Health inspection·June 14, 2023

§483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. 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 3/20/2023, the California Department of Public Health (CDPH) received a complaint alleging the residents at the facility constantly scream out and no one has been assisting them, the residents had been verbally abused by staff, including the Director of Nursing (DON), who has been telling residents to shut up, and Resident 1 went into cardiac arrest (when the heart suddenly stops beating) on 10/10/2022 while at the facility and staff performed cardiopulmonary resuscitation [(CPR)- an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped] against Resident 1’s documented wishes. On 3/21/2023 at 9 a.m., CDPH made an unannounced visit to the facility to investigate the complaint allegations and determined Resident 1, who had a ‘Do Not Resuscitate’ ([DNR] when the heart stops beating, or a person stops breathing, there are no rescue measures taken, including CPR) order in place, suffered a cardiac arrest, while at the facility, on 10/10/2022 and the facility’s nursing staff changed Resident 1’s Physician’s Order for Life-Sustaining Treatment ([POLST] a written medical order from a physician that give people with serious illness control over their own care by specifying the types of medical treatment they want to receive during serious illness) to indicate Resident 1 was a Full Code (if a person’s heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provide to keep them alive), performed CPR on Resident 1 against the resident’s wishes, and then transferred Resident 1 to a General Acute Care Hospital (GACH) with the POLST that indicated a Full Code. Resident 1 was intubated (a tube placed a through the mouth and down the throat to assist a person with breathing) at the GACH. The facility failed to: 1. Ensure Resident 1’s POLST indicating DNR was honored and Resident 1’s care wishes were carried out when she went into cardiac arrest and became unresponsive. 2. Ensure Resident 1’s POLST was not changed from DNR to a Full Code status without Resident 1’s or Resident 1’s family member’s (FM 1) consent. 3. Ensure GACH was provided with correct POLST to indicate Resident 1 was a DNR. 4. Ensure the facility obtained a consent for the end-of-life care wishes, via POLST, from Resident 1, who was deemed able to understand and make her decisions and failed to allow Resident 1’s FM 1 to complete Resident 1’s POLST. 5. Ensure staff clarified conflicting code status between Resident 2’s POLST, DNR instructions and the Physician’s Orders (PO). 6. Ensure staff clarified conflicting code status between Resident 3’s POLST that indicated full code instructions for the end-of-life care and the PO that indicated a DNR status. 7. Follow the facility’s policy and procedures (P/P), titled “Do Not Resuscitate Order,” that indicated the facility will not use CPR when there is a DNR, and residents have rights to participate in decision- making regarding his or her care. These failures resulted in: a. Resident 1 receiving CPR against her wishes and not in accordance with her documented POLST instructions (10/1/2022) for DNR when Resident 1 experienced a sudden cardiac arrest on 10/10/2022. b. The facility providing the wrong POLST with a Full Code status to the GACH at the time of Resident 1's transfer (10/10/2022), resulting in Resident 1 being intubated, which was against her wishes. c. Placing Resident 2 and Resident 3 at risk of having their end-of-life care wishes violated due to conflicting information between their POLST and the POs directions for end-of-life care. A. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on 10/1/2022 with diagnoses including chronic obstructive pulmonary disease ([COPD] a lung disease that blocks airflow and makes it difficult to breathe), chronic (persisting for a long time) hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). The Face Sheet indicated Resident 1's FM 1 was Resident 1's power of attorney ([POA] a person appointed to manage a person's property, medical and financial affairs). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/10/2022, the MDS indicated, Resident 1's cognitive (awareness of one's own strengths and limitation to make decisions) skills for daily decision-making were moderately impaired. During a review of Resident 1'a History and Physical (H&P), dated 10/1/2022, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's form named ‘DPOA’ (a durable power of attorney prevents the loss of an agent's authority to act at a time when principals incapable of making their own decisions need someone to step in and make the) dated 2/21/2021, the DPOA indicated FM 1 had the authority to make financial decisions if Resident 1 became disabled or incompetent. There was no indication that medical decisions were designated to FM 1. During a review of Resident 1's POLST dated 10/1/2022, the POLST indicated documented instructions ‘Do Not Resuscitate/DNR’ (allow natural death). During a review of Resident 1's POLST dated 10/10/2022 (nine days later), the POLST indicated Resident 1 was a Full Code and had to have CPR if the heart stopped or the resident stopped breathing. This POLST was signed by the licensed vocational nurse (LVN 1) and LVN 2. The POLST indicated a verbal consent was obtained from FM 1 at 11:43 a.m., on 10/10/2022 to change Resident 1's code status from DNR to a Full Code. On 10/11/2022 the physician signed this POLST after Resident 1 expired (died). During a review of Resident 1's Physician’s Order (PO) dated 10/10/2022 and timed at 11:43 a.m., the PO indicated Resident 1's POLST was changed from DNR to a Full Code via verbal consent through a telephone call with FM 1 due to Resident 1's transfer GACH via 911. During a review of Resident 1's Progress Notes (PN) dated 10/10/2022 and timed at 11:44 a.m., documented by LVN 1, the PNs indicated at 11:20 a.m., Resident 1 was non-arousable with a blood pressure of 70/33 millimeters of mercury [(mmHg) unit of measurement, reference range is 120/80 mmHg], a heart rate of 46 beats per minute (normal heart rate 60-100 beats per minute) and an oxygen saturation (amount of oxygen in the blood with [normal range 95% to 100%]) rate of 65% on room air. The PN indicated, paramedics were called at 11:28 a.m., and arrived at 11:36 a.m. The PN indicated at 11:43 a.m., two licensed nurses spoke with FM 1 and the POLST was changed to a Full Code via verbal consent. During a review of Resident 1's PNs, dated 10/10/2022 and timed at 12:18 p.m., completed by the registered nurse (RN 1), the PNs indicated at 11:21 a.m., Resident 1 became unresponsive and at 11:30 a.m., Resident 1 stopped breathing. The PNs indicated Resident 1's chest compression were started and at 11:36 a.m., the paramedics arrived at the facility and took over Resident 1's care. During an interview on 3/22/2023 at 12:20 p.m. with RN 1, RN 1 stated, Resident 1 was alert and oriented, the morning of her rounds (10/10/2022). RN 1 stated, at 11:21 a.m., LVN 1 called her and said Resident 1 was unresponsive. RN 1 stated, the staff checked Resident 1's POLST which indicated Resident 1 was a DNR. RN 1 stated, LVN 1 called FM 1 at 11:43 a.m., (10/10/2022) and FM 1 changed the POLST to a Full Code status. RN 1 stated, at 11:30 a.m., Resident 1 stopped breathing and had no pulse (heartbeat) and staff started chest compressions. RN 1 stated, DNR means do not resuscitate and the facility should have followed the resident's wishes. RN 1 stated, the Director of Nurses (DON) told her, Resident 1 was not self-responsible and did not have the capacity to make decisions. RN 1 stated, the POLST is a physician's order with directions for nurses should do for residents in an emergency. RN 1 stated, the POLST was signed on 10/10/2022 at 11:43 a.m., by verbal consent from FM 1 via the telephone, LVN 1 spoke to FM 1 and LVN 2 was the witness. During an interview on 3/22/2023 at 12:55 p.m., with LVN 1, LVN 1 stated, Resident 1 was unarousable at 11:20 a.m., (10/10/2022) and CPR was started before the paramedics came to the facility. LVN 1 stated, she called FM 1 after the paramedics arrived and FM 1 told her to change Resident 1's code status to a Full Code, so she (LVN 1) created a new POLST with LVN 2 as a witness. LVN 1 admitted LVN 2 was not actually on or near the phone when FM 1 asked to change Resident 1's code status to a Full Code. LVN 1 stated, a POLST is a PO, and a nurse cannot change a PO without notifying the physician. During an interview on 3/24/2023 at 8:52 a.m., with FM 1, FM 1 stated, the facility called her and said Resident 1 was unresponsive and was a Full Code. FM 1 stated she never gave consent to make changes to Resident 1's POLST to a Full Code and wanted Resident 1's status to remain a DNR. FM 1 stated the facility did not tell her they had already begun Resident 1's CPR and stated she later found out Resident 1 was intubated when the resident arrived at the GACH. FM 1 stated, Resident 1 told her she (Resident 1) did not want any tubes and wanted to be a DNR. FM 1 stated, Resident 1 would be so mad that this happened because they (FM 1 and Resident 1) had talked about it for decades, that Resident 1 did not want to be resuscitated. During an interview on 3/24/2023 at 12:01 p.m., with LVN 2 and a concurrent review of Resident 1's POLST dated 10/10/2022, the POLST indicated Resident 1 was a Full Code. LVN 2 stated, when he entered Resident 1's room, staff were already performing CPR. LVN 2 stated he was informed that Resident 1 was a DNR prior to him taking over CPR but was instructed to do CPR by LVN 1. LVN 2 stated, while he was doing compressions, LVN 1 came into Resident 1's room and said FM 1 wanted to send Resident 1 to the hospital via paramedics. LVN 2 stated, LVN 1 told him Resident 1's code status had been changed to a Full Code by FM 1. LVN 2 stated, he did not hear FM 1 say to change Resident 1's code status to Full Code but was told by LVN 1 to sign Resident 1's POLST as a witness and acknowledged he should not have signed the POLST. LVN 2 stated, if there was a verbal consent to change a code status, two licensed nurses needed to sign the POLST as a witness. LVN 2 confirmed his signature was on the POLST as the second witness to the code status change, although he did not actually witness FM 1 saying to change Resident 1 to Full Code. During an interview and concurrent record review on 3/24/2023 at 12:46 p.m., with the DON, Resident 1's POLST, dated 10/1/2022 was reviewed. The DON stated Resident 1's POLST indicated Resident 1 was a DNR. The DON stated she told RN 1 that Resident 1 did not have the capacity to make decisions but after reviewing Resident 1's H&P, stated she did not know Resident 1's physician indicated Resident 1 had the capacity to make decisions. During an interview on 3/24/2023 at 1:08 p.m., with the Admissions Director (AD), the AD stated, she received an email on 10/1/2022 with confirmation from FM 1 of Resident 1's wishes to be a DNR and she (AD) informed the Social Worker Assistant (SWA) regarding Resident 1's code status as a DNR. During an interview on 3/24/2023 at 1:24 p.m., with the Social Worker Assistant (SWA), the SWA stated, she remembered an email that she received indicating Resident 1 wished to be a DNR. The SWA stated, when she saw the POLST (10/1/2022) in Resident 1's clinical record stating Resident 1 was a DNR, she assumed everything was in place. The SWA stated, FM 1 was only the DPOA over Resident 1's finance. During an interview on 3/24/2023 at 4:21 p.m., with FM 1, FM 1 stated, it was horrible seeing Resident 1 with a tube down her throat at the GACH and she asked them to take it out. FM 1 stated she was crying so much, bawling her eyes out and was very emotional and made such a scene in the emergency room (ER) because she was "in shock!!" FM 1 stated, Resident 1's fingers turned blue and looked like she was in pain when the tube was taken out, and the doctor at the GACH had to give Resident 1 Morphine (a medication used to relieve moderate to severe pain). FM 1 stated it was horrible watching Resident 1 go through all of that, Resident 1 died within an hour or two after the tube was taken out and she (FM 1) witnessed Resident 1 take her last breath. FM 1 stated, "how did this happen? this was not the way Resident 1 was supposed to die!" FM 1 stated, she was alone in the ER witnessing Resident 1 die, it was so hard to talk about and that was why she delayed reporting it to the DPH. FM 1 stated she was in great emotional pain, in a bad place and started drinking a lot of alcohol after Resident 1 died. FM 1 stated, she started seeing a grief counselor and the therapist helped her file a report with the DPH. During a review of Resident 1's GACH records (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the GACH on 10/10/2022 at 12 p.m. During a review of the GACH's History of Present Illness (HPI), dated 10/10/2022, the HPI indicated Resident 1 had a prior documented DNR code status. The HPI indicated EMT (emergency medical technician) reported that Resident 1's code status was recently changed to DNR with full treatment including a ventilator (breathing machine). During a review of the GACH's Reexamination/Reevaluation/ED Course, dated 10/10/2022, the (RREC) indicated Resident 1 was intubated for respiratory failure and airway protection. When FM 1 arrived, it was confirmed that Resident 1 was a DNR with comfort care only. FM 1 wished Resident 1 to be extubated and verbalized understanding that Resident 1 would likely not get enough oxygen which could be fatal. During a review of the GACH's Staff Progress Notes (SPN) dated 10/10/2022 and timed at 1:17 p.m., the SPN indicated FM 1 was at Resident 1's bedside stating Resident 1 "would be so upset if she knew she was intubated." The SPN indicated the ER doctor was made aware and the plan was to create a new POLST to indicate DNR and comfort care instead of Full Code. During a review of the GACH's Hospital Course (HC), the HC indicated Resident 1 was brought to the GACH from a skilled facility, lethargic, for evaluation of respiratory distress (a life-threatening condition where the lungs cannot provide the body's vital organs with enough oxygen). In the ER Resident 1 was intubated but later FM 1 arrived, and Resident 1 was made a DNR and was extubated, per FM 1's wishes. Resident 1 expired on 10/10/2022 at 6:53 p.m. B. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on 11/26/2022 with diagnoses including dementia (loss of intellectual functioning), and hypertension ([HTN] high blood pressure). During a review of Resident 2's MDS, dated 11/30/2022, the MDS indicat