Health inspection·January 8, 2025

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 — (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii)Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). 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: 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— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (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); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is— (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). California Code of Regulations, Title 22, Section 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: (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. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 11/16/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident death. Upon investigation, CDPH determined the facility failed to: 1. Notify Resident 1’s physician, when on 11/3/2024, Resident 1’s blood pressure (BP - the measurement of the pressure or force of blood inside your arteries [muscular walled tubes that carries blood from the heart to tissues and organs in the body], normal range less than 120/80 millimeters of mercury [mmHg - unit of pressure measure]) dropped from 118/75 mmHg on 11/2/2024 at 7:03 p.m. to 89/54 mmHg on 11/3/2024 at 1:00 a.m. 2. Develop and implement a care plan for Resident 1’s hypotension (low blood pressure wherein the force of blood pushing against your artery walls is lower than normal) when Resident 1 had that diagnosis upon admission. 3. Implement the facility’s P&Ps when Licensed Vocational Nurse (LVN) 1 failed to complete a Change of Condition (COC – when there is a sudden and significant change from a resident’s health) and notify Resident 1’s physician when notified by Certified Nursing Assistant (CNA) 1 of a low BP reading at 1:00 a.m. on 11/3/2024. 4. Develop and implement interventions and closely monitor Resident 1’s BP every 15 to 30 minutes after a low BP reading at 1:00 a.m. on 11/3/2024. As a result, Resident 1's BP continued to drop on 11/3/2024 with observations of coffee ground discharge (appears dark brown in color, fluid that comes out of the body) upon tracheal suctioning (a procedure that uses a suction catheter [a flexible, hollow tube used to remove fluids or secretions from a resident's airway] to remove mucus [a slimy, sticky, gelatinous substance produced normally in the body] and other secretions from the airway through a tracheostomy tube [trach tube - a curved tube made of metal or plastic that is inserted into the trachea or windpipe through a surgically created opening in the neck]) and blood in the stool (material in a bowel movement). On 11/3/2024 at 10:15 a.m. Resident 1’s BP dropped to 38/28 mmHg. Subsequently, on 11/3/2024 at 10:20 a.m., Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation and treatment. Resident 1 died in the GACH on 11/13/2024 (time not indicated). A review of Resident 1’s Record of Admission indicated the facility initially admitted the 48-year-old male resident on 5/30/2024 and readmitted on 6/26/2024, with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it) with loss of consciousness (the state of being awake, alert, aware and responsive) and hypotension. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/6/2024, indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 required oxygen therapy (a treatment that provides extra oxygen to residents with breathing problems or lung diseases), suctioning, tracheostomy (surgical procedure that creates an opening in the neck to insert a tube into the windpipe) care, and an invasive mechanical ventilator (a method of respiratory support that involves a tube inserted into the resident's airway and connected to a machine called a ventilator to deliver air into the lungs). The MDS indicated Resident 1 required a feeding tube (G-tube - medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) while residing in the facility. A review of Resident 1's History & Physical (H&P), dated 6/26/2024, indicated the resident did not have the capacity to understand and make decisions due to traumatic brain injury (a brain injury that occurs when the brain is damaged by a sudden external force). A review of Resident 1’s Medication Administration Record (MAR), dated 11/2024, indicated Resident 1 was on a G-tube feeding every shift (Glucerna 1.5, is a calorically dense formula with low-glycemic carbohydrates clinically shown to help minimize blood sugar response) with pump set at 80 millimeter per hour (ml – unit of measurement/hour) for 20 hours to provide 1,600 ml/2,400 kilocalorie (unit used to express the energy value of food) starting at 12 p.m. and to continue for 20 hours or until total volume is complete. A review of Resident 1's physician's telephone order, dated 11/3/2024 at 7:29 a.m., indicated the physician ordered one (1) liter (L - unit of measurement) sodium chloride solution 0.9 (normal saline - a solution of water and salt) percent (% - per one hundred) 75 millimeters (ml - unit of measurement) per hour (hr.) intravenously (IV - refers to administering a substance, such as a drug or fluid, into a vein using a needle or tube) every shift for low BP for one day only. A review of Resident 1's physician's telephone order dated 11/3/2024 at 8:00 a.m., indicated the physician ordered 1 L sodium chloride solution 0.9 % 250 ml/hr. intravenously every shift for low BP for one day only. A review of Resident 1's physician's telephone order, dated 11/3/2024 at 8:31 a.m., indicated the physician ordered Midodrine hydrochloride (a medication used to treat low BP) oral (by mouth) tablet 10 milligrams (mg - unit of measurement) to be given through G-tube every eight hours as needed for systolic BP (pressure in your arteries when your heart beats and pumps blood out, essentially the "top number" in a BP reading) of less than 90 mmHg. A review of Resident 1's physician's telephone order dated 11/3/2024 at 9:55 a.m., indicated the physician ordered to transfer Resident 1 to the GACH via 911 (telephone number to call for emergency services) transfer due to tracheal blood, blood in stool, and hypotension with 46/27 mmHg BP reading (time not indicated in the order). A review of Resident 1's Los Angeles Fire Department (LAFD) paramedics (health professionals certified to perform advanced life support procedures) report, dated 11/3/2024 timed at 10:00 a.m., indicated that the paramedics were notified at 10:00 a.m. on 11/3/2024. The paramedics report indicated that Resident 1 at 10:12 a.m. (on 11/3/2024) had a BP of 38/28 mmHg and pulse rate (PR- number of times the heart beats per minute) of 102 beats per minute (bpm), and at 10:25 a.m. (on 11/3/2024) had a BP of 31/30 mmHg and PR of 112 bpm. The report indicated the paramedics arrived to find Resident 1 with hypotension, shortness of breath (the uncomfortable feeling of being unable to breathe deeply enough or getting enough air), bradycardia (a condition where the heart beats slower than normal, or less than 60 beats per minute, while at rest), complaints of pain, and resident on ventilator. The report indicated the paramedics transferred Resident 1 to the GACH. During a concurrent interview and record review on 11/17/2024 at 11:40 a.m., Resident 1's Weights and Vitals Summary report, dated 11/2/2024 to 11/3/2024 was reviewed with Registered Nurse (RN) 1. RN 1 stated Resident 1's BP of 89/54 mmHg on 11/3/2024 at 1:00 a.m. was not reported to her (RN 1). RN 1 further stated had LVN 1 reported this to her, she would have immediately notified the physician. RN 1 stated the next vital signs check done for Resident 1 was around 6:17 a.m. (on 11/3/2024) after the RT 1 reported that Resident 1 had coffee ground discharge during suction. The report indicated Resident 1's BP on 11/2/2024 at 7:03 p.m. was 118/75 mmHg and on 11/3/2024 at 7:34 a.m. was 85/56 mmHg. During a concurrent interview and record review on 11/17/2024 at 12:13 p.m., Resident 1's change in condition form dated 11/3/2024, timed at 10:00 a.m. was reviewed with RN 2. RN 2 stated Resident 1 had a BP of 38/28 mmHg (at 10:15 a.m.), with tracheal bleeding, blood in stool with dark brown in color, loose stool with foul (smelly) odor, and with distended (enlarged or stretched out) and rigid (stiff) abdomen. RN 2 stated around 8:00 a.m. (11/3/2024), RN 2 reported to Medical Doctor (MD) 1 that Resident 1's BP was 86/54 mmHg and received an order to give IV fluids of normal saline 250 ml/hr. and Midodrine hydrochloride 10 mg via G-Tube. During a telephone interview on 11/19/2024, at 8:09 a.m., LVN 1 stated she received a low BP reading from CNA 1 for Resident 1 at 1:00 a.m. (on 11/3/2024). LVN 1 stated she could not recall the exact BP reading. LVN 1 stated she elevated Resident 1's feet, rechecked Resident 1's blood pressure after 15 minutes and was able to obtain a normal reading (116/62 mmHg). LVN 1 stated she did not complete a COC about Resident 1's low BP. LVN 1 stated she did not inform the attending physician and the RN Supervisor about Resident 1's low BP. LVN 1 stated she did not monitor Resident 1's blood pressure again until the end of her shift. During a concurrent interview and record review on 11/19/2024 at 3:43 p.m., with RN 1, Resident 1's COC form dated 11/3/2024, timed at 6:17 a.m. was reviewed. RN 1 stated at 6:17 a.m. (on 11/3/2024) RT 1 reported that Resident 1 had a coffee ground discharge during suctioning Resident 1. RN 1 stated Resident 1's BP was 82/50 mmHg (at 6:17 a.m.) and after inserting and administration of an IV fluid (normal saline) BP was rechecked after 15 minutes, and Resident 1's BP was 69/44 mmHg around 6:30 a.m. (11/3/2024). During an interview on 11/20/2024 at 10:10 a.m., the Administrator stated LVN 1 was not available for interview at this time because LVN 1 threatened to kill herself. The Administrator stated LVN 1 was kept safe. During a telephone interview on 11/20/2024 at 2:09 p.m., MD 2 stated he was not notified regarding Resident 1's change of condition and low BP at 1:00 a.m. (on 11/3/2024). MD 2 further stated had he been informed of Resident 1's BP drop, he would have ordered a normal saline bolus (a single, large dose of medicine or fluid such as normal saline) and if not effective he would order to transfer Resident 1 to the GACH right away. During a telephone interview on 11/20/2024 at 3:23 p.m., MD 1 stated he was not made aware of Resident 1's low BP at 1 a.m. on 11/3/2024. MD 1 stated he received a call around 6:00 a.m. on 11/3/2024. MD 1 stated Resident 1's vital signs should have been monitored closely every 15 to 30 minutes after the BP dropped at 1:00 a.m. on 11/3/2024. During an interview on 11/20/2024 at 4:41 p.m., the Director of Nursing (DON) stated LVN 1 should have reported Resident 1's low blood pressure to RN 1 and should have notified Resident 1's physician to obtain further orders. This would have allowed Resident 1 to receive necessary interventions sooner. The DON also stated LVN 1 failed to monitor Resident 1's blood pressure as frequently as required. A review of the current facility-provided policy and procedure (P&P) titled, "Notification of Changes," with last reviewed date of 11/28/2023, indicated the facility informs the resident physician when there are changes involving life threatening conditions. The P&P indicated. "The facility notifies the physician and resident representative of: ... b. A significant change in the