Health inspection·August 23, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00901349. Class A Citation was written. Code of Federal Regulations, Title 42, Section 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, including but not limited to the following: California Code of Regulations, Title 22, Section 72311. Nursing Service--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. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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. California Code of Regulations, Title 22, Section 72313. Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. California Code of Regulations, Title 22, Section 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 7/6/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation regarding quality of care. The facility failed to ensure that Resident 1 who had a change in condition (CIC- is a sudden significant deviation from a patient's baseline in physical, cognitive mental ability to make decisions), manifested by chest congestion (abnormal or excessive accumulation of a body fluid), and productive cough, was assessed without a delay in treatment: The failed to: 1. Ensure Licensed Vocational Nurse (LVN) 3 immediately checked Resident 1's vital signs (blood pressure [BP], heart rate [HR], respirations [RR], oxygen saturation [O2 Sat - amount of oxygen in the blood] and temperature [Temp]) when Certified Nursing Assistant (CNA) 2 informed LVN 3 that Resident 1 had a change in condition on 6/14/2024 at around 7:30 AM. 2. Ensure LVN 3 immediately informed Registered Nurse (RN) 1, who was on duty when Resident 1 had a CIC and Resident 1's chest was congested and had a productive cough (a cough that produces mucus) on 6/14/2024 at around 7:30 AM. 3. Ensure RN 1 immediately checked and assessed Resident 1's BP, HR, RR, O2 Sat, and Temp, and performed chest auscultation (listening to the sounds of the lungs and heart) in accordance with the resident's care plan (CP- a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), after LVN 3 informed RN 1 that Resident 1 had a productive cough on 6/14/2024 at 10 AM. 4. Ensure RN 1 immediately notified a medical doctor (MD) or the nurse practitioner (NP- a nurse with advanced clinical education and training) and provided an accurate assessment report that Resident 1 had a CIC with productive cough and chest congestion on 6/14/2024 at around 7:30 AM. These deficient practices resulted in 7 hours 10 minutes delay of necessary medical services for Resident 1. On 6/14/2024 at 2:30 PM, Resident 1 was found unresponsive (when a person does not react or able to react in a normal way when touched, spoken to) in the facility. On 6/14/2024 at 2:40 PM, Resident 1 was transferred to a general acute care hospital (GACH) via 911. The GACH diagnosed Resident 1 with septic shock (a life-threatening condition in which a widespread infection caused organ failure and dangerously low blood pressure) and severe dehydration (a life-threatening emergency that happens when the body's response to an infection damages vital organs and, often, causes death). Resident 1 died on 6/16/2024 at 3:23 PM, two days following transfer to the GACH. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on 7/28/2023 and was readmitted on 12/23/2023 with diagnoses including heart transplant (the patient's own heart is either removed and replaced with the donor heart), immunodeficiency (decreased ability of the body to fight infections and other diseases) due to drugs, essential hypertension (high blood pressure), chronic kidney disease stage 4 (longstanding disease of the kidneys leading to renal failure), and quadriplegia (complete or partial loss of muscle strength that affects all four limbs and body from the neck down). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST - is a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him or herself) dated 7/20/2023, indicated, Resident 1 selected "Do Not Attempt Resuscitation/DNR (allow natural death)". The POLST Interventions included "Selective Treatment - Goal of treating medical conditions while avoiding burdensome measures... Use medical treatment, intravenous (IV - into a vein [blood vessel] antibiotics (medication to prevent or treat infection), and IV fluids as indicated..." A review of Resident 1's Physician Order Summary Report dated 12/23/2023, indicated, Resident 1 was able to consent and/or participate in treatment plan. A review of Resident 1's Minimum Data Set (MDS - a required standardized assessment and care planning tool) dated 5/1/2024, indicated, Resident 1 was cognitively intact (mental ability to make decisions on activities of daily living), and was dependent on staff for activities of daily living, and used wheelchair for mobility. A review of Resident 1's Nursing Notes dated 6/14/2024 at 10 AM indicated, LVN 3 documented that Resident 1's O2 Sat was 95% (normal between 95% and 100%) on room air. However, the progress notes did not indicate LVN 3, or RN 1 also checked Resident 1's BP, HR, RR, and or assessed the resident's breath sounds (Respiratory sounds, are specific sounds generated by the movement of air through the respiratory system [lungs etc]. Lungs that are functioning normally create a smooth, soft sound, and clear sounds). A review of Resident 1's Nursing Notes on the Change of Condition (COC - is a clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains that, without intervention, may result in complications or death) dated 6/14/2024 at 10 AM, indicated, the licensed nurses did not describe Resident 1's productive cough such as presence of phlegm (thick substance secreted from the lungs and respiratory passages) and frequency that can be indicative of a respiratory problem. The progress notes indicated LVN 3 informed Family Member for Resident 1 (FMR1) that Resident 1 had a productive cough. A review of Resident 1's Nursing Notes on the COC dated 6/14/2024 at 10 AM, indicated, LVN 3 did not document the character, color, and amount of Resident 1's productive cough in accordance with the resident's CP. The progress notes indicated there were no additional orders to identify the root cause of the resident's symptoms of cough and chest congestion. The progress notes indicated LVN 3 informed FMR1 that Resident 1 had a productive cough. A review of Nurse Practitioner (NP) 1 order dated 6/14/2024 at 10:38 AM, indicated RN 1 documented to give Resident 1 Geri-Tussin (medication for cough) 5 milliliters (mL - a unit of measure in fluid volume) by mouth every six hours as needed for cough. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a technique that provides a framework for communication between members of the health care team and used as a tool to foster patient safety) Communication form dated 6/14/2024 at 2:30 PM, indicated, LVN 3 documented that Resident 1 had CIC with congestion, cough, shortness of breath (SOB), tachycardia (HR over 100 beats per minute [bpm]; normal heart rate 60-100 bpm), and difficult to arouse (lack of awareness, alertness, and wakefulness). The SBAR form indicated, Resident 1 had a productive cough (consistency and color not indicated). The SBAR indicated Resident 1's BP was 104/58 millimeters of mercury (mmHg - normal 120/80mmHg), HR was 150 bpm (normal 60-100 bpm), RR was 30 breaths per minute (normal 16-20 breaths per minute) and Temp was 100.3 degrees Fahrenheit (F - unit of measurement: Average normal body temperature 98.6 degrees F). However, there was no SBAR dated 6/14/2024 from 7:30 AM after CNA 3 informed LVN 3 that the resident had a CIC. A review of Resident 1's Care Plan titled "Alteration in respiratory function," dated 6/14/2024 with a re-evaluation date of 6/17/2024, indicated, Resident 1 had an alteration in respiratory function as evidenced by productive cough with SOB and congestion. The CP interventions included to notify the MD to obtain Lab orders, assess Resident 1's productive cough and the character and amount, color, and odor of the sputum, and the resident's breath sounds including RR. A review of MD 1's order documented by RN 1 on 6/14/2024 at 2:50 PM, indicated MD 1 gave an order to transfer Resident 1 to GACH for SOB, lethargy (an unusual decrease in consciousness), desaturation (low oxygen level in the blood) via 911 (the telephone number used to reach emergency medical, fire, and police services). A review of Resident 1's CP titled "Periods of lethargy at risk for fall/injury" dated 6/14/2024 with a re-evaluation date of 6/17/2024, indicated, Resident 1 had periods of lethargy at risk for fall/injury. The CP interventions included to notify the MD if Resident 1 continued to have change in level of consciousness (a state in one's awareness and alertness). A review of Resident 1's CP titled "elevated temperature" dated 6/14/2024 with a re-evaluation date of 6/17/2024, indicated, Resident 1 had an elevated temperature. The CP interventions included to administer prescribed medication, provide cooling measures (unspecified) for comfort, Lab orders, monitor vital signs, and report changes to MD in accordance with the facility's policy and procedure titled "Emergency Care". A review of Resident 1's Nursing Notes dated 6/14/2024 at 2:30 PM, indicated that on 6/14/2024 at 2:30 PM, LVN 3 informed FMR1 via telephone, that Resident 1's condition was deteriorating (worsening/declining), and that resident was unresponsive, was desaturating, was receiving supplemental (extra) oxygen, the resident's HR was 150 bpm, and that the resident was transferred to a GACH Emergency Room (ER) via 911 on 6/14/2024 at 2:30 PM. A review of Resident 1's GACH Emergency Room (ER) records dated 6/14/2024 at 3:15 PM, indicated, Resident 1 arrived to the GACH from the facility on 6/14/2024 (time not specified). The Resident had altered mental status (AMS - a change in mental function) showing symptoms of with lethargy and confusion with a Glasgow Coma Scale (GCS - describes the extent of impaired consciousness) of 7 (GCS score range from 3 to 15; 15 means fully awake, score of 8 or less means person is in a coma [prolonged unconsciousness brought on by illness or injury]). The ER records further indicated the resident required a Bilevel (a pressure-controlled, time-triggered, time-cycled mode of ventilation that allows unrestricted, spontaneous breathing with or without pressure support) Positive Airway Pressure (BIPAP - a small breathing device that helps a person breathe more easily) machine to assist Resident 1 with breathing. A review of Resident 1's GACH ER Laboratory result dated 6/14/2024, indicated, Resident 1 tested positive for COVID-19 (a highly contagious respiratory disease caused by a respiratory virus). A review of Resident 1's GACH ER Lab records dated 6/14/2024 ordered at 3:16 PM, indicated, Resident 1 was positive for Escherichia coli (E. Coli - a bacterial infection in the intestines that causes damage to the kidneys) in the blood, positive for COVID-19 through a nasal swab, and positive for Pseudomonas Aeruginosa (a bacterial infection that can cause pneumonia, and bloodstream infections) in the urine resulting in urinary tract infection (UTI - infection in the urinary system). A review of Resident 1's GACH ER Lab records dated 6/14/2024 at 3:17 PM, indicated, Resident 1's arterial blood gas (ABG - a test that measures the balance of oxygen and carbon dioxide in the body to see how well the lungs are working) was metabolic acidosis (too much acid in the blood interfering), WBC was 10.68 thous/mcL, and lactic acid (a chemical in the body that is produced when cells break down carbohydrates for energy) was 4.2 millimoles per Liter (mmol/L - unit of measurement; normal is between 0.5 and 2.2). A review of Resident 1's GACH ER records dated 6/14/2024 at 3:27 PM, indicated, Resident 1 had an electrocardiogram (ECG or EKG - a quick test to check the heart rhythm), with results of sinus tachycardia (Heartbeat greater than 100 bpm; normal 60 to 100 bpm) at 135 bpm. A review of Resident 1's GACH ER diagnostic records dated 6/14/2024 at 3:40 PM, indicated, Resident 1's chest Xray (CXR) indicated Resident 1 had pulmonary vascular congestion/edema (enlargement of the blood vessels in the lungs), and infection, plus minus atelectatic (collapse of the lungs) changes. A review of Resident 1's GACH recurring laboratory (Lab) results indicated that on 6/14/2024 at 4:58 PM, Resident 1's blood was drawn for white blood count (WBC - cells responsible for fighting infection). The same Lab results indicated Resident 1's WBC was 11.5 thousand/microliter (thous/mcL-unit of measurement: Normal range is between 4.0-10.5 thousand per mcL). A review of Resident 1's GACH ER diagnostic records dated 6/14/2024 at 5:41 PM, indicated, Resident 1's computed tomography (CT - an imaging test that helps detect diseases and injuries in the body) scan of the brain, indicated the resident had bilateral (both sides) mastoid (large bone behind the ear) effusions (accumulation of fluid in response to negative pressure or inflammation). A review of Resident 1's GACH ER diagnostic records dated 6/14/2024 at 5:43 PM, indicated, Resident 1's CT scan of the chest, abdomen, and pelvis indicated the resident had bilateral pneumonia, and volume overload which small ascites (accumulation of fluid in the abdomen) and diffused anasarca (extreme swelling throughout the entire body). A review of Resident 1's GACH ER records dated 6/14/2024 at 6:24 PM, indicated, Resident 1's FMR1, changed Resident 1's code status from DNR to a trial of intubation and aggressive treatment but no chest compressions, shock, or dialysis. The GACH ER records indicated Resident 1 was intubated (tube insertion through mouth or nose down into the windpipe to open the airway so oxygen can get through) due to hypoxemia (low levels of oxygen in the bl