Health inspection·March 6, 2024

F684 Quality of Care § 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, including but not limited to the following: Title 22 CALIFORNIA CODE OF REGULATIONS: § 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 01/11/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about a resident’s death. The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) check the vital signs (temperature, pulse, respirations, blood pressure [BP] and oxygen saturation [O2 sat- amount of oxygen in the blood]), monitored, immediately provide necessary medical assistance, and remained with Resident 1, after LVN 1 noticed that Resident 1, “did not look good” on 12/3/23 at around 7:00 p.m. 2. Provide immediate emergency care including cardiopulmonary resuscitation (CPR- emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) for Resident 1 who was found unresponsive (when a person does not react when talked to) on 12/3/23 at 7:30 p.m., as per facility’s policy. As a result, Resident 1 was left unattended and without emergency life-saving services for 30 minutes. Paramedics (staff trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) pronounced Resident 1’s dead at the facility on 12/3/23. Time of death was not indicated. A review of Resident 1’s Admission Record indicated Resident 1, a 90-year-old male was admitted to the facility on 7/7/23 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions. A review of Resident 1’s Physician's Orders for Life Sustaining Treatment (POLST - a medical order that helps give people with serious illness more control over their care during a medical emergency), dated 7/8/23, indicated to attempt CPR and provide full treatment of prolonging life by all medical effective means. A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/12/23, indicated Resident 1 had mild cognitive impairment (when a person has some trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 required one-person physical assist with bed mobility, dressing, toileting, and personal hygiene, and two-person physical assistance for transfers. A review of Resident 1’s history and physical (H&P) dated 7/19/23 at 1:30 p.m., indicated, Resident 1 had paralysis (complete or partial loss of muscle strength) of vocal cords and larynx (the area of the throat containing the vocal cords and used for breathing, swallowing, and talking) … and recurrent aspiration (when something such as food, liquid, or some other material accidentally enters the airway). A review of Resident 1’s Active Orders dated 12/3/23, indicated Resident 1 was on Regular mechanical soft (easy to chew/easy to bite) thin liquids diet, and aspiration precautions (effective 7/20/23). A review of Resident 1’s Nurses Notes dated 12/3/23 at 8 p.m., indicated LVN 1 documented that on 12/3/23 at 5:30 p.m., Resident 1 was observed eating dinner. On 12/3/23 at 7 p.m., the LVN 1 heard Resident 1 yelling out, “help, help, help.” Resident 1 asked for water and LVN 1 opened a bottle of water and Resident 1 tolerated the water well. On 12/3/23 at 7:30 p.m., LVN 1 documented that upon rounding, Resident 1 was noted to be unresponsive but still breathing. Immediately called another charge nurse (CN – [LVN]) and Registered Nurse (RN) supervisor. Resident 1 was started on oxygen via a non-rebreather mask (NRB - a device used to assist in the delivery of higher oxygen flow rate in emergencies) at 15 liters per min (L/min). Paramedics arrived at 7:40 p.m. and took over CPR. Paramedics worked on Resident 1 for about 20 minutes but were unsuccessful. Paramedics pronounced Resident 1 dead in the facility on 12/3/23. The nurses’ notes failed to indicate when Resident 1 was given meals and did not indicate if the food provided to Resident 1 was compliant with the Active Orders regarding meals. A review of Resident 1’s Nurses Notes by LVN 1, late entry date 12/4/23, timed at 1:13 a.m., indicated that on 12/3/23 at 7:30 p.m., LVN 1 found Resident 1 unresponsive. Resident 1 was placed on oxygen at 15 liters per min (L/min) via a nonrebreather mask. There was no documentation LVN 1 checked Resident 1’s heart and respiratory rate to determine if the resident needed immediate CPR. LVN 1 also documented in the Nursing Notes also indicated the paramedics pronounced Resident 1 on 12/3/23. A review of paramedics’ report dated 12/3/2023, indicated paramedics were dispatched to the facility at 7:36 p.m. and arrived at 7:39 p.m. and continued CPR. Resident 1’s last known well time was 5:45 p.m. Unknown cause of arrest and unwitnessed. Resident 1 was unresponsive, pulseless (no heartbeat), and apneic (not breathing). Paramedics documented Resident 1 had a cardiac arrest (the heart stop beating) at 7:34 p.m., the facility staff had initiated CPR 5 to 10 minute prior to calling paramedics. At 7:44 p.m., Resident 1 did not have a pulse or respirations. Paramedics performed CPR on Resident 1 but Resident 1 did not respond to resuscitation efforts and received a total of four doses of epinephrine (a medication to treat many life-threatening conditions) 1 milligram (mg- unit of measurement) was pronounced dead. The paramedics report indicated a general acute care hospital 1 (GACH) medical doctor (MD) pronounced Resident 1 dead in the facility on 12/3/23, however, time of death was not indicated. A review of Resident 1’s care plan on “Dysphagia (difficulty swallowing) dated 10/22/23, indicated Resident 1 will be free of aspiration by next review date of 12/12/23. The care plan interventions included speech therapy to evaluate and treat, dysphagia treatment, diet modification, oral motor exercises and caregiver training. The care plan interventions did not include monitoring Resident 1’s meals. A review of Resident 1’s Autopsy (an examination of a body after death to determine the cause of death or the character and extent of changes produced by disease) information provided by Resident 1’s family member dated 12/18/23 at 1:15 p.m., indicated, under case summary, that the year 2022, Resident 1 to the Medical Intensive Care Unit (MICU – a unit in a hospital that care for patients who require intensive, round-the-clock care from a highly trained group of doctors, nurses, and other healthcare) following a witnessed aspiration event where he was intubated (insert of a tube into a body part, usually the trachea, for ventilation) and had a tracheostomy (surgical procedure to open an airway through an incision in the trachea). Under Respiratory System, the autopsy report indicated, “There was a bolus of undigested food material in the larynx (airway) … The immediate cause of death in this case is aspiration of food bolus. Patients with neurodegenerative diseases (type of diseases in which cells of the central nervous system stop working or die) including Alzheimer’s have increased risk of aspiration as further evidenced by this patient’s prior history of aspiration events. Other potential etiologies (cause or origin of disease) for sudden death such as coronary (blood vessels that surround and supply the heart with oxygen and other nutrients) artery occlusion (blockage) or pulmonary (lung) thromboembolic (blood clot in the artery blocking blood flow) were not seen in this case. The autopsy also identified Resident 1’s COVID-19 infection (an infectious respiratory disease caused by the SARS-CoV-2 virus), pneumonia (infection of one or both lungs), and amyloidosis (a group of diseases in which protein builds up in certain organs) to likely not be major contributing factors to Resident 1’s death. On 1/11/24 at 11:33 a.m., during an interview, Family Member 1 (FM 1) stated he went to the facility on 12/3/23 the same night Resident 1 died. FM 1 stated upon inquiry, LVN 1 told him that she “peeked” into Resident 1’s room (Resident 1 bed was by the door [bed A]) on 12/3/23 (no time specified) and noted that Resident 1 “looked unwell.” FM 1 stated LVN 1 told him that [LVN 1] left Resident 1 unattended and proceeded to administer medication to another resident in a different room. FM 1 stated that LVN 1 told him that she (LVN 1) later returned to Resident 1’s room and found Resident 1 unresponsive (unknown time). On 1/11/24 at 3:44 p.m., during a telephone interview LVN 1 stated Resident 1 was on aspiration precautions, however, LVN 1 failed to identify aspiration precautions. LVN 1 stated that on 12/3/23 at around 7 p.m., she heard Resident 1 yell out asking for water to drink. LVN 1 stated that at around 7:30 p.m., while she (LVN 1) was by the Treatment Cart (storage for medical or treatment supplies) right outside Resident 1’s room, she “peeked” in Resident 1’s room (Resident1’s bed was located by the door) and noted that Resident 1 “did not look good. His [Resident 1] eyelids were closed and the eyeballs moving underneath the closed eyelids.” LVN 1 stated she did not go inside the room to evaluate Resident 1’s condition and take his vital signs (respiratory and heart rates). LVN 1 stated she went to another resident’s room “few doors down” to give an ointment to another staff and did not call a supervisor or another LVN to go immediately to check on Resident 1’s status. LVN 1 stated she then returned to Resident 1’s room (time unknown) and noted Resident 1 unresponsive to pain when performing sternal rub (involves using your knuckles to vigorously rub the breastbone to find out if a patient reacts to pain). LVN 1 did not check Resident 1’s breathing and heart rate and left Resident 1 alone (time unknown), went to the Nursing Station to ask for assistance and to page Code Blue (an announcement that means that an adult is having a medical emergency, usually cardiac or respiratory arrest for all nursing staff available to assist with the emergency). LVN 1 stated she then went back to Resident 1’s room and initiated CPR. LVN 1 confirmed not checking Resident 1’s heart and respiratory rates. LVN 1 further stated she should have gone into Resident 1’s room to evaluate Resident 1 when she first noticed that something was wrong. LVN 1 further stated she should not have left Resident 1 alone because any second wasted (not giving emergency care) could have caused irreversible harm to Resident 1. On 1/11/24 at 5:19 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1’s nursing notes regarding Resident 1’s medical emergency on 12/3/23 at 7:30 p.m. The DON stated Resident 1 was on aspiration precautions and should have always been monitored during meals. The DON stated Resident 1 was closing his hands around his abdomen. The DON stated LVN 1 should have checked on Resident 1 immediately when LVN 1 suspected Resident 1 had a change in condition (COC - a deterioration in health, mental, or psychosocial status which can be life-threatening). The DON stated staff need to respond immediately and provide the necessary treatment/measures whenever a resident develops a COC. The DON stated that quick response is necessary to make sure that proper measures and immediate treatment is provided to a patient. The DON further stated a resident could die if found unresponsive and necessary treatment/appropriate measures are delayed. The DON stated nurses must always stay/remain with a resident whenever the resident is non-responsive while summoning for help by shouting help. The DON stated that other nurses should check the code status (the type of emergent treatment a person would or would not receive if their heart or breathing stops) of the resident and call 911 for paramedics to continue to provide emergency care. On 1/16/24 at 12:13 p.m., during an interview with Registered Dietician (RD), the RD stated she assesses residents and that noodles are acceptable and are included on the facility’s spread sheet provided by the menu company. On 1/16/24 at 12:23 p.m., during an interview, the DON stated, the DON and nursing staff did not know what motor exercises were, what diet modification was and what care giver training was provided for Resident 1. The DON stated other disciplines in the facility should have been involved in the dysphagia care plan initiated by speech therapist for Resident 1. The DON confirmed and stated that the care plan was not individualized to meet Resident 1’s needs. On 1/16/24 at 12:45 p.m., during an interview with Dietary Supervisor (DS), DS stated noodles are very soft for residents on mechanical diet. A review of the facility’s policy and procedures (P&P) on Change of Condition reviewed on 1/23, indicated the purpose was to define guidelines for the timeliness in the notification of the identified change in the resident's condition. The procedures for Life Threatening Change indicated that the licensed nurse would initiate appropriate first aid measures until emergency response personnel arrive on the scene. The resident observation and assessment information, nursing intervention, physician contacts and resident's responsible party notification will be documented under the progress note section in PointClick Care (documentation software). A review of the facility’s P&P titled, “Emergency Procedure – Cardiopulmonary Resuscitation - Disaster Emergency Response, indicated that if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the DNR or code status of the individual. Following initial assessment, begin CPR with chest compressions. A review of the facility’s P&P titled, “Emergency Procedure – Choking - Disaster Emergency Response, indicated that for Unconscious Resident—Lying Down reviewed 1/24, to call for help if assistance is not already present but “do not leave the resident unattended.” The facility failed to provide immediate emergency care including CPR for Resident 1 who was found unresponsive on 12/3/23 at 10:40 p.m., as per facility’s policy. As a result, Resident 1 did not receive the necessary emergency life-saving services immediately. The paramedics pronounced Resident 1’s death at the facility on 12/3/23 at 6:04 p.m. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a substantial factor in the death of Resident 1.