Other·April 29, 2022

F684 § 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. § 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: (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. § 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 2/3/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1’s quality of care and death. The facility failed to ensure Resident 3, who was at risk for cardiac (heart) distress related to chronic kidney disease (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease), received care and services in accordance with professional standards of practice and had an initial care plan with interventions to address Resident 3’s heart condition by failing to: 1. Implement Resident 3’s Physician’s Orders to hold Amiodarone (a medication used to treat certain types of serious [possibly fatal] irregular heartbeat (such as persistent ventricular fibrillation/tachycardia) and to hold the Metoprolol (medication used to treat heart failure and high blood pressure) for heart rate below 60 beats per minute on 1/17/2022 and 1/18/2022.  2. Identify and assess Resident 3’s change of condition related to the resident’s hypertension (high blood pressure, a common condition when the force of blood against the artery wall is too high; hypertension is blood pressure above 130/80 millimeters of mercury [mmHg, a unit of pressure]) when the resident’s blood pressure was elevated at 155/93 mmHg on 1/20/2022. 3. Develop and implement Resident 3’s care plan for significant co-morbidities (the condition of having two or more diseases at the same time, including atrial fibrillation, obesity and kidney disease) and risk for cardiovascular complications (such as hypertension, hypotension [lower than 90/60 mmHg] and cardiac distress). 4. Obtain Resident 3’s vital signs (reflect essential body functions, including heartbeat, breathing rate, temperature, and blood pressure) at the beginning of the night shift (11 PM to 7 AM) on 1/20/2022 when the resident had change of condition, as per facility’s policy. 5. Obtain orders for blood pressure and heart rate parameters requiring notification of Resident 3’s attending physician. As a result, on 1/21/2022 at 4:45 AM, Resident 3 was unresponsive, not breathing, and cardiopulmonary resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) was initiated. Paramedics pronounced Resident 3 deceased at 5:07 AM on 1/21/2022. A review of Resident 3’s Admission Record indicated the facility admitted the resident, an 87-year-old female, on 11/9/2021, with diagnoses including atrial fibrillation (an irregular heart rate), chronic kidney disease (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease), atherosclerosis (fatty deposits in the arteries), and anemia (lack of red blood cells). A review of Resident 3’s Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 11/16/2021, indicated Resident 3 had severely impaired cognition (unable to remember, comprehend, and make decisions). Resident 3’s active diagnoses included coronary artery disease, hypertension, and renal failure. The MDS indicated Resident 3 was expected to return to the community. A review of the Physician’s Order for Resident 3, dated 11/27/2021, indicated to administer Amiodarone (medication to treat certain types of serious [possibly fatal] irregular heartbeat) 200 milligrams (mg) by mouth once daily for atrial fibrillation and to hold if the heart rate was less than 60 beats per minute. A review of the Physician's Order for Resident 3, dated 11/29/2021, indicated to administer Metoprolol (medication is a beta-blocker used to treat chest pain [angina], heart failure, and high blood pressure) 25 mg (half tablet) by mouth twice daily for hypertension and hold if the systolic blood pressure (top number) was less than 110 mmHg, or if the heart rate was less than 60 beats per minute. A review of Resident 3's care plan indicated there were no care plans addressing the resident’s heart disease, hypertension, and use of blood pressure medications. A review of Resident 3’s Medication Administration Record (MAR), dated 1/16/2022 and timed at 7:30 AM, indicated the resident's blood pressure was 85/50 mmHg and Metoprolol was held. For the second dose of the day, scheduled at 5:30 PM, there was an “x.” A review of Resident 3's MAR indicated Metoprolol 25 mg was administered on 1/17/2022, 1/18/2022, and 1/19/2022 at 7:30 AM and 5:30 PM. The MAR indicated the Amiodarone was administered to Resident 3 on these same days. Resident 3’s heart rate was 58 beats per minutes on 1/17/2022 and 56 beats per minutes on 1/18/2022 and Amiodarone was not held as ordered by the physician. On 1/20/2022 at 7:30 AM, Resident's 3 blood pressure was 155/93 mmHg and at 5:30 PM the blood pressure was 147/84 mmHg. A review of Resident 3's nursing Progress Notes on 1/20/2022 indicated there was no documentation the attending physician was notified of the elevated blood pressure at 7:30 AM and at 5:30 PM. A review of Resident 3’s nursing Progress Notes on 1/20/2022 for the 11 PM to 7 AM (1/21/2022), indicated there was no documentation a set of vital signs was taken at the start of the shift at 11 PM or through the night. A review of Resident 3's nursing Progress Notes dated 1/21/2022, timed at 8:22 AM, indicated at 11 PM on 1/20/2022, Resident 3 was sleeping on her back, no distress, no sign of any discomfort. At 2:30 AM, on 1/21/2022, Resident 3 was in bed and observed with movement. At 4:45 AM Resident 3 was unresponsive and not breathing, CPR was initiated, and Code Blue (means that there is an urgent medical emergency for other staff to assist) was called. The paramedics arrived and continued CPR but were unable to revive Resident 3 and paramedics pronounced the resident deceased at 5:07 AM on 1/21/2022. A review of the Certificate of Death dated 1/26/2022 indicated Resident 3’s immediate cause of death was myocardial infarction (heart attack) and coronary artery disease. On 3/3/2022 at 10 AM, during an interview, the Director of Nurses (DON) stated she could not find any notes indicating the physician was notified of Resident 3's changes in blood pressure on 1/16/2022 and 1/20/2022. The DON stated the licensed nurses must notify the physician when the residents have a change of condition. The DON stated the licensed nurses needed to notify the physician when Resident 3's blood pressure was 85/50 mmHg on 1/16/2022 and when the resident refused her medication. On 3/4/2022 at 9 AM, during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not administer the resident's blood pressure medication on 1/16/2022 because the reading was low (85/50 mmHg). LVN 1 stated she was new and did not know she had to notify the physician. LVN 1 stated she did not document in the nursing notes the change or elevation in residents’ blood pressure (155/93 mmHg) on 1/20/2022 and she did not notify the physician. On 3/4/2022 at 3:30 PM, during an interview, LVN 2 was asked what the “x” meant on the MAR on 1/16/2022 at 5:30 PM and LVN 2 stated Resident 3 refused to have her blood pressure taken and the medication. LVN 2 stated she did call the physician to report the resident’s refusing medications but did not document it. On 3/7/2022 at 11 AM, during a telephone interview, LVN 3 stated she was assigned to work with Resident 3 the 11 PM (1/20/2022) to 7 AM (1/21/2022) shift and was not aware Resident 3's blood pressure had been elevated. LVN 3 stated she did not take Resident 3’s vital signs at the beginning of her shift. On 3/16/2022 at 11 AM, during a telephone interview, the DON stated the nurse should have taken Resident 3’s vital signs during the night shift (1/20/2022 -1/21/2022). The DON stated Resident 3’s blood pressure and heart rate needed to be monitored because the resident had an elevated blood pressure in the morning and a change of condition should have been initiated. On 3/16/2022 at 3:30 PM, during a telephone interview, Physician 1 (attending physician) stated he did not recall being notified about Resident 3's change in blood pressure and being low at 85/50 mmHg. Physician 1 stated if he had been notified, he would have ordered for the nurse to re-check the blood pressure and if it remained low, he would have ordered to transfer the resident to a General Acute Care Hospital (GACH). Physician 1 added that if he had been notified about the high blood pressure at 155/93 mmHg, he would have ordered to re-check the blood pressure and if it remained high, then he would have adjusted the medication. On 3/23/2022 at 9:30 AM, during an interview, the DON stated she could not locate Resident 3's care plan for blood pressure medications and the necessary interventions such as calling the physician when there was a drop or increase of the resident’s blood pressure. A review of the facility's policy and procedure titled, "Change of Condition Notification," revised 4/1/2015 indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition such as a significant change in the resident's physical, mental or psychosocial status. The policy indicated notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification was required. A licensed Nurse will document the following: Date, time, and pertinent detail of the incident and the subsequent assessment in the Nursing notes, the time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether order was received. A review of the facility's policy and procedure titled, "Obtaining Vital Signs," revised on 8/22/2019 indicated vital signs are clinical measurements that indicate the state of a resident's basic body functions. Vital signs will be taken with the following frequency but not limited to as ordered by the physician, when there is a change in the resident's condition, and every shift for 72 hours after an incident or unusual occurrence. A review of facility's policy and procedure, titled, "Comprehensive Person-Centered Care Planning," revised November 2018, indicated the facility will provide person centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs or residents in order to obtain or maintain the highest physical, and psychosocial well-being. The baseline care plan summary will be developed and implemented, using the necessary combination of problem specific are plans, within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for the resident, initial goals based on the admission orders, physician orders, social services. The facility failed to ensure Resident 3, who was at risk for cardiac distress related to chronic kidney disease, received care and services in accordance with professional standards of practice and had an initial care plan with interventions to address Resident 3’s heart condition by failing to: 1. Implement Resident 3’s Physician’s Orders to hold Amiodarone and to hold the Metoprolol for heart rate below 60 beats per minute on 1/17/2022 and 1/18/2022. 2. Identify and assess Resident 3’s change of condition related to the resident’s hypertension when the resident’s blood pressure was elevated at 155/93 mmHg on 1/20/2022. 3. Develop and implement Resident 3’s care plan for significant co-morbidities and risk for cardiovascular complications (such as hypertension, hypotension and cardiac distress). 4. Obtain Resident 3’s vital signs at the beginning of the night shift (11 PM to 7 AM) on 1/20/2022 when the resident had change of condition, as per facility’s policy. 5. Obtain orders for blood pressure and heart rate parameters requiring notification of Resident 3’s attending physician. As a result, on 1/21/2022 at 4:45 AM, Resident 3 was unresponsive, not breathing, and CPR was initiated. The paramedics pronounced Resident 3 deceased at 5:07 AM on 1/21/2022. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 3.