Health inspection·September 29, 2023

On 8/22/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation. The facility failed to report unexpected death of Resident 3 within 24 hours to the California Department of Public Health (CDPH) in accordance with the facility's policy and procedures titled, "Unusual Occurrence Reporting" revised 12/2007. As a result of the investigation, the Department determined the facility did not have complete and accurate documented evidence surrounding Resident 3's death that occurred in the facility on 6/12/2023. A review of Resident 3's Admission Record indicated the facility admitted Resident 3 on 11/12/2021 with diagnoses including aphasia (difficulty speaking) following cerebral infarction (stroke), diabetes mellitus (a chronic, metabolic disease characterized by elevated levels of blood sugar), Alzheimer's disease (progressive mental decline due to generalized breakdown of the brain), hypertension (high blood pressure), calculus of ureter (formation of stone in urinary tube) , anemia ( low red blood cells), osteoarthritis (the breakdown of joint cartilage add underlying bone), hypothyroidism (abnormally low activity of the thyroid gland) and radiculopathy of the lumbar region (inflammation of a nerve root in the lower back). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/18/2021, indicated Resident 3's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. In addition, Resident 3 was totally dependent and required full staff assistance to perform bed mobility, dressing, eating and toilet with the assistance of one person. A review of Resident 3's physician order dated 12/15/2021 indicated Resident 3 was a full code (if a person's heart stopped beating and or they stopped breathing, all resuscitation procedures will be provided to keep them alive). A review of Resident 3's change in condition form (COC - a form that details a decline or improvement in a resident's condition that may require a change in treatment) dated 6/12/2023 timed at 2 p.m., indicated Resident 3 was having shortness of breath (SOB - difficulty breathing) and 911 (emergency medical response telephone number that dispatches paramedics to the location of the emergency) was called. The paramedics (a medical professional who specializes in emergency treatment) intubated (a process where a healthcare provider inserts a tube through the person's mouth or nose, then down into their windpipe/airway to assist with breathing) Resident 1 at the facility. No other information was included/documented on the COC. During an interview on 8/22/2023 at 3:20 p.m., the registered nurse supervisor (RNS) confirmed she did not document lifesaving treatment provided to Resident 3 on 6/12/2023. RNS stated she was consumed with calling 911 and trying to reach the family of Resident 3. RNS stated she should have documented the details of treatment rendered in the nursing progress notes. During a concurrent interview and record review on 8/22/2023 at 3:44 p.m., Resident 3's nursing progress notes dated 6/12/2023 were reviewed. Licensed vocational nurse 1 (LVN 1) stated the progress notes indicated Resident 3 was noted with SOB, called 911 who responded right away, performed intubation suctioning (the removal of secretions from the lungs of a patient with an artificial airway in place) "but the resident did not" ... end of note. No further documentation noted on this date regarding this incident. LVN 1 assessed the resident and found Resident 3 having shallow, fast respirations and appeared to be in distress. LVN 1 was unable to obtain Resident 3's blood pressure using a manual blood pressure cuff (tightening a strap around the patient's arm and slowly increasing the pressure with a handheld pump to measure the blood pressure) and the O2 saturation (a measure of how much oxygen is circulating in the blood, normal levels are between 95 and 100%) was 89%. LVN 1 stated the paramedics arrived shortly after, connected Resident 3 to an ECG (electrocardiogram-records the electrical signal from the heart to check for different heart conditions) monitor which indicated Resident 3's heart beat had stopped and then the paramedics started CPR (cardiopulmonary resuscitation-life saving techniques of pumping on chest to restore blood circulation and delivering breaths in the absence of spontaneous breathing). LVN 1 stated the CPR was unsuccessful and Resident 3 died. LVN 1 was asked why her actions were not documented and stated it was the facility practice when in an emergent situation the RNS was responsible documenting all treatments rendered. During an interview on 8/23/2023 at 11:58 a.m., the director of nursing (DON) was not working at the facility on 6/12/2023 when Resident 3 was found unresponsive. The DON was asked if the incident should have been reported to the Department and stated, "No, it should not have been reported because the police would conduct their own investigation." The DON was not able to provide any documented evidence that facility reported Resident 3's death to the Department. A review of the facility's policy and procedures titled, "Unusual Occurrence Reporting" revised 12/2007, indicated, "death of a resident, employee, or visitor because of unnatural causes (e.g., suicide, homicide, accidents, etc.). Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event should be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. The administration to keep a copy of written reports on file." A review of the facility's undated policy and procedures titled, "Charting and Documentation" statement indicated, "... Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. ... . 4. Entries included in the resident's clinical record should be made, by a licensed personnel (e.g., [example] RN ... LVN ... .". The facility failed to report unexpected death of Resident 3 within 24 hours to CDPH in accordance with the facility's policy and procedures titled "Unusual Occurrence Reporting" revised 12/2007. As a result of the investigation, the Department determined the facility did not have complete and accurate documented evidence surrounding Resident 3's death that occurred in the facility on 6/12/2023. The above violation had a direct or immediate relationship to the health, safety, or security of all 62 residents residing in the facility.