Other·May 23, 2025

Code of Federal Regulations, Title 42, Section 483.10(g)(14) - Notification of Changes (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) Code of Federal Regulations, Title 42, Section 483.21 - Comprehensive person-centered care planning (a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must— (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — Code of Federal Regulations, Title 42, Section 483.25 - Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, including but not limited to the following: California Code of Regulations, Title 22, Section 72311 - Nursing Service- General (a) Nursing Service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at the least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (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. California Code of Regulations, Title 22, Section 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On March 21, 2025, at 11:42 a.m., an unannounced visit was conducted at the facility to investigate quality care issues. It was determined that the facility failed to ensure the physician was notified when Patient 1 had an oxygen saturation (measures of how effectively the body is transporting oxygen from the lungs to the tissues) of 35 % (normal oxygen saturation level ranges between 95% and 100%) at 1:37 a.m., on March 7, 2025. This failure caused a delay in provision of appropriate interventions and a delay in transfer to the general acute care hospital (GACH) when Patient 1’s change in condition was not reported to the physician until around 11 a.m., nearly ten hours later than Patient 1’s initial change in oxygen saturation level, resulting in an emergency endotracheal intubation (insertion of a flexible plastic tube called an endotracheal tube (ET) into the mouth or nose and then into the airway to hold it open and provide oxygen) upon arrival at the GACH on March 7, 2025, due to respiratory distress and severe hypoxemia (abnormally low concentration of oxygen in the blood). Patient 1 expired while at the GACH due to cardiopulmonary arrest on March 26, 2025. A review of Patient 1's admission records indicated the patient was admitted on February 27, 2025, with diagnoses which included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety disorder (chronic condition characterized by an excessive and persistent sense of apprehension), alcohol use disorder (impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences), and sepsis (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body, that can lead to death).  A review of Patient 1's "History and Physical," dated March 5, 2025, indicated the patient had the capacity to make decisions. A review of Patient 1's "Order Summary Report," indicated the following: - On March 3, 2025, "O2 [oxygen] 3 LPM [liters per minute] VIA NASAL CANNULA [a thin tube inserted into the body for oxygen delivery] CONTINUOUS PER CONCENTRATOR/TANK every shift for SOB [shortness of breath]."  - On March 7, 2025, "Send to ED [emergency department] for further treatment and evaluation ..." A review of Patient 1's "Progress Notes," dated March 7, 2025, at 06:18 a.m., indicated "...Late Entry [for 1:37 a.m.] ...CNA (Certified Nursing Assistant) reported patients (sic) O2 level at 35, patient was noted not having his nasal cannula on. O2 was placed and went up to 80. Nasal cannula was switched to non-rebreather mask [medical device used to deliver high concentration of oxygen] and O2 level went up to 87 ..."  A review of the nurses’ progress notes did not indicate the physician was notified when Patient 1 had an oxygen saturation level of 35 %, and that the patient’s O2 level was at 87 % even when the patient had a non-rebreather mask. A record review of Patient 1's "eINTERACT SBAR (situation, background, assessment, recommendation) Summary for Providers," dated March 7, 2025, at 11:57 a.m., indicated, " ...At 11:20 AM, the resident was noted not wearing his oxygen. Upon entering the room, resident's (Patient 1) HOB (head of bed) was on fowlers (sic) position [common positioning technique where the head of the bed is elevated between 45 and 90 degrees]. Upon assessment, the resident (patient) was pale, awake, alert but altered [thinking, awareness, or behavior is abnormal], skin was warm to touch, VS (vital sign) has significant O2 (oxygen) level of 56%, went up to 88-91% after we put him on non-rebreather (sic) mask on 5 L (liters) oxygen. MD made aware with an order to send patients to ED for further treatment and management.  During an interview on March 21, 2025, at 3:19 p.m., Registered Nurse (RN) 1 stated that on March 7, 2025, at approximately 10 a.m., Patient 1 had removed oxygen, and his oxygen levels were low. RN 1 stated that they placed a non-rebreather mask on at 10 liters to get the oxygen levels up. RN 1 stated they notified the patient’s physician, and the physician ordered Patient 1 to be transferred to the GACH.  During an interview on March 24, 2025, at 1:41 p.m., RN 2 stated that if a patient had a low oxygen saturation of 57%, they would place oxygen at high flow oxygen (form of non-invasive respiratory support that delivers high volumes of oxygen directly to the patient through nasal cannulas), contact the physician, and the facility staff would transfer the patient to the hospital.  During an interview on March 24, 2025, at 3:21 p.m., Licensed Vocational Nurse (LVN) 1 stated that on March 7, 2025, Patient 1 was removing his oxygen, and his oxygen saturation was at 57% before paramedics came. LVN 1 stated she was at the bedside with Patient 1 until the medics came to transport the patient to GACH.  During an interview on March 25, 2025, at 11:52 a.m., LVN 2 stated that normal oxygen saturation should be above 90%. LVN 2 stated that they should notify the physician if a patient’s oxygen saturation is below 90%. LVN 2 stated Patient 1 had an order for oxygen via nasal cannula at 3 liters, however; on March 7, 2025, around midnight, she was alerted by the CNA that Patient 1's oxygen saturation was 35%, and he was removing his oxygen. LVN 2 stated that they should have contacted the physician to report Patient 1's low oxygen saturation.   During a telephone interview on April 10, 2025, at 3:58 p.m., the Attending Physician (AP) stated, he was not aware Patient 1 had an episode of low oxygen saturation level after midnight on March 7, 2025, or that a non-rebreather mask was used. The AP stated he was informed by a licensed staff at around 11 a.m., on March 7, 2025, that the patient (Patient 1) had a high carbon dioxide (CO2) level of 41 (normal level 21-31). The AP stated he was not informed of the patient’s low oxygen saturation of 35%. The AP stated, if he had been informed of an earlier episode of low oxygen saturation, he would have sent the patient to the hospital. On April 15, 2025, at 4:26 p.m., a concurrent telephone interview and record review was conducted with the Director of Nursing (DON), and she stated the following: a. Patient 1 had a change in condition around 1:37 a.m., on March 7, 2025, due to low oxygen saturation of 35 %. b. The staff were expected to notify the physician of a patient’s low oxygen saturation level, since this is considered a change of condition. c. If a patient has COPD and there are episodes of desaturation, the licensed nurses were expected to monitor the patient closely. d. The patient (Patient 1) had a low oxygen saturation level, so the patient should have been transferred to the hospital; however, the patient refused. e. There was no documentation that the patient was closely monitored. f. The patient had a high critical level of CO2 on March 7, 2025, the physician should have been notified and since the attending physician did not respond, the Medical Director should have been notified. She verified there was no documentation in the patient’s progress notes that the Medical Director was called on the critical level of CO2. A review of Patient 1's "Emergency Department Records," dated March 7, 2025, at 1:25 p.m., indicated " ...64-year-old male patient (Patient 1) presents to the ER (Emergency Room) ...for evaluation of difficulty in breathing. History is limited due to patient's altered level of consciousness. Patient is difficult to arouse and is unable to answer questions...Procedures in the Emergency Department...Procedure Narrative: Endotracheal Intubation... Intubation indications: respiratory failure and severe hypoxemia. It was felt the patient required emergency intubation ..." A review of Patient 1's hospital document titled, "Discharge Summary," dated March 26, 2025, indicated, patient was pronounced deceased following confirmation of asystole (complete absence of electrical activity in the heart), absent heart sounds, no spontaneous respirations, no pupillary or corneal reflex. The patient was admitted to a shortness of breath and lethargy (reduced alertness, slow response, or drowsiness). The patient’s plan of care noted a diagnosis of Acute Hypercapnic Hypoxic Respiratory Failure (a serious medical condition where the lungs cannot provide enough oxygen to the body and cannot remove enough carbon dioxide [colorless and odorless gas]) likely secondary to Pneumonia (an infection of the lungs), Healthcare Associated Pneumonia (pneumonia that developed in a facility). The patient required reintubation and mechanical ventilation (a life-support technique that uses a machine to move air in and out of the lungs). The discharge diagnosis was cardiac arrest secondary to acute respiratory failure and pneumonia caused by ESBL (Extended-Spectrum Beta-Lactamase - bacteria resistant to many commonly used antibiotics). A review of Patient 1’s Certificate of Death, indicated the patient’s immediate cause of death was cardiopulmonary arrest on March 26, 2025. A review of the facility's policy and procedure titled "Change in a Resident's Condition or Status," revised February 2021, indicated, " ...1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) ... d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly ... 2. A "significant change" of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions ...” Based on interview and record review, it was determined that the facility failed to ensure the physician was notified when Patient 1 had an oxygen saturation of 35 % at 1:37 a.m. on March 7, 2025. This failure caused a delay in provision of appropriate interventions and a delay in transfer to the GACH when Patient 1’s change in condition was not reported to the physician until around 11 a.m., nearly ten hours later than Patient 1’s initial change in oxygen saturation level, resulting in an emergency endotracheal intubation upon arrival at the GACH on March 7, 2025, due to respiratory distress and severe hypoxemia. Patient 1 expired while at the GACH due to cardiopulmonary arrest on March 26, 2025. 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 to Patient 1.