Other·June 8, 2023

§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 subparts. Title 22 § 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 4/27/2023, the California Department of Public Health made an unannounced visit to the facility to investigate an allegation regarding the quality of resident care and treatment. The facility failed to ensure Resident 1's respiratory care was consistent with professional standards of practice to meet the resident's goal for Resident 1 by failing to: 1.Ensure the facility had readily available supply of a nonrebreather mask (medical device used to provide constant flow supplemental oxygen in an acute medical emergency). 2.Implement the facility's policy and procedures, "Emergency Supplies Planning", to maintain appropriate medical supplies to accommodate the needs of residents for emergency situations. As a result, there was a delay in providing necessary lifesaving intervention before the paramedics (are healthcare professionals who responds to emergency calls for medical help outside of a hospital) arrived. Resident 1's oxygen saturation (amount of oxygen circulating in the blood) dropped to 79 percent (%, one part in every hundred - ideal range is 95% to 100%) and Resident 1 was transferred to the general acute hospital (GACH 1) on 4/24/2023. A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on 2/3/2023 with diagnoses including, acute respiratory failure with hypoxia (condition in which there is a decreased oxygen level in arterial blood.), congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and dysphagia (difficulty swallowing food or liquid). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/7/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADL-bed mobility, transfer, dressing, eating, toilet use, and personal hygiene). A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) form, dated 4/24/2023, indicated a change of condition (COC) was reported due to shortness of breath with oxygen saturation of 81% (normal oxygen saturation is 90% and above) on room air. A review of Resident 1's Progress Notes dated, 4/24/2023 indicated, Resident 1 had difficulty of breathing, oxygen saturation of 79%-83% on room air, the charge nurse put resident on oxygen via nasal canula (NC) at five liters per minute (lpm) and oxygen saturation increased to 85%. A review of Resident 1's care plan risk of cardiovascular complications dated 2/3/2023, had a goal to be free of chest pain, shortness of breath, edema... The interventions included to provide oxygen as needed per physician (Medical Doctor - MD's) order. During an interview with Paramedics 1 (PM 1), on 4/27/2023 at 1:02 p.m., PM 1 stated, when they arrived at the facility, Resident 1's oxygen saturation was in the mid 80% via simple face mask at five lpm. PM 1 stated, LVN 1 reported that Resident 1 desaturated (drops in blood oxygen level) for more than 30 minutes and facility staff was unable to increase her oxygen saturation using a NC and simple face mask. PM 1 stated, Resident 1 should have been placed on a nonrebreather mask to provide constant oxygen supplement, but the facility did not have any available nonrebreather mask. PM 1 further stated, when he asked for a nonrebreather mask from LVN 1, LVN 1 showed him a bag valve mask instead (also known as ambu-bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). PM 1 further stated, upon arrival, they put Resident 1 via nonrebreather mask with 15 lpm of oxygen and Resident 1's oxygen saturation increased to 96% instantly. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 4/27/2023 at 2:35 p.m., stated Resident 1 has a history of respiratory failure. LVN 1 stated, Resident 1 had shortness of breath on 4/24/2023 at 5:23 p.m., which required an oxygen supplement. LVN 1 stated, she put her on oxygen supplement via nasal canula initially and then switched simple face mask (a basic disposable mask, made of clear plastic, to provide oxygen therapy) to try to increase her oxygen saturation, but Resident 1's oxygen saturation did not increase to more than 90% which prompted her to call for emergency 911 (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) at 5:30 p.m. LVN 1 stated, in that scenario, they needed to use a nonrebreather oxygen mask, but the facility did not have any available nonrebreather mask in the facility. A review of Resident 1's medical records from Fire Department 1 (FD 1) indicated, paramedics arrived at the facility on 4/24/2023 at 6:09 p.m. and found Resident 1's oxygen saturation was 88% with oxygen supplement on five lpm via simple face mask. Staff at the facility stated they did not have any nonrebreather mask available. Patient was placed on nonrebreather mask and oxygen saturation increased on 96%. A review of Resident 1's Medical Records, "Emergency Department Encounter Note", from the GACH 1 indicated the following: a. Resident 1 presented in the Emergency department (ED) on 4/24/2023 for low oxygen saturation and unable to increase oxygen saturation at the facility b. Chest x-ray (an imaging study that takes pictures of bones and soft tissues) resulted Resident 1 has an extensive pulmonary infiltrate (a shadow seen on a chest x-ray and assumed to represent blood, pus, or other body fluids in the lung) or edema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). During an interview with Director of Nursing (DON), on 4/27/2023 at 2:59 p.m., the DON stated and confirmed, the facility did not have any nonrebreather mask when the incident happened which prompted her to borrow from their sister's facility. The DON stated, they were not able to increase Resident 1's oxygen saturation due to unavailability of a nonrebreather mask. DON further stated, if a resident desaturated and was not given proper medical device such as a nonrebreather mask, it could lead to a resident having cardiac arrest and death. The DON further stated now the facility have nonrebreather mask on stock and was delivered within 24 hours after the incident happened. A review of the facility's policy and procedures (P&P) titled, "Emergency Supplies Planning", revised on 8/2018 indicated, an adequate supply of emergency water, food, medical supplies and non-medical emergency items and equipment is maintained in appropriate quantities and in accordance with all applicable regulations to accommodate the needs of residents, staff members and their family members for emergency situations. The same P&P also indicated, supplies and equipment are stored in clearly designated locations and easily accessible. The facility failed to ensure Resident 1's respiratory care was consistent with professional standards of practice to meet the resident's goal for Resident 1 by failing to: 1.Ensure the facility had readily available supply of a nonrebreather mask. 2.Implement the facility's policy and procedures, "Emergency Supplies Planning", to maintain appropriate medical supplies to accommodate the needs of residents for emergency situations. As a result, there was a delay in providing necessary lifesaving intervention before the paramedics arrived. Resident 1's oxygen saturation dropped to 79 percent and Resident 1 was transferred to the GACH 1 on 4/24/2023. The above violation had a direct relationship to the health, safety, and security of Resident 1.