Other·September 28, 2023

§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. CFR §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 8/8/2023, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was non-responsive when the family went to visit. The complaint alleges it took the family member 15 minutes to wake up Resident 1, and once awake the resident stared off to the side and did not verbally respond. On 8/8/2023, the CDPH conducted an unannounced visit at the facility. During the investigation, it was discovered Resident 1 had a decline in level of consciousness and decreased meal consumption starting on 8/5/2023. The licensed nurses failed to notify the physician of Resident 1’s change in condition. The facility failed to: 1. Ensure Resident 1 was assessed and monitored on 8/5/2023, 8/6/2023, and 8/7/2023 for a change in level of consciousness (a person’s awareness and understanding of what is happening in his or her surroundings), decreased meal consumption and decline in condition. 2. Ensure Resident 1’s physician was notified immediately on 8/5/2023, 8/6/2023, and 8/7/2023 for a change in level of consciousness decreased meal consumption and decline in condition. 3. Ensure timely transfer to the general acute care hospital (GACH). 4. Ensure a physician’s order to monitor for complications such as changes in level of consciousness, nausea, and vomiting every shift related to dialysis (a treatment to clean your blood when your kidneys are not able to). 5. Follow their Policy and Policy (P&P) titled, “Change of Condition Reporting,” by failing to notify the physician of all symptoms and unusual signs in Resident 1’s change in level of consciousness and decreased meal consumption which started on 8/5/2023. As a result, Resident 1 received a delay in emergency medical care when Resident 1 had an initial change in condition on 8/5/2023 but was not transferred to the general acute care hospital (GACH) until 8/7/2023. Resident 1 sustained a stroke (damage to the brain from blood flow interruption) and was admitted to the GACH for acute encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) secondary to a stroke, with nasogastric tube (a tube inserted through the nose into the stomach for food and medication to bypass the throat in high risk choking patients) placement for dysphagia (difficulty swallowing). A review of Resident 1’s Admission Record, dated 8/9/2023, indicated Resident 1, was a 76 year-old female, was admitted to the facility on 8/9/2022 with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dependence on renal dialysis (a treatment for people whose kidneys are unable to filter out waste in the blood). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/8/2023, indicated Resident 1 required supervision (oversight, encouragement or cueing) for eating, and had moderate cognitive impairment. A review of Resident 1’s Order Summary Report, dated 3/25/2023, indicated to monitor for complications such as changes in level of consciousness, nausea, and vomiting every shift related to dialysis. During a review of Resident 1’s “Meal Log – Documentation Survey Report”, for the month of August 2023, indicated on 8/5/2023, there was no documented meal percentages recorded. The meal log indicated on 8/6/2023, Resident 1 had no documentation of meals eaten for breakfast or lunch, and 0 – 25 percent (%) for dinner. The meal log indicated on 8/7/2023, Resident 1 had no documentation of meals eaten for breakfast and lunch. A review of Resident 1’s Progress Note, dated 8/7/2023, at 1:13 p.m., indicated Resident 1 did not eat breakfast, and was noted to be lethargic (sluggish) with altered mental status (a change in mental function). The progress note indicated 911 was called for Resident 1’s unresponsiveness.  A review of Resident 1’s Physician’s Telephone Order, dated 8/7/2023, untimed, (authored by Licensed Vocational Nurse [LVN] 2), indicated to transfer Resident 1 to the hospital via 911 ambulance.  A review of Resident 1’s general acute care hospital (GACH) History and Physical (H&P), dated 8/7/2023, at 3:33 p.m., indicated Resident 1 presented to the GACH with slurred, muffled speech, was disoriented (confused) with weakness of the left upper and lower extremity (left arm and leg). The GACH H&P indicated Resident 1 was admitted for acute encephalopathy secondary to a stroke, with nasogastric tube placement for dysphasia. A review of Resident 1’s GACH Magnetic Resonance Imaging (MRI, a medical examination used to generate images of the body) report of the brain, dated 8/7/2023, at 4:36 p.m., report indicated Resident 1 had ischemic (tissue death due to lack of oxygen) changes consistent with an acute stroke. A review of Resident 1’s GACH “Progress Note”, dated 8/9/2023, at 12:39 p.m., Resident 1 was not alert and oriented, pupils were sluggish (abnormally slow to respond to light), the resident did not withdraw from painful stimuli, and was unable to follow commands. During an interview on 8/8/2023, at 2:32 p.m., Certified Nursing Assistant (CNA) 1, stated on 8/6/2023, during the 7 a.m. to 3 p.m. shift, Resident 1 was restless and called CNA 1 by a different name. CNA 1 stated Resident 1 was normally alert and oriented. CNA 1 stated she was not sure if she reported Resident 1’s change of condition to anyone. CNA 1 stated when there was a change of condition, she must report it to the charge nurse and document it. CNA 1 stated on 8/7/2023, she tried to feed Resident 1 breakfast but was unable to because the resident was not fully awake. During an interview on 8/8/2023, at 2:38 p.m., LVN 2 stated on 8/7/2023, Resident 1 did not eat breakfast because the resident was tired, and the resident was still noted to be lethargic at lunch time. LVN 2 stated he attempted to contact Resident 1’s primary physician (Physician) 1 at 9:15 a.m., 10 a.m., and 10:30 a.m., but could not get a hold of anyone. LVN 2 stated 911 was called at approximately 1 p.m. on 8/7/2023. During an interview on 8/8/2023, at 3:04 p.m., the Director of Nursing (DON), stated on 8/7/2023, at approximately 11:00 a.m., Resident 1 appeared lethargic despite normal vital signs (measurements to assess the body’s physical health) and did not respond to the sternal rub (a technique to test an unconscious person’s responsiveness) and pinch. The DON stated she told Registered Nurse (RN) 1 to call 911.   During an interview on 8/9/2023, at 2:15 p.m., CNA 2 stated on 8/5/2023 in the morning, prior to dialysis, Resident 1 was wide awake. CNA 2 stated Resident 1 came back exhausted from dialysis and would not wake up for dinner. CNA 2 stated normally Resident 1 had a good appetite. CNA 2 stated she notified LVN 1 that Resident 1 did not eat dinner because of being too tired. CNA 2 stated Resident 1 was last able to feed herself one week prior. CNA 2 stated she was not sure why she did not document on the meal log for 8/5/2023, and that she may have forgotten or could have been a glitch with the electronic charting. During an interview on 8/9/2023 at 3:15 p.m., with Resident 1’s Roommate (Resident 2), Resident 2 stated she noticed Resident 1 had not been unable to fully wake up since 8/5/2023.  A review of Resident 2’s MDS, dated 6/18/2023, the MDS indicated Resident 2 had mild cognitive impairment. During an interview on 8/11/2023, at 11:40 a.m., CNA 3 stated on 8/6/2023, Resident 1’s responsible party (RP) 1 was visiting and was concerned about Resident 1 “acting strange.” CNA 3 stated RP 1 asked her what was going on with Resident 1. CNA 3 stated she informed LVN 3 of RP 1’s concern. CNA 3 stated at approximately 5 p.m., on 8/6/2023, CNA 1 tried to wake up Resident 1 to eat dinner but Resident 1 was not able to wake up, so she notified LVN 3. CNA 3 stated LVN 3 told CNA 3 Resident 1 was tired due to dialysis (last dialysis treatment was on 8/5/2023). During an interview on 8/16/2023, at 9 a.m., RP 1 stated on 8/6/2023, at approximately 4 p.m., Resident 1 was difficult to arouse and would not wake up during his visit. RP 1 stated after 15 minutes, he was able to wake up Resident 1. RP 1 stated Resident 1 was staring off to the “right towards the sky,” and had trouble speaking. RP 1 stated when Resident 1 opened her eyes he tried to snap his fingers in front of her eyes to get the resident‘s attention, but the resident would not blink. RP 1 stated he asked CNA 3 what was wrong with Resident 1 and requested to speak to a nurse. RP 1 stated he spoke to LVN 3 who took Resident 1’s vital signs and blood sugar and told RP 1 the results were normal. RP 1 informed LVN 3 that Resident 1 would not stop looking up to the right. RP 1 stated LVN 3 did not assess Resident 1’s pupils. RP 1 stated that normally when Resident 1 returned from dialysis, the resident was tired but able to communicate verbally without difficulty. RP 1 stated Resident 1 did not get out of bed on 8/6/2023 for dinner, nor did the resident have anything to eat. During an interview on 8/16/2023, at 10 a.m., LVN 3 stated on 8/6/2023, at approximately 5:30 p.m., Resident 1 had family members visiting that evening. LVN 3 stated she did not remember RP 1’s complaint. LVN 3 stated she remembered Resident 1 was awake and alert on 8/6/2023, while up in a chair eating without any problems.  During an interview on 8/16/2023, at 12:45 p.m., with Physician 1, stated the last time he visited Resident 1 was in July 2023, and on that day, the resident was alert and oriented, able to discuss her medical condition, and answered questions. Physician 1 stated he was informed of Resident 1’s change of condition on 8/7/2023, via text or email. Physician 1 stated he could not remember at what time, but he told the facility to transfer Resident 1 to the GACH. Physician 1 stated if there was an emergency, the facility did not need his permission to call 911. During an interview on 8/16/2023, at 2:29 p.m., LVN 1 stated she worked on 8/5/2023, from 3 p.m. to 11 p.m., and did not remember who was working that day, or which CNAs she was working with. LVN 1 stated CNA 2 did not informed her Resident 1 was tired and not eating. LVN 1 stated she remembered that Resident 1 was sleepy and could not feed herself but did not remember whether that was on 8/5 or 8/6/2023. LVN 1 stated Resident 1 seemed “OK.” During an interview on 8/24/2023, at 8:10 a.m., CNA 2 stated that on 8/5/2023, Resident 1 ate 60% of her breakfast before leaving for dialysis, and 0% for dinner after coming back from dialysis because the resident was “too tired.” CNA 2 stated she informed the charge nurse (LVN 1). CNA 2 stated on 8/6/2023, Resident 1 ate 0% of breakfast and lunch, and she (CNA 2) was unable to awaken the resident.  During an interview on 8/24/2023, at 8:37 a.m., the DON stated on 8/7/2023, she made rounds at approximately 11 a.m. The DON stated Resident 1’s Family Member (FM) 1 was present when she tried to stimulate Resident 1, but the resident was not very responsive. The DON stated Resident 1 was just “grunting” and she (DON) told one of the nurses to call 911. During an interview on 8/24/2023, at 2:43 p.m., Family Member (FM) 1 stated on 8/7/2023 at approximately 12 pm, she went to visit Resident 1. FM 1 stated Resident 1 looked “dead”. FM 1 stated she asked the DON when was the last time they (facility’s nurses) checked on Resident 1, and the DON stated Resident 1 ate and was OK after taking her vital signs. FM 1 stated she told the DON Resident 1 was not OK and she was not going to leave Resident 1 at the facility like that. FM 1 stated LVN 2 stated he was going to text MD 1 for approval to send Resident 1 to the emergency room. FM 1 stated LVN 1 tried to wake Resident 1 up but she was not responsive. FM 1 stated she told LVN 2, “Obviously she needs to go to the hospital so can you call an ambulance?” A review of the facility’s policy and procedure (P&P) titled, “Change of Condition Reporting”, dated 5/20/2020, indicated all changes in residents’ medical condition are to be communicated to the physician as soon as possible. The P&P further indicated changes in physical or mental behavior will be communicated to the physician by the licensed nurse and documented. The P&P indicated if unable to contact the attending physician or alternate physician timely, notify the Medical Director for follow-up to change in resident condition. The facility failed to: 1. Ensure Resident 1 was assessed and monitored on 8/5/2023, 8/6/2023, and 8/7/2023 for a change in level of consciousness, decreased meal consumption and decline in condition. 2. Ensure Resident 1’s physician was notified immediately on 8/5/2023, 8/6/2023, and 8/7/2023 for a change in level of consciousness decreased meal consumption and decline in condition. 3. Ensure timely transfer to the GACH. 4. Ensure a physician’s order to monitor for complications such as changes in level of consciousness, nausea, and vomiting every shift related to dialysis. 5. Follow their P&P titled, “Change of Condition Reporting,” by failing to notify the physician of all symptoms and unusual signs in Resident 1’s change in level of consciousness and decreased meal consumption which started on 8/5/2023. As a result, Resident 1 received a delay in emergency medical care when Resident 1 had an initial change in condition on 8/5/2023 but was not transferred to the GACH until 8/7/2023. Resident 1 sustained a stroke and was admitted to the GACH for acute encephalopathy secondary to a stroke, with nasogastric tube placement for dysphasia. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.