Health inspection·April 17, 2024

42 CFR §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 subpart. 22 CCR §72311, Nursing Services - General (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time - limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 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. The facility failed to provide respiratory treatment and care for Resident 13, who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems) and history of pneumonia (a serious infection of one or both lungs in which the air sacs fill with pus and other liquid). The facility failed to: 1. Closely monitor Resident 13's respiratory condition, including response to treatment after being identified to have a change of condition (COC, a sudden clinically important deviation from a patient's baseline) when Resident 13 develop a cough on 3/20/2024. 2. Perform a complete respiratory assessment (breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion of the chest with each breath) as per policies and procedures (P&P) on Residents COC, Pneumonia, Bronchitis [inflammation of the lining of bronchial tubes, which carry air to and from the lungs], and Lower Respiratory Infections -Clinical Protocol, and Resident Examination and Assessment. 3. Monitor and notify the attending physician (Physician 1) about Resident 13's worsening cough. 4. Notify Physician 1, on 3/21/2024, of Resident 13's chest X-ray results and recommendation to repeat X-rays if symptoms persisted or worsened. As a result: 1. Resident 13 having inability to sleep, fatigue (extreme sense of tiredness and lack of energy that can interfere with a person's usual daily activities), poor appetite, and loss of ability to taste food/fluids. 2. Transferring Resident 13 to General Acute Care Hospital 1 (GACH 1) on 3/24/2024, because of fever, coughing, and difficulty breathing. At GACH 1, Resident 13 was diagnosed with pneumonia and required intravenous (IV- delivered into a vein) antibiotics (medications used to treat infection). These failures had the potential for further decline and complications related to increased risk for sepsis (a life-threatening infection in the blood that travels throughout the entire body), respiratory failure, organ failure, and death. On 3/23/2024, the survey team entered the facility to conduct recertification survey. A review of Resident 13's Admission Record indicated the facility initially admitted the 93-year-old female on 6/23/2023, and the most recent readmission was dated on 1/6/2024. Resident 13's diagnoses included pneumonia, asthma (chronic [ongoing] disease in which the bronchial [passages in the lungs] that extend from the trachea [windpipe] and airways in the lungs that become narrowed and swollen, making it difficult to breathe), and hypertension (high blood pressure). A review of Resident 13's Physician Order, dated 1/6/2024, indicated to administer Ipratropium-Albuterol Inhalation Solution (combination medication used to help control the symptoms of lung diseases and treat air flow blockage) ipratropium 0.5 milligrams (mg) - albuterol 3 mg (2.5 mg base) in three milliliters (ml) solution, vial inhaler, every four hours as needed for SOB (shortness of breath). A review of Resident 13's Minimum Data Set (MDS - standardized assessment and care screening tool) dated 1/10/2024, indicated Resident 13 had moderate impaired cognition (ability to comprehend, think, solve problem, process information, and make decisions). The MDS indicated, Resident 13 required substantial to maximum assistance for activities of daily living (ADLs such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 13's History and Physical exam (H&P) completed by Physician 1 on 1/25/2024, indicated that Resident 13 had the capacity to understand and make decisions. A review of Resident 13's COC, dated 3/20/2024 and timed at 9:22 p.m., indicated Resident 13 had nonproductive cough (a cough that is dry and does not produce sputum [mixture of saliva and mucus coughed up]). The COC did not include Resident 13's respiratory assessment. A review of Resident 13's chest X-rays results, dated 3/21/2024, indicated no acute focal consolidation (fluid or other material that consolidates inside the lung) or effusion (buildup of fluid between the chest cavity and the tissue lining the lungs). The x-ray indicated, if Resident 13's symptoms persisted or worsened, then the recommendation was to repeat frontal (front) and lateral (side) chest X-rays. A review of Resident 13's COC, dated 3/23/2024 and timed at 5:37 pm, indicated Resident 13 had productive cough and redness on the eyes, the respiration was even and unlabored (easy/relaxed), there was no shortness of breath, and Resident 13 did not get good sleep in the past two nights (3/21/2024 and 3/22/2024). The COC indicated the Director of Nursing (DON), assessed Resident 13 and the lung sounds were clear and no wheezing (high-pitched whistling sound made while breathing) was noted. The COC indicated Resident 13 did not have fever (high body temperature) or change in level of consciousness. The COC indicated Physician 1 was notified about Resident 13's COC on 3/23/2024 at around 5:15 pm and ordered Robitussin Peak Cold DM (Dextromethorphan-Guaifenesin - a combination medication used to relieve coughs) oral (by mouth) syrup 100 -10 milligrams (mg- unit of measurement) per 5 milliliters (ml- unit of measurement), every four hours as needed for 30 days. A review of Resident 13's nursing Progress Note, dated 3/24/2024 at 6:25 pm, indicated that on 3/24/2024 at 5 pm, Family Member 1 (FM 1) called concerned about Resident 13's difficulty of breathing. The Progress Note indicated Resident 13's oxygen saturation (02 sat - amount of oxygen in the blood) was 94 percent (% - normal range is 95-100%) while Resident 13 was on oxygen at two liters per minute (2 L/min) via nasal cannula (NS- a flexible tube used to deliver oxygen through the nose). The Progress Note indicated Physician 1 was notified regarding Resident 13 having difficulty of breathing with new orders. A review of Resident 13's Physician Order dated 3/24/2024, indicated to administer oxygen inhalation at 2L/min via nasal cannula as needed for shortness of breath/comfort. A review of Resident 13's Physician Progress Note dated 3/24/2024, no time specified, indicated Resident 13's 02 sat was 90%, had cough and rhonchi (coarse, loud sounds caused by constricted larger airways) upon chest assessment. A review of Resident 13's nursing Progress Note dated 3/24/2024, indicated that at 6:40 pm Resident 13 developed a fever of 100.7 degrees Fahrenheit (F- normal body temperature range is between 97 F and 99 F), Physician 1 was notified and ordered transferring Resident 13 to GACH 1. A review of Resident 13's Transfer to Hospital Summary form, dated 3/24/2024 at 10:40 pm, indicated Resident 13 was transferred to GACH 1 due to fever, coughing, and difficulty breathing. A review of Resident 13's GACH Emergency Department note dated 3/24/2024, untimed, indicated, Resident 13 presented with cough and SOB. GACH Emergency Department note indicated, Resident 13, "reported that over the past week, [Resident 13] was having increased congested sounding cough, but unable to bring up any sputum." GACH Emergency Department note indicated, "[Resident 13] reported to facility staff associated shortness of breath, with increased wheezing sensation requiring oxygen." GACH ED diagnosed Resident 13 with pneumonia. A review of Resident 13's GACH 1 chest X-ray report dated 3/25/2024 and timed at 12:32 am, indicated, subtle patchy infiltrates (areas filled with fluid, may be a manifestation of aspiration [breathing in food particles in airway]) in the right lower lung zone. A review of Resident 13's GACH 1 Infectious Disease Specialist Progress Note, dated 3/28/2024, indicated Resident 13 was treated for pneumonia with IV Zosyn (a combination of two antibiotics namely piperacillin and tazobactam) 3.375 grams (gm, unit of measurement). The Progress Note indicated to discontinue Zosyn and continue Levaquin (levofloxacin - antibiotic) 500 mg for three more days. On 3/24/2024 at 10:15 a.m., during a concurrent interview with the Director of Nursing (DON) and a review of Resident 13's clinical record, the DON could not find documented evidence that a care plan was developed on 3/20/2024, when Resident 13 was identified to be coughing. On 3/23/2024 at 10:30 am, during an observation, Resident 13 was sitting in a wheelchair outside room, in the hallway and was not receiving oxygen therapy. Upon interview, Resident 13 was observed coughing continuously. Resident 13 stated feeling tired, was unable to sleep because of constantly coughing during the night and was bothering others with the cough. Resident 13 stated feeling that other residents were staring when coughing. Resident 13's eyes appeared watery, red, and sunken. Resident 13 stated having nonproductive cough for a couple days and felt fatigued from not being able to sleep. Resident 13 stated receiving medication (Ipratropium- Albuterol) inhalation (via inhaler, a device that gets medicine directly into a person's lungs. The medicine is a mist or spray that the person breathes in) but the medication was not working. A review of Resident 13's Care Plan developed on 3/23/2024 for Resident 13's having a productive cough, included in the interventions: -Monitoring for any shortness of breath and notify Physician 1. -Administering medication as ordered, Robitussin Peak Gold DM oral syrup every four hours for 30 days. -Monitoring vital signs (measurement of the body's most basic functions such as heartbeat and breathing rates, and body temperature) every shift for the next three days and notify Physician 1 if any significant or any abnormalities. On 3/23/24 at 4:10 pm, a concurrent observation in Resident 13's room and interview with Resident 13 in the presence of the Director of Nursing (DON) was conducted. Resident 13 was in bed and appeared tired. Resident 13's eyes were watery, red, and sunken in. Resident 13 reported coughing for a few days and unable to cough up any sputum. Resident 13 stated feeling fatigued from not sleeping well at night due to constantly coughing. Resident 13 stated having no appetite and unable to taste food since the cough started which the nurses were aware. Resident 13 stated the nurses were giving some type of liquid medication, which did not work at all. The DON auscultated (examine by listening to the sounds of the heart, lungs, arteries, and belly using a stethoscope (a medical instrument used for listening to sounds in the body) Resident 13's lungs and stated Resident 13's lungs were clear (no abnormal sounds). The DON stated the respiratory assessment must be performed when a resident displays any respiratory concerns including coughing. The DON stated Resident 13 should have had a respiratory assessment as soon as Resident 13 started coughing on 3/20/2024, to identify problems and prevent worsening of Resident 13's condition. On 3/23/2024 at 4:30 pm, during an interview Licensed Vocational Nurse 1 (LVN 1) stated that on 3/18/2024, Resident 13 received COVID-19 vaccine and developed a cough approximately two days after. LVN 1 stated Resident 13's cough was a reaction to the vaccine. On 3/23/2024 at 4:43 p.m., during a concurrent interview with the DON and a review of Resident 13's clinical record, the DON stated there was no documentation Physician 1 was notified of the chest X-rays report and the recommendation from the radiologist (a medical doctors that specialize in diagnosing and treating injuries and diseases using medical imaging [radiology] procedures such as X-rays) to repeat the X-rays if cough persisted or worsened. The DON admitted that not notifying Physician 1 led to a delay in Resident 13's care. On 3/23/2024 at 5 pm, during a telephone interview, Physician 1 (who was also the facility's medical director), stated the nurses did not inform him of Resident 13's worsening cough and the recommendations to repeat chest x-ray the if symptoms (cough) persisted or worsened was not implemented. Physician 1 stated not being informed Resident 13 had the eyes red and sunken. MD 1 stated, "it was normal part of aging to feel fatigued, be unable to sleep, and have some type of discomfort such as aches." A review of facility's policy and procedures (P&P) titled, "Change in a Resident's Condition or Status" revised 2/22/2024, indicated, "Our facility shall promptly notify the resident, his or her Attending Physician, Attending Licensed Healthcare Practitioner acting within the scope of his or her professional /licensure, representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments., resident rights, etc.). Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and relevant and pertinent information for the provider, including (for example) information prompted by the SBAR [Situation - Background - Assessment - Recommendation, a written or verbal communication tool used by the healthcare team to provide essential and concise information, usually during crucial situations). The P&P also indicated, "policy interpretation and implementation included, "the nurse will notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition." A review of a facility P&P titled "Pneumonia, Bronchitis, and Lower Respiratory Infections -Clinical Protocol" revised, 2/22/2024, indicated, "as part of assessment and recognition: I. As part of the initial assessment, the physician will help identify residents who have recently had pneumonia or bronchitis and who are at risk for getting respiratory infections (for example, those with COPD or a history of respiratory failure). 2. The staff will identify residents with symptoms that suggest possible bronchitis or pneumonia (for example, dyspnea (at rest and/or on exertion), tachypnea, increased sputum production, chest pain, chronic cough, or hemoptysis [blood in the mucus]). 3. The staff and physician will identify individual risk, such as significant oral or dental disease, presence of a feeding tube, or clinically significant swallowing abnormalities. The P&P also included: "Clinical signs suggesting more severe cases may tachypnea (respiratory rate in the upper 20's [breaths per minute]) with labored [difficult] respirations, unstable vital signs, and a substantial and persistent decline in pulse oximetry results of greater than 3% from baseline." A review of a facility P&P titled, "Resident Examination and Assessment," with a revision date of 2/2014, indicated, "The purpose of this procedure is to examine and asse