Health inspection·December 10, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy for pronouncing death for one resident (Resident 1) in a census of 96 when two licensed vocational nurses (LVNs) worked out of their scope of practice (services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license) and pronouced the resident's death. Residents Affected - Few This failure resulted in a violation of the facility's policy and had the potential to jeopardize resident health and safety. Findings: Resident 1 was admitted to the facility in 2024 with diagnoses that included Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD). A review of Resident 1's, Order Summary Report dated [DATE], indicated an order for hospice (an end-of-life service for the terminally ill) for a diagnosis of COPD. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 9:47 a.m., RN1 stated, Only a physician or RN can pronounce a resident deceased . A review of Resident 1's Progress Notes dated [DATE] at 1:38 a.m., Licensed Vocational Nurse 2 (LVN 2) documented, Resident noted in bed with eyes closed, no signs of life or respiratory effort. Not responsive to verbal or tactile stimuli. No palpable pulse for one minute, checked by two LVNs on site. No heart or respiratory sounds, checked by two LVNs on site. Time of death called at 0142 by two LVNs . During an interview with the Hospice Clinical Consultant (HCC) on [DATE] at 2:06 p.m., the HCC stated the nurse's note dated [DATE] at 1:42 a.m., indicated a Non-Visit note which indicated the hospice nurse did not go to the facility and Licensed Vocational Nurse 3 (LVN 3) had pronounced Resident 1 deceased . During an interview with the Director of Nursing (DON) on [DATE] at 3:07 p.m., the DON verified Resident 1 was pronounced dead by LVN 2 and LVN 3. The DON stated, If a resident is on hospice and expires, only a physician or RN may pronounce a resident as expired. The DON further stated, An LVN cannot pronounce a resident as expired. A review of the facility policy titled, Death of a Resident, Documenting dated 10/2023 indicated, A Page 1 of 2 555219 555219 12/10/2024 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0658 resident may be declared dead by a licensed physician or registered nurse with physician authorization in accordance with state law . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555219 Page 2 of 2