Health inspection·October 24, 2024

§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). §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 residents' choices. § 72523(a) 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 8/22/2024, the California Department of Health (CDPH) received a complaint alleging a resident (Resident 1) had trouble breathing and was not assisted by the facility staff. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) when she coded and received a pacemaker (a small electronic device placed in the chest to monitor heart rate and rhythm and to give the heart electrical stimulation when it does not beat normally). On 9/5/2024 CDPH conducted an unannounced visit to the facility to investigate the Complaint allegation. Upon investigation, CDPH determined Resident 1 complained of a persistent headache, dizziness, and anxiety (feeling of fear dread, and uneasiness) for approximately five hours before she (Resident 1) had to call 911 herself. Resident 1 was transferred to a GACH where she was diagnosed with a complete heart block and treated with a pacemaker implantation. The facility failed to: 1. Ensure Resident 1 was monitored and reassessed when Resident 1 had a change of condition (COC) that included a persistent headache, dizziness, and anxiety. 2. Ensure Resident 1's physician was notified when she was assessed with a COC including a persistent headache, dizziness, and anxiety. 3. Ensure Resident 1 did not experience a persistent headache, dizziness, and anxiety, without the staff's timely interventions, and instructions to call 911 herself, for medical care. 4. Follow its policy and procedures (P/P), titled "Nursing Documentation" which indicated its purpose was to communicate the resident's status, provide a complete, comprehensive, and accessible accounting of care and monitoring provided. 5. Follow its P/P titled "Routine Resident Checks" which indicated staff shall make routine resident checks to maintain the resident's safety and well-being every 2 hours, and more if needed to determine if the resident's needs were met, identify any change in the resident's condition, or any resident's concerns, assist as needed, notify the charge nurse, physician, and document findings and care provided. As a result, Resident 1 called 911 herself for transfer to a GACH where she was diagnosed with a complete heart block and treated with a pacemaker implantation. This deficient practice had the potential to result in Resident 1's death. A review, Resident 1's Admission Record Sheet (Face Sheet) indicated Resident 1, a 91-year-old female, was initially admitted to the facility on 5/1/2024 and readmitted on 8/16/2024. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/23/2024, indicated under activity level from section "gg," Resident 1 was able to make independent decisions that were reasonable and consistent. A review, Resident 1's COC dated 8/10/2024 and timed at 7:05 p.m., indicated Resident 1 complained of dizziness and a persistent nagging headache with pain of 7 out of 10 (an 11 eleven point scale where pain in rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) that was unresponsive and/or with minimal relief to standard analgesics (medications used to relieve pain). A review of Resident 1's Physician Progress Notes dated 8/10/2024, indicated Resident 1 was assessed with headaches after being out in the sun. The Physician Progress Notes indicated to monitor Resident 1 for 72 hours and continue the current treatment plan. The Physician Progress Notes indicated Resident 1's physician informed Resident 1 of his plan to transfer her (Resident 1) to the emergency room for intravenous ([IV] fluids injected into the vein to treat dehydration and/or prevent it) hydration, and a computerized head scan ([CT Scan] a scan that uses many x-rays to create pictures of the head, including the skull, brain, eye sockets and sinuses) if her condition worsened. A review of Resident 1's Nursing Progress Note dated 8/10/2024, indicated Resident 1 was reassessed on 8/10/2024 at 11:41 p.m., over four hours after Resident 1's COC was identified. A review of Resident 1's Transfer Form dated 8/11/2024 and timed at 12:38 a.m., indicated Resident 1 was transferred to a GACH by paramedics because of dizziness and pain rated at 4 out of 10 (unspecified location). A review of Resident 1's GACH's Emergency Department (ED) documentation dated 8/11/24 and timed at 1:06 a.m., indicated Resident 1 complained of dizziness, headache and ringing in her ears for eight hours. The ED documentation indicated Resident 1 had sinus rhythm with a premature atrial complex (early heart beats/signals that momentarily interrupt the normal sinus rhythm by inserting an extra heartbeat), a bifascicular block (a type of heart block that causes the heart to pump to slowly or out of rhythm) with no ventricular conduction (the process by which electrical signals are transmitted through the hearts ventricles. This process is essential for the heart to pump blood efficiently) in three hours. The ED documentation indicated Resident 1 was started on dopamine (a medication used to treat low blood pressure, low heart rate and cardiac arrest) and Isuprel (a medication used to treat low heart rate, and several types of heart rhythm problems) consecutively and Resident 1 was admitted to the Intensive Care Unit ([ICU] a specialized unit for patient's requiring critical medical care) with an impression of a complete heart block, sinus pause (when the heart stops or pauses) and dizziness. A review of Resident 1's GACH's Discharge Summary dated 8/16/2024 and timed at 12:51 p.m., indicated Resident 1 was admitted to the GACH for a symptomatic third-degree atrioventricular block ([AV] a complete heart block) that required a pacemaker placement. During an interview on 9/5/2024 at 11:29 a.m., with Resident 1, Resident 1 stated, a month ago (8/10/2024), while sitting on the facility's patio, she experienced a headache that would come and go, and dizziness. Resident 1 stated, the symptoms persisted and intensified, and at 5 p.m., she told her assigned nurses (Certified Nursing Assistant 5 [CNA 5] and Licensed Vocational Nurse 4 [LVN 4]) several times that she did not feel well and would like to go to the GACH. Resident 1 stated after over an hour of waiting for assistance her roommate went to get help. Resident 1 stated LVN 4 came and checked her vital signs (v/s) and no one checked on her after that. Resident 1 stated around midnight (on 8/11/2024) along with the persistent dizziness and headaches, she started to feel anxious and could not breathe. Resident 1 stated she once more asked LVN 4 to call the paramedics. Resident 1 stated LVN 1 checked her v/s and then told her, she (LVN 1) could not call the doctor and/or the paramedics because she (Resident 1) was okay. Resident 1 stated she insisted there was something wrong with her and LVN 1 told her to call the paramedics herself. Resident 1 stated she felt neglected by the nurses and stated if she had listened to the nurses, stayed at the facility, and not called the paramedics herself, to be transferred to the GACH for medical care, she could have died. During an interview on 9/6/2024 at 3:32 p.m., with LVN 4, LVN 4 stated on 8/10/2024 at 7:05 p.m., Resident 1 had a COC (headaches and dizziness). LVN 4 stated she notified Resident 1's physician who instructed her to monitor Resident 1. LVN 4 stated she took Resident 1's v/s and monitored her by visual checks but did not record Resident 1's progress or v/s in the nursing progress notes. LVN 4 stated she did not notify Resident 1's physician of Resident 1's persistent signs and symptoms (s/s) and she did not call the paramedics despite Resident 1's requests to be transferred to the GACH, because even though Resident 1 had a persistent headache and dizziness, her v/s remained stable, and she (LVN 4) did not know what else to do. During an interview on 9/6/2024 at 4:09 p.m., with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated it was the responsibility of the licensed nurses to ensure residents were assessed, monitored, and reassessed during a COC. RNS 2 stated when a COC was identified an hourly assessment should have been conducted to include v/s, signs and symptoms, and the findings documented in the resident's progress notes, to identify the progress and/or changes in the resident's condition, to prevent a delay of care and services that could put a resident's life in danger. During an interview on 9/6/2024 at 5:28 p.m., with the Director of Nursing (DON) the DON stated it was the responsibility of all nursing staff to identify, assess, monitor, and reassess a resident when a COC was noted. The DON stated, the nursing staff should have notified Resident 1's physician for a higher level of care and treatment, to prevent any health complications that could have arose from a delay in care. After reviewing Resident 1's Progress Note, The DON stated there were no other succeeding assessments documented for Resident 1, after the initial COC was identified, until Resident 1 was transferred to the GACH (8/11/2024 at 12:38 a.m.). During a telephone interview on 9/9/2024 at 11:30 a.m., Resident 1's Physician stated the licensed nursing staff were expected to monitor and reassess residents during a COC to identify persistent changes that could indicate worsening of Resident 1's condition and to notify him of any changes so he could give instructions for care as needed. A review of the facility's P/P, titled, "Guidelines for Notifying Physicians of Clinical Problems" revised 2/2014, indicated the facility must: Communicate to the medical staff a resident's medical problem in a timely manner, ensure all significant changes in resident status are assessed and documented in the medical record, and ensure the charge nurse or supervisor must call the attending physician of the resident at any time if they feel (nursing judgement and critical thinking) a clinical situation requires immediate discussion and management, and for any unrelieved/ persistent signs and symptoms during a change in condition. A review of the facility's P/P titled, "Nursing Documentation" dated 6/27/2022, indicated the purpose of nursing documentation was to communicate the resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. The P/P indicated clinical judgment determined the need for additional data collection and/or more frequent documentation that includes the resident's status, assessment, and interventions, expected outcomes, evaluation of the resident's outcomes and responses to nursing care. A review of the facility's P/P titled, "Routine Resident Checks" revised 7/2013, indicated staff shall make routine resident checks to help maintain resident safety and well-being every 2 hours, and more if needed to determine if the residents' needs were met, identify any change in the residents' condition, identify any resident concerns, and see if the resident needed any assistance, the person conducting the resident rounds must promptly inform the charge nurse and/ or nurse supervisor of the residents' change in condition and medical needs, and the nursing supervisor and/or charge nurse shall keep documentation related to these routine checks, including the time, identity of the person who was doing the resident checks and the outcomes of each check/ resident rounds. The facility failed to: 1. Ensure Resident 1 was monitored and reassessed when Resident 1 had a change of condition (COC) that included a persistent headache, dizziness, and anxiety. 2. Ensure Resident 1's physician was notified when she was assessed with a COC including a persistent headache, dizziness, and anxiety. 3. Ensure Resident 1 did not experience a persistent headache, dizziness, and anxiety, without the staff's timely interventions, and instructions to call 911 herself, for medical care. 4. Follow its policy and procedures (P/P), titled "Nursing Documentation" which indicated its purpose was to communicate the resident's status, provide a complete, comprehensive, and accessible accounting of care and monitoring provided. 5. Follow its P/P titled "Routine Resident Checks" which indicated staff shall make routine resident checks to maintain the resident's safety and well-being every 2 hours, and more if needed to determine if the resident's needs were met, identify any change in the resident's condition, or any resident's concerns, assist as needed, notify the charge nurse, physician, and document findings and care provided. As a result, Resident 1 called 911 herself for transfer to a GACH where she was diagnosed with a complete heart block and treated with a pacemaker implantation. This deficient practice had the potential to result in Resident 1's death. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. 2 Bay Crest Care Center CA00916609 "B" Citation