into the brain) left her unable to breathe on her own and was dependent on a ventilator attached to a tracheostomy tube in her neck. Resident 1 had multiple diagnoses, which included, chronic respiratory failure, past opioid (narcotic pain medication) dependence, hypertension (high blood pressure), dysarthria (disruption of normal speech ability), gastrostomy (feeding tube into the stomach), seizures, hypothyroidism (low thyroid activity), esophagitis (inflammation of the passage that carries food to the stomach), gastroesophageal reflux disease (stomach acid backs up into the esophageal passage), and morbid obesity (over 100 pounds overweight). Resident 1's record contained orders to change her tracheostomy tube once a month on day shift or as necessary, due to malfunction. Resident 1 had her tracheostomy changed by Registered Nurse 2 (RN 2) and Respiratory Therapist 3 (RT 3) at approximately 10:33 pm on 7/15/18. The Medical Director, who was also Resident 1's attending physician, was interviewed on 7/30/18 at 8:45 am. When asked why his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZGV11 Facility ID: CA230000044 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555151 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOWS POST ACUTE 320 N Crawford St Willows, CA 95988 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE orders contained the direction to do the monthly tracheostomy tube change on day shift, he responded that more resources are available on day shift in case of problems. He added that tracheostomy tubes are changed on other shifts due to other circumstances, such as accidental or purposeful removal of the tracheostomy tube, such as removal by the resident. Individual interviews with the RN 2 and RT 3 were completed on 7/30/18 at 9:30 am and 9:55 am. When each was asked why they did not follow physician's orders to change the tracheostomy tube on day shift, both indicated that they had time to do it that evening and that Resident 1 consented to the procedure by nodding "yes." During their respective interviews on 7/30/18 at 9:30 am and 9:55 am, RN 2 and RT 3 both stated that they did not feel any pressure or repercussions to change Resident 1's tracheostomy tube on 7/15/18, despite the last monthly change being on 6/15/18. They agreed that doing the change on the 29th, 31st, or 32nd day would be acceptable. According to RN 2 and RT 3's interviews on 7/30/18 at 9:30 am and 9:55 am, Resident 1 was prepared for the tracheostomy change on 7/15/18 at 10:33 pm. RN 2 and RT 3 met at the bedside. RN 2 stated that RT 3 was responsible to bring the necessary equipment to the bedside and set up for the procedure. RN 2 stated that she removed the tracheostomy tube and RT 3 was standing by, ready to reinsert the new tube, with RN 2 at the bedside. During interview, RT 3 stated that he did not have a smaller sized tracheostomy tube available at the bedside, which was standard practice according to the American Association for Respiratory Care and the facility's policy. A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZGV11 Facility ID: CA230000044 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555151 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOWS POST ACUTE 320 N Crawford St Willows, CA 95988 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE smaller size at the bedside was to ensure that if there was a problem placing the same size tracheostomy tube, a smaller sized tube would be on hand. RN 2 and RT 3 stated they did not have a smaller sized tracheostomy tube at the bedside of Resident 1. The facility's "tracheostomy tube change" policy, revision date 1/2/14 was reviewed. The policy read, "gather supplies: two tracheostomy tubes, one the size of the tube the patient has in place and the other one a size smaller." According to interview with RN 2 on 7/30/18 at 9:30 am, RT 3 was not able to replace the removed tracheostomy tube after several attempts. According to interview with RN 2, she took over attempting to get the new tube in. RN 2 stated she thought she had inserted the tracheostomy tube in the trachea. At one point, RN 2 and RT 3 stated they attached the oxygen supply but realized that the airway was not patent (open exchange of air through the respiratory passages) and Resident 1 was gasping for air. RN 2 stated she attempted repositioning Resident 1, placing the tube, then placing just the inner cannula, and then just the obturator, but could not establish a patent airway. The tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula (which can be used for daily cleaning and suctioning, and an obturator (has a smooth rounded tips to guide the tube's insertion). When none of these attempts succeeded in reestablishing Resident 1's airway, RN 2 and RT 3 stated they initiated a "code." A "code" is a crisis where the resident may die, so outside emergency personnel are called. According to review of Resident 1's nursing notes, when Resident 1 health condition continued to decline and she became cyanotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZGV11 Facility ID: CA230000044 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555151 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOWS POST ACUTE 320 N Crawford St Willows, CA 95988 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (skin turning blue due to lack of oxygen), RN 2 and RT 3 initiated Cardiopulmonary Resuscitation (CPR) and continued it until the emergency personnel took over. According to RN 2 during interview on 7/30/18 at 9:30 am and concurrent review of the emergency personnel's log, the emergency personnel arrived on scene 4 minutes after receiving the emergency call, on 7/15/18 at 10:41 pm. According to the emergency personnel's report, dated 7/15/18, Resident 1's airway was completely obstructed (blocked). Resident 1 was cyanotic and did not have a detectable carotid pulse (large arteries in the neck). The emergency personnels' attempts to open the resident's airway failed. They contacted their affliated local hospital's physician and the physician ordered the cessation (stopping) of rescusitation efforts. Resident 1 died from a cardiac arrest (heart attack) after her airway could not be opened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VZGV11 Facility ID: CA230000044 If continuation sheet 5 of 5