Other·June 20, 2024

42 C.F.R., §483.24(a)(3) Cardiopulmonary Resuscitation Services (a) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. (3) Ensure that each facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians’ orders, such as DNRs, and the resident’s advance directives. 22 CCR §72517 (b)Staff Development (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. 22 CCR §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 5/7/2024 at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. The facility failed to: 1. Implement its policy and procedures (P/P) titled, “Emergency Procedures for Cardiopulmonary Resuscitation” ([CPR] an emergency procedure to restart a person’s heart and breathing after one or both suddenly stop) by not activating the emergency medical system (EMS, a system that provides medical care) for Resident 65, who was observed unresponsive in bed, at 4 a.m., on 2/15/2024. 2. Provide emergency care to Resident 65 consistent with the minimum standards of care for a resident with full code status (indicating that medical personnel should do everything possible to save a person’s life in a medical emergency). As a result, the facility failed to take appropriate action when a resident with full code status was observed to be unresponsive, which resulted in Resident 65’s death and placed 54 other residents, with full code status, at risk of not receiving timely life saving measures. A review of Resident 65’s closed record (face sheet), indicated Resident 65 was a 93-year-old male, admitted with diagnoses that included encephalopathy (brain disease that causes confusion and memory loss), sepsis (a life-threatening condition in which the body responds improperly to an infection), acute respiratory failure (occurs when the lungs cannot release enough oxygen into a person’s blood), and pneumonia (an infection that affects one or both lungs). A review of Resident 65’s progress notes dated 2/15/2024, at 4 a.m., indicated Certified Nurse Assistant (CNA) 1 observed Resident 65 unresponsive with no rise or fall of the chest and non-responsive to tactile (touch) and verbal stimuli. A review of Resident 65’s Minimum Data Set ([MDS] an assessment and care screening tool) dated 2/14/2024, indicated Resident 65’s cognitive patterns (the process of thinking) were severely impaired. The MDS indicated Resident 65’s required extensive assistance (one-to-two-person assistance from staff members) for activities of daily living ([ADLs]- an individual's daily self-care activities such as toileting, showering, dressing oneself). The MDS indicated Resident 65’s was dependent on staff for toileting, showering and upper/lower body dressing. A record review of Resident 65’s Change of Condition (COC) document, dated 2/3/2024, indicated Resident 65’s code status was full code. A review of Resident 65’s progress note, dated 2/15/2024 at 4:30 a.m., indicated on 2/15/2024, at 4 a.m., CNA 1 observed Resident 65 in bed, flaccid (loose or floppy limbs), cool to touch with no rise and fall of the chest, and nonresponsive to tactile (touch) and verbal stimuli. The progress note indicated CNA 1 notified Licensed Vocational Nurse (LVN) 1 of Resident 65’s COC at 4 a.m. and a Code Blue (a medical emergency code used to describe a resident who is in cardiac or respiratory arrest) was called. The progress note indicated LVN 1 and LVN 2 performed CPR on Resident 65 for 20 minutes. The progress note indicated at 4:20 a.m., LVN 1 notified Resident 65’s primary physician (Physician 1) via telephone, and Physician 1 pronounced Resident 65 deceased (dead) over the phone. During a telephone interview, on 5/8/2024 at 4:10 p.m., LVN 1 stated on 2/15/2024 around 4 a.m., CNA 1 went to Resident 65’s room to reposition him. LVN 1 stated CNA 1 ran back out of the room informing her that Resident 65 did not “look good”. LVN 1 stated she went into Resident 65’s room, assessed the resident’s pulses (the regular movement of blood through your body that is caused by the beating of your heart and that can be felt by touching certain parts of your body) and announced a Code Blue. LVN 1 stated she initiated CPR on Resident 65 at 4:02 a.m. LVN 1 stated LVN 2 came to assist with CPR for 20 minutes. LVN 1 stated 911 (an emergency telephone number that people can call for emergency medical assistance) was not called because she called to notify Physician 1 of Resident 65’s situation at 4:20 a.m. LVN 1 stated Physician 1 pronounced Resident 65 dead over the telephone. LVN 1 stated Physician 1 did not assess the resident prior to pronouncing the resident dead. LVN 1 stated the importance of calling 911 was for the paramedics (healthcare professionals trained to respond to emergency calls for medical help outside of a hospital) to assist with intubation (a process in which a tube is inserted through a person's mouth or nose, then down into their airway to get air in and out of the lungs), setting up any intravenous (IV, through a vein) fluids and/or medications, and “do things that we can't do when giving CPR to save a life.” LVN 1 stated the risk of not calling 911 during a Code Blue would result in a resident’s death. During an interview, on 5/8/2024 at 3:25 p.m., Registered Nurse (RN) 1 stated during a Code Blue, a resident’s airway, breathing, and circulation should always be checked, followed by the resident’s POLST (Physician Orders for Life Sustaining Treatment- a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). RN 1 stated if a resident had no vital signs and was a full code, staff should start CPR immediately. RN 1 stated another staff should be asked to call 911 right away, and another staff should notify the resident’s physician on the resident’s condition immediately. RN 1 stated paramedics had the capacity to handle life threatening situations and provide advanced cardiac life support. RN 1 stated 911 was not called on 2/15/2024, after CNA 1 observed Resident 65 unresponsive. During an interview, on 5/10/2024 at 11:46 a.m., the Director of Nursing (DON), stated CPR should be initiated if a resident was found unresponsive without a pulse and not breathing. The DON stated during a Code Blue, staff were supposed to call for assistance, take a crash cart to the resident’s room and call 911 immediately. The DON stated 911 was not called on 2/15/2024, when CNA 1 observed Resident 65 unresponsive in bed. The DON stated if 911 was called as soon as a Code Blue was called, Resident 65 might have received prompt lifesaving care. During an interview, on 5/9/2024 at 3:05 p.m., Resident 65’s physician, Physician 1 stated she could not recall the details but remembered she received an early morning phone call regarding Resident 65 on 2/15/2024. Physician 1 stated LVN 1 informed her Resident 65 coded around 4 a.m. Physician 1 stated staff found the resident unresponsive, took vital signs and initiated CPR, which was performed for 20 minutes, per LVN 1. Physician 1 stated the standard of practice was to initiate CPR and call 911. Physician 1 stated she did not have any notes or documentation from the call received from the facility on 2/15/2024 regarding Resident 65. A review of Resident 65’s Death Certificate, dated 5/13/2024, indicated Resident 65’s cause of death was respiratory failure. A record review of the facility’s policy and procedure (P/P), titled, “Emergency Procedures- Cardiopulmonary Resuscitation,” dated February 2018, indicated if an individual was found unresponsive, staff would briefly assess for abnormal or absence of breathing and if a sudden cardiac arrest was likely, staff should begin CPR, instruct another staff member to activate the emergency response system (code) and call 911. The P/P indicated staff should continue with CPR until an emergency medical personnel arrived. The facility failed to: 1. Implement its policy and procedures (P/P) titled, “Emergency Procedures for Cardiopulmonary Resuscitation” by not activating the EMS for Resident 65, who was observed unresponsive in bed, at 4 a.m., on 2/15/2024. 3. Provide emergency care to Resident 65 consistent with the minimum standards of care for a resident with full code status. As a result, the facility failed to take appropriate action when a resident with full code status was observed to be unresponsive, which resulted in Resident 65’s death and placed 54 other residents, with full code status, at risk of not receiving timely life saving measures. These violations, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 65.