Health inspection·October 31, 2024

42 CFR § 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. 22 CFR §72311 - Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 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. (c)(2)(D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 9/16/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) expired in the facility on 9/15/2024, at approximately 11 a.m. On 9/17/2024, the CDPH conducted an unannounced visit at the facility to investigate the FRI. During the visit, CDPH discovered Licensed Vocational Nurse (LVN) 2 did not reassess Resident 1 after a change of condition ([COC] a sudden or gradual change in a patient’s physical, cognitive, behavioral, or functional status). The facility failed to: 1. Ensure LVN 2 reassessed Resident 1 and promptly notified Resident 1’s physician after a COC of wheezing (when breathing becomes difficult due to narrowed or blocked airways in the lungs), vomiting, and sweating on 9/15/2024, at 8:00 a.m. 2. Document Resident 1’s vital signs after treatments for a COC of shortness of breath, wheezing, vomiting, and sweating were observed. As a result, on 9/15/2024, at 10:57 a.m., Resident 1 expired, approximately 3 hours after she was observed with shortness of breath, wheezing, vomiting, and sweating. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1 was a 78-year-old female initially admitted to the facility on 5/12/2021, and last readmitted on 5/15/2023, with diagnoses including hydrocephalus (a condition in which fluid accumulates in the brain), diabetes mellitus (when the body is unable to control the amount of glucose in the blood), aphasia (a language disorder that affects a person’s ability to understand and express written and spoken language), gastro-esophageal reflux disease (a chronic condition that occurs when stomach contents leak into the esophagus, causing irritation), gastrostomy ([G-tube] a surgical opening in the stomach for nutrition, hydration, and medication), and right sided hemiplegia (in ability to move one side of the body) and hemiparesis (weakness to one side of the body). A review of Resident 1’s care plan titled, “At risk for aspiration (when food, liquid, or other material is inhaled into the lungs), dehydration, and tube feeding intolerance…,” dated 5/16/2023, indicated Resident 1 will be free from signs and symptoms of dehydration daily. The staff interventions indicated to observe and report signs and symptoms of tube feeding intolerance such as nausea and vomiting, aspiration, choking, cough, change of level of consciousness, increase in shortness of breath, wet voice, gurgled sounding voice, and congestion. A review of Resident 1’s care plan titled, “Impaired nutritional and hydration status related to dependence on enteral feed (a method of delivering nutrients and fluids directly into the digestive system through a tube)” dated 5/16/2023, indicated Resident 1 will show evidence of good hydration. The staff interventions included to observe and report coughing, choking, vomiting, congestion, gurgling sounding voice, cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood), runny nose, teary eyes, increase in temperature, throat clearing, shortness of breath, rhonchi (abnormal breath sounds that resemble snoring or gurgling)/wheezing to the physician promptly. A review of Resident 1’s History and Physical (H&P), dated 5/13/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool) dated 8/12/2024, indicated, Resident 1’s cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 was dependent on staff for personal hygiene, showering, and dressing. The MDS indicated Resident 1 required the use of tube feeding (a method of providing nutrition, fluids, and medications directly into the stomach through a tube). A review of Resident 1’s “Order Summary Report”, indicated active orders as of 9/15/2024, indicated to administer Tylenol (medication used to relive mild pain) 325mg 2 tablets via G-tube every 6 hours as needed for fever, Ipratropium-Albuterol Solution (a medication that dilates the airways of the lungs) 0.5-2.5 milligram ([mg] a unit of mass or weight) per (/) milliliter ([ml] a unit of measurement), inhale orally every 4 hours as needed for shortness of breath, wheezing, and congestion via nebulizer (a small machine that turns liquid medicine into a mist that be easily inhaled) and Zofran (a medication used to prevent nausea and vomiting) 4mg 1 tablet via G-tube every 4 hours as needed for nausea and vomiting. A review of Resident 1’s “Change in Condition Evaluation,” dated 9/15/2024, at 8:00 a.m., indicated Resident 1 had an episode of wheezing, vomiting of clear mucous (viscous [thick] secretions produced by the mucous membranes [moist inner linings of nose, mouth, lungs, and stomach]), and sweating. The COC Evaluation indicated Resident 1’s physician was not notified. A review of Resident 1’s “Paramedic Run Sheet,” dated 9/15/2024, at 10:29 a.m., indicated, 911 (an emergency number for any police, fire, or medic) was called at 10:29 a.m. Paramedics arrived at the facility at 10:35 a.m. and continued cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure that is done when breathing or heartbeat has stopped). Paramedics pronounced Resident 1 deceased at 10:57 a.m. A review of Resident 1’s “Progress Notes, dated 9/15/2024 at 11:15 a.m., indicated, Resident 1 had wheezing, sweating, and vomited at 7:45 a.m. The Progress Notes indicated Resident 1 was “treated for the symptoms, reassessed, and administered 2 liters (L, unit of measurement) of oxygen.” During an interview on 9/17/24, at 1:28 p.m., Certified Nursing Assistant (CNA) 3 stated Resident 1 was total care (provides all the care for a patient during their shift). CNA 3 stated on 9/15/2024, at 7:45 a.m., Resident 1 looked tired and had lots of saliva (a bodily fluid) coming out of her mouth. CNA 3 stated she reported Resident 1's condition to LVN 2. CNA 3 stated LVN 2 gave Resident 1 a breathing treatment around 8:00 a.m. CNA 3 stated she found Resident 1 unresponsive around 10:13 a.m. and called for help. During a telephone interview on 9/18/2024, at 3:07 p.m., LVN 2 stated on 9/15/2024, at 7:40 a.m., CNA 2 notified her (LVN 2) that Resident 1 vomited and was sweating. LVN 2 stated she assessed Resident 1 and observed Resident 1 had shortness of breath, was wheezing and sweating. LVN 2 stated she observed vomit on Resident 1's shirt and on the side of Resident 1's mouth. LVN 2 stated on 9/15/2024, at 7:50 a.m., she administered Ipratropium-Albuterol Solution 0.5-2.5 mg/ml, Zofran, and Tylenol. LVN 2 stated at 7:51 a.m., she removed Resident 1's blankets. LVN 2 stated at 8:04 a.m., she took Resident 1' s vital signs (measurements of the body's basic functions) and the readings were as follows: 1. Blood pressure was 128/62 millimeters of mercury ([mm/hg] a unit of measurement for pressure, normal range 120/80mm/hg). 2. Pulse was 68 (a measurement of a patient's heart rate, normal range 60-100 beats per minute). 3. Respirations was 22 (number of breaths per minute, normal range 12 to 20). 4. Temperature was 98.5 Fahrenheit (a scale for measuring temperature, normal range 97F to 99F). 5. Oxygen saturation was 95 percent (%) (measures how much oxygen is in the blood, normal range 95% to 100%). LVN 2 stated there were no documented follow-up vital signs after interventions and treatment were provided to Resident 1. LVN 2 stated, "If it was not documented then it was not done." LVN 2 stated she did not notify Resident 1's physician of the change of condition because she wanted to administer medications to the other residents in the facility. LVN 2 stated Resident 1's airway should have been the priority. LVN 2 stated it was very important to reassess the resident to assess the effectiveness of the interventions. LVN 2 stated not reassessing and not notifying the physician placed Resident 1 at risk for worsening of her condition. During a telephone interview on 9/19/2024, at 11:15 a.m., Registered Nurse (RN) 1 stated LVN 2 did not report that Resident 1 had shortness of breath, wheezing, vomited and was sweating. RN 1 stated Resident 1's symptoms were considered a change of condition. RN 1 stated once the medications were given to Resident 1, LVN 2 should have reassessed Resident 1 at least 15 minutes after the breathing treatment was administered. RN 1 stated LVN 2 should have reassessed Resident 1's oxygen saturation again after 30 minutes. RN 1 stated LVN 2 should have reassessed and monitored Resident 1 in 15 to 30 minutes intervals to see if the interventions were effective. RN 1 stated the interventions should have been documented in detail, and the physician notified when the symptoms were identified. RN 1 stated if the physician was called another treatment such as an X-ray (used to create images of the inside of the body to help diagnose and treat a variety of conditions) could have been ordered. RN 1 stated due to Resident 1's risk for aspiration the X-ray would show if Resident 1 had an infection or aspirated (the act of breathing in food or liquid into the lungs). RN 1 stated LVN 2's failure to notify the physician when Resident 1 was observed with shortness of breath, wheezing, vomiting, and sweating, might have resulted in Resident 1's death. During a concurrent interview and record review on 9/19/2024, at 2:30 p.m., with the Assistant Director of Nursing (ADON), Resident 1's care plan titled, "At risk for aspiration, dehydration, and tube feeding intolerance ...," dated 5/16/2023, and "Impaired nutritional and hydration status related to dependence on enteral feed," dated 5/16/2023, were reviewed. The ADON stated Resident 1 was at risk for aspiration. The ADON stated the care plan interventions indicated to call Resident 1' s physician promptly for signs and symptoms of shortness of breath, wheezing, and vomiting. The ADON stated Resident 1's physician was not notified for the signs and symptoms to be corrected with new interventions, and possibly new physician orders. During a concurrent interview and record review on 9/19/2024, at 2:40 p.m., with the ADON, Resident 1's "Change in Condition Evaluation," dated 9/15/2024, was reviewed. The ADON stated Resident 1's physician was not notified of Resident 1's change of condition. The ADON stated the physician should have been called as soon as possible because Resident 1 was vomiting and sweating. The ADON stated 30 minutes after treatment, a new set of vitals should have been documented and Resident 1 should have been reassessed. The ADON stated Resident 1 was found unresponsive at 10:13 a.m. and was pronounced dead at 10:57 a.m. The ADON stated if the physician was notified earlier, the physician would have probably ordered a stat (immediately without delay) X-ray to rule out aspiration to prevent worsening the condition of Resident 1. During a concurrent interview and record review on 9/19/2024, at 2:50 p.m., with the ADON, Resident 1's "Progress Notes," dated 9/15/2024, at 11:15 a.m. was reviewed. The ADON stated reassessing a resident within 30 minutes after interventions were performed is a generalized standard of practice. The ADON stated the vital signs were not documented and that meant the vital signs were not done. The ADON stated auscultation (listening to the sounds of the body) of Resident 1's lung sounds were not documented, and it was unclear if the treatment was effective. During a review of the facility's policy and procedure (P&P) titled, "Charge Nurse," dated 2003, indicated, the Charge Nurse was delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties. The P&P indicated to charge nurses notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. The P&P indicated to notify the resident's attending physician and next of kin when there is a change in the resident's condition and ensure that residents who are unable to call for help are checked frequently. The P&P indicated to review care plans daily to ensure that appropriate care is being rendered, inform the Nurse Supervisor of any changes, and ensure the nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. During a review of the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition or Status," dated 5/2017, indicated, prior to notifying the physician the nurse will make detailed observations and gather relevant and pertinent information. The P&P indicated the staff will monitor and document the resident's progress and response to treatment and the physician will adjust accordingly. The facility failed to: 1. Ensure LVN 2 reassessed Resident 1 and promptly notified Resident 1’s physician after a COC of wheezing, vomiting, and sweating on 9/15/2024 at 8:00 a.m. 2. Document Resident 1’s vital signs after treatments for a COC of shortness of breath, wheezing, vomiting, and sweating were performed. As a result, Resident 1 expired, at 10:57 a.m., approximately 3 hours after she was observed with shortness of breath, wheezing, vomiting, and sweating. 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 the violation was a substantial factor in the death of Resident 1.