Other·April 27, 2023

On 2/4/2023 the California Department of Public Health (CDPH) conducted an unannounced onsite visit to investigate a complaint related to resident services not performed per physician order and resident rights. The facility failed to: 1. Monitor Resident 1 every four hours for a Change of Condition (COC - a deterioration in a resident's physical or mental condition), check vital signs (temperature, blood pressure, heart rate, pulse, and oxygen saturation [amount of oxygen in the blood]), and immediately provide necessary medical services when Resident 1 had an acute medical COC on 5/22/2021 between 8 a.m. and 8:52 p.m. 2. Implement a physician's order to monitor Resident 1 every four hours for COC. Staff identified Resident 1 with increased drowsiness and sleepiness on 5/22/2021 between 8 a.m. and 8:52 p.m. 3. Administer intravenous (IV- into a vein [blood vessel]) fluids timely following a physician's order on 5/22/2021 at 11:12 a.m. These deficient practices resulted in staff finding Resident 1 not breathing and non-responsive (unconscious, and possibly dead or dying) to verbal or painful stimuli (a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli such as shaking of the shoulders) on 5/22/2021 at 8:52 p.m. Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and further care. Resident 1 expired at the GACH on 6/4/2021. A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 10/23/2015 and readmitted Resident 1 on 7/18/2019 with diagnoses including hypothyroidism (a condition when the thyroid gland does not make enough thyroid hormone), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 4/26/2021, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required extensive two staff assist for bed mobility, and dressing, and total dependence for transfers. A review of Resident 1's COC document dated 5/22/2021 timed at 11:50 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1 had gradual (slow progress) altered level of consciousness (AMS - change in mental function that can quickly become life-threatening), and was groaning (deep suffering), weak, drowsy, and responded to verbal and tactile (having to touch) stimuli by moving the resident's hands. The COC indicated Resident 1 was offered but pushed away medication, food, and water. LVN 1 documented he (LVN 1) left a message for a physician to call LVN 1 back and notified Resident 1's family member on 5/22/2021, at 11 a.m. The COC indicated "MD (medical doctor) called back (unspecified time) and ordered unspecified IV hydration (fluid) and unspecified blood work to be collected on 5/24/2021 for Resident 1. The COC indicated Resident 1's blood pressure (BP) was 145/90 millimeters of mercury (mmHg, normal BP -120/80 mmHg). A review of Resident 1's Order Listing Report dated 5/20/2020 to 6/20221, indicated to "monitor abnormal signs/symptoms every shift for ... AMS." The order listing report further indicated "if ... including AMS ... increase monitoring to every four hours" for Resident 1. A review of Resident 1's physician order dated 5/22/2021 timed at 11:12 a.m., indicated to "administer D51/2NS (Dextrose and Salt - IV replacement fluid/blood volume expander), at 50 cubic centimeter (cc- unit of measurement) per hour times two liters today (5/22/2021) and tomorrow (5/23/2021) every shift for hydration until 5/23/2021 ... 400 cc per shift (eight hours in a shift)." A review of Resident 1's IV Administration Treatment Record for 5/2021, indicated to start "D51/2NS at 50 cc per hour times two liters today (5/22/2021) and tomorrow (5/23/2021) for increase in sleepiness every shift for hydration until 5/23/2021 ... 400 cc per shift" to start on 5/22/2021 at 3 p.m. for Resident 1. The IV administration treatment record indicated "X" on 5/22/2021 for the day shift (7 a.m. to 3 p.m.) and indicated number "6" and "X" on 5/22/2021 for the evening shift (3 p.m. to 11 p.m.). The IV administration treatment record chart code "X" indicated not administered or not ordered for that time frame and number "6" indicated "Hospitalized" for Resident 1. A review of Resident 1's "Health Status Note" dated 5/22/2021 timed at 3:53 p.m., indicated a RN (Registered Nurse) "started new peripheral IV (PIV- away from the center of the body IV) after three attempts to right forearm ... with good venous (vein blood) return." The health status note indicated flushed (clear out) IV access with 10 milliliters (ml - unit of measurement) ... The health status note did not indicate when or if the IV fluid (D51/2NS) was started or administered to Resident 1, or if the RN assessed and recorded Resident 1's vital signs (temperature, blood pressure, pulse, respiration, and oxygen saturation [amount of oxygen in the blood]). A review of Resident 1's "Health Status Note" dated 5/22/2021 timed at 4 p.m., indicated an RN documented unspecified IV fluid was started at 4 p.m., was infusing (administer into a vein) well for Resident 1. The health status note did not indicate if the RN assessed Resident 1 for COC or recorded Resident 1's vital signs between 8 a.m. to 8:52 p.m. A review of Resident 1's medical chart, did not indicate if an RN assessed Resident 1 for COC or Resident 1's vital signs on 5/22/2021 between 8 a.m. and 8:52 p.m. A review of Resident 1's "Health Status Note" dated 5/22/2021 at 8:52 p.m., indicated an RN documented that an unnamed Certified Nursing Assistant (CNA) called the aforementioned RN to check on Resident 1 on 5/22/2021 at 8:30 p.m. The health status note indicated Resident 1 was not breathing and was non-responsive to verbal or painful stimuli, BP 95/48 mmHg and paramedics (a trained staff to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) called. ... The health status note further indicated the paramedics arrived on 5/22/ 2021at 8:45 p.m. and assessed Resident 1. The health status note indicated Resident 1 was transported to a GACH on 5/22/2022 at 8:45 p.m. A review of Resident 1's GACH Emergency Department (ED) Notes signed by an RN dated 5/22/2021 timed at 9:38 p.m., indicated Resident 1 was altered, bradycardic (slow heart rate [pulse]), and hypotensive (low blood pressure) ... Left pupil (the center eye through which the light passes through) blown (largely dilated and unresponsive to light) and right pupil pinpoint (remain very small even in bright light)." A review of Resident 1's GACH "Department of Emergency (ED) Medicine Treatment" record dated 5/23/2021 timed at 4:58 a.m., indicated Resident 1 was brought to the ED with complaint of AMS since 6 p.m. The ED medicine treatment note indicated that per Emergency Medical Services (EMS - emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport a person to further care). Resident 1 was bradycardic as low as 35 beats per minute (bpm). The ED medical treatment record further indicated the following interventions were implemented for Resident 1 on 5/22/2021: -Two (2) liters IV bolus (free flowing) 0.9% Sodium Chloride (NaCL - salt and water) at 9:15 p.m. and 10:32 p.m., -Zosyn (medication to treat infection) Intravenous Piggy Bag (IVPB) 3.375 grams (gm - unit of measurement); and -Vancomycin (medication to treat infection) IVPB 1000 mg at 10:05 p.m. A review of Resident 1's GACH "Neurology Consultation Note" dated 5/22/2021, indicated Resident 1 was brought in by EMS on 5/22/2021 at 6 p.m. Resident 1 was hypotensive (low blood pressure), obtunded (diminished responsiveness to stimuli), not following commands and a concern for sepsis (the body's extreme response to an infection and is a life-threatening medical emergency) of unknown source and the physician was unable to obtain Resident 1's mental status. Resident 1 was diagnosed with AMS. A review of Resident 1's GACH "Neurology Consultation Note" dated 5/22/2021, indicated Resident 1 was discharged 6/4/2021 and discharge disposition was Resident 1 expired (died). On 2/14/2023 at 10:30 a.m., during an interview, the facility's Assistant Medical Records Director (AMRD) stated the facility did not create a care plan for drowsiness or sleepiness based on Resident 1's COC dated 5/22/2021. The AMRD stated care plans are important for directing and revising care for a resident as needed. On 3/2/2023 at 2 p.m., during a concurrent interview and record review with LVN 1, Resident 1's COC document dated 5/22/2021 at 11:50 a.m. was reviewed. LVN 1 stated Resident 1 was usually alert, oriented times two to three (name, date/year/ location), was able to feed herself, and enjoyed coloring activities. LVN 1 stated on 5/22/2021 between 8 a.m. and 9 a.m., CNA 1 notified him (LVN 1) that Resident 1 did not eat breakfast and was very sleepy. LVN 1 stated he assessed Resident 1, and Resident 1 was drowsy (sleepy and lethargic- lack of mental alertness), was responding to tactile and verbal stimuli but kept "going back to sleep." LVN 1 stated Resident 2 "was raising her hands to push food away." LVN 1 stated he did not call 911 (a phone number used to contact the emergency service) to transfer Resident 1 to a GACH because Resident 1 was still responding to tactile and verbal stimuli but kept going back to sleep. LVN 1 stated he contacted Medical Doctor 2 (MD 2 - the on call physician) and "I left a message" on 5/22/2021. LVN 1 stated he informed a supervisor (unidentified) to expect a call back from MD 2. On 3/6/2023 at 10:40 a.m., during a concurrent interview and record review with the Assistant Director of Nursing (ADON), Resident 1's COC dated 5/22/2021 timed at 11:50 a.m., was reviewed. The ADON stated the facility should record vital signs as soon as a resident is identified with a COC. The ADON stated the facility's Medical Director should be contacted and notified of a resident's COC if the primary physician does not call back within 30 minutes. The ADON stated, "with a significant change in condition like [Resident 1's COC], I would immediately send the resident out with paramedics to the hospital." The ADON further stated IV fluids should be started "right away" as soon as the order is received. The ADON stated Resident 1's COC was identified between 8 a.m., and 9 a.m. on 5/22/2021, after Resident 1 was found collapsed (loss of consciousness) in bed. The ADON stated Resident 1's "delayed quality of care was avoidable." The ADON stated Resident 1's progress notes did not indicate if the facility notified the Medical Director that Resident 1 had a COC. The ADON stated, "I don't see much documentation. There is no telling what could have happened. There should have been more frequency in documentation" for Resident 1. On 3/7/2023 at 2:30 p.m., during an interview, Registered Nurse Supervisor (RNS) stated, "IV fluids should be started as soon as I get the order." RNS stated when a resident has a COC for AMS "[ the facility] must call 911 immediately. We don't have to wait for the doctor." On 3/16/2023 at 4:06 p.m., during an interview and record review with the ADON, Resident 1's Medication Administration Record (MAR) for the month of 5/2021 was reviewed. The ADON stated, "I do not believe the resident [Resident 1] received IV D51/2NS ordered by the physician on 5/22/2021 on the 3 p.m. to 11 p.m. shift." The ADON further stated that the licensed staff should document if any IV fluid or medications are pulled from the facility's Emergency Kit (Ekit). The ADON stated the licensed should have documented the specific IV fluid infusing on the progress notes and also on the current IV MAR for Resident 1. The ADON stated an "X" marked on a MAR indicated that a medication or IV fluid was not administered or not ordered for that time frame. The ADON stated that code number "6" on the MAR indicated a resident was hospitalized. The ADON stated licensed staff should contact the pharmacy for authorization to pull IV fluids or medications from the Ekit. The ADON stated the pharmacy verifies a physician's order and then provides the facility with an authorization document number to pull IV fluid or medications from the facility's Ekit. A review of the facility's RN Job Description revised 8/2011, indicated ... the following: "6. Evaluates and monitors residents' condition and provides professional nursing care ... 8. Initiates emergency support measures ... and physician orders 10. Performs assessment functions including identification changes in the resident's physical or psychological condition (i.e., changes in lab data, vital signs, mental status). 14. Administers medications ordered by the physician." A review of the facility's policy and procedures titled "Physician Orders, Accepting, Transcribing and Implementing (Noting)," revised on 11/2012, indicated, "licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented." ... "2. If medication is available in Emergency Box, the first dose may be obtained from the box ..." A review of the facility's LVN Job Description updated 8/2021, indicated ... the LVNs "performs interventions and treatments in a timely manner." A review of the facility's policy and procedures (P&P), titled "Change of Condition, Resident," revised 11/2017, indicated "it is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner." The P&P included: "1. Upon noting or receiving report of a change a resident's physical, mental or psycho social status, the licensed nurse will evaluate the resident's condition. 2. In the event of a life-threatening situation or serious injury, the charge nurse may elect to contact personnel services to assist with care and possible transport to an acute hospital ... 6. Continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed, until the acute episode has subsided, and the resident is stable." The facility failed to: 1. Monitor Resident 1 every four hours for a COC and the check vital signs, and immediately provide necessary medical services when Resident 1 had an acute medical COC on 5/22/2021 between 8 a.m. and 8:52 p.m. 2. Implement a physician's order to monitor Resident 1 every four hours for COC. Resident 1 was identified with increased drowsiness and sleepiness on 5/22/2021 between 8 a.m. and 8:52 p.m. 3. Administer IV fluids timely following a physician's order on 5/22/2021 at 11:12 a.m. These deficient practices resulted in staff finding Resident 1 not breathing and non-responsive to verbal or painful stimuli a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli such as shaking of the shoulders on 5/22/2021 at 8:52 p.m. Resident 1 was transferred to a GACH for evaluation and further care. Resident 1 expired at the GACH on 6/4/2021. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.