Other·September 9, 2022

42CFR §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. 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. On 6/16/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding the death of a resident and the lifesaving interventions taken by the facility. The facility failed to provide cardiopulmonary resuscitation (CPR - refers to any medical intervention used to restore circulatory [the system that moves blood throughout the body] and/or respiratory [breathing in and out] function that has stopped) to Resident 4. Resident 4's Advance Directive (a legally and ethically binding document used by people to state that their medical and end-of-life treatment decisions will be made by someone on their behalf when they become severely ill) Acknowledgment form, signed on 2/19/2020, which was the most current and updated document, indicated Resident 4 was a full code (if a person's heart stopped beating or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The facility failed to update the physician’s order changing the code status of Resident 4 to full code to reflect what was indicated in Resident 4’s Advance Directive Acknowledgment form (signed on 2/19/2022). As a result, on 7/16/2022 at 11:45 p.m., Certified Nursing Assistant 1 (CNA 1) saw Resident 4 sitting down in her wheelchair in her room unresponsive, called Licensed Vocational Nurse 1 (LVN 1), and did not provide CPR to Resident 4. On 7/17/2022 at 12 a.m., Physician 1 pronounced Resident 4 dead. A review of Resident 4's Admission Record indicated the facility originally admitted the 66-year old female resident on 8/22/2018 and was re-admitted on 7/13/2022 with diagnoses including COVID-19 (a highly infectious disease that is spread from person to person through droplets released when an infected person coughs, sneezes, or talks), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar). A review of Resident 4's Physician Orders for Life-Sustaining Treatment (POLST - is a written medical order from a physician, nurse practitioner or a physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness), dated 6/1/2019, indicated the following: 1. Do not attempt resuscitations. Allow natural death. 2. Comfort-focused treatment - primary goal of maximizing comfort. 3. No artificial means of nutrition, including feeding tubes (medical device used to provide nutrition to people who cannot obtain nutrition by mouth). The POLST indicated, "POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts .... A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D (A-instruction about CPR, B-Medical Interventions, C-Artificially Administered Nutrition, and D-Information and Signatures), writing "VOID" in large letters, and signing and dating this line." A review of Resident 4's physician's order, dated 8/19/2019, indicated Do Not Resuscitate (DNR - directs healthcare providers not to administer CPR in the event of cardiac [pertaining to heart] or respiratory [pertaining to the lungs] arrest). A review of Resident 4's Advance Directive Acknowledgment form, signed by Resident 4 on 2/19/2020 and signed by both Social Services Director 2 (SSD 2) and Physician 1 on 7/16/2020, indicated the "Preferred Intensity of Care Authorization / Decisions" are the following: - Yes to cardio-pulmonary resuscitation; - Yes to hospitalization; - Yes to intravenous fluids (IV fluids - fluids delivered to the body through a small tube inserted into a vein); - No to tube feeding; - No to medication restriction; - No to treatment restriction; - No to palliative care (comfort care with or without curative intent); - No to hospice care (comfort care without curative intent); and - CPR for 15 minutes only. A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/16/2022, indicated the resident had the ability to make self understood and understood others. The MDS indicated Resident 4 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene, and bathing; used a wheelchair (a chair with wheels used when walking is difficult or impossible due to illness or injury) and a walker (a device that gives additional support to maintain balance while walking). A review of Resident 4's physician's order, dated 7/1/2022 at 1:17 p.m., indicated an order for Resident 4 to undergo right total hip arthroplasty surgery (hip replacement) on 7/5/2022 at General Acute Care Hospital 1 (GACH 1). A review of Resident 4's Progress Notes, dated 7/1/2022 at 4:43 p.m., indicated Resident 4 left for surgery on 7/1/2022 at 4:10 a.m. to GACH 1. A review of Resident 4's Progress Notes, dated 7/11/2022 at 5:45 pm, indicated Registered Nurse 2 (RN 2) documented that at the facility Resident 4 was noted to be very sleepy and lethargic (slow or sleepy), unable to keep eyes open, and not able to answer questions appropriately. RN 2 notified Physician 1 and Physician 1 put in a new order to transfer Resident 4 to GACH 2 and RN 2 called 911 (emergency medical services). A review of Resident 4’s physician’s order, dated 7/11/2022 at 7: 15 p.m., indicated an order for Resident 4 to be transferred to GACH 2. A review of Resident 4's Progress Notes, dated 7/17/2022 at 12:53 a.m., indicated LVN 1 documented that CNA 1 found Resident 4 in her room unresponsive on 7/16/2022 at 11:45 p.m. with absent radial pulse (pulse taken from the wrist) and apical pulse (heartbeat heard in the left center of your chest, just below the nipple). The Progress Notes indicated on 7/17/2022 at 12 a.m., Resident 4 was pronounced dead. During a record review on 8/5/2022 at 9:55 a.m., with the Assistant Director of Nursing (ADON), Resident 4's chart (a three-ring binder used to hold resident's paper medical records which can be found in the nurses station) was observed with POLST, signed by Resident 4 on 6/1/2019, on top of the Advance Directive Acknowledgment form signed by Resident 4 on 2/19/2020. During a concurrent interview and record review of the POLST and Advance Directive Acknowledgment form, the ADON stated that she believed that LVN 1, who took care of Resident 4 on 7/16/2022, followed the POLST, dated 6/1/2019, that indicated DNR because it was what the LVN 1 first saw. The ADON stated that because there were two documents indicating two different things, it confused the nurse. The ADON stated that if it were her, she would have followed the most recent document which was the Advance Directive Acknowledgment form indicating Resident 4 was a full code. The ADON stated that because Resident 4 was a full code, and was found unresponsive on 7/16/2022 at 11:45 p.m., LVN 1 should have started CPR while another nurse called 911. During an interview on 8/5/2022 at 12:06 p.m., Physician 1 stated Resident 4 was his patient. Physician 1 stated he cannot remember the specific times when the documents were made or signed, but what he knew was that people can change their minds. Physician 1 stated if he was looking at the two documents (POLST and Advance Directive Acknowledgment form), he would go for the most recent one (Advance Directive Acknowledgment form). During an interview on 8/5/2022 at 1:15 pm, the DON stated she would have followed the POLST signed by Resident 4 on 6/1/2019 because it was in Resident 4's chart and the Advance Directive Acknowledgment signed by Resident 4 on 2/19/2020 was in the old chart (chart that was kept by the medical records department). During a concurrent record review, Resident 4's POLST was on top of the Advance Directive Acknowledgment form on both the old chart and Resident 4's current chart. The DON stated Resident 4's POLST indicated DNR, but Resident 4's Advance Directive Acknowledgment indicated full code. The DON stated that with two conflicting documents, the facility should have done an interdisciplinary (resident or resident representative, DON, social worker, physician) meeting with the resident to clarify Resident 4's wishes. The DON stated the conflicting documents confused staff and led to Resident 4’s wishes not being followed. The DON stated that based on Resident 4's Advance Directive Acknowledgment form signed on 2/19/2020, the resident wanted CPR for fifteen minutes which meant chest compressions and breaths for 15 minutes, to receive intravenous fluids which meant that Resident 4 wanted fluids that go through the vein, no treatment restriction, no medication restriction, no palliative care, no hospice care, and wanted hospitalization if the facility found Resident 4 in distress. During an interview on 8/5/2022 at 2:22 p.m., and concurrent record review of the Advance Directive Acknowledgment and POLST, SSD 1 stated the Advance Directive Acknowledgment and POLST go together as part of the resident admission packet and were created together at the same time and should have matching information. SSD 1 stated she was not employed yet at the time Resident 4 created the Advance Directive Acknowledgment that Resident 4 signed on 2/19/2020. SSD 1 further stated that once residents created and signed the Advance Directive Acknowledgment and POLST, the forms would be flagged (in a three-ring binder, only the middle and bottom holes of the paper are filed so that a portion of the paper is showing or sticking out of the binder) for the physician to sign. SSD 1 stated that it should have been a team effort of the social services, nursing, and medical records departments to ensure that these forms were accurate and signed by the resident and physician. SSD 1 stated there was an absence of a POLST that should have complemented Resident 4's Advance Directive Acknowledgment that Resident 4 signed on 2/19/2020. SSD 1 stated that it was important that the Advance Directive Acknowledgment and POSLT have matching information, but because Resident 4's chart did not have matching information in the Advance Directive Acknowledgment and the POLST, it created conflicting information which led to not respecting Resident 4's wishes. During a telephone interview on 8/5/2022 at 2:39 p.m., LVN 1 stated that on 7/16/2022 between 9:30 p.m. to 9:45 p.m., LVN 1 saw Resident 4 was seated in a wheelchair next to Resident 4's bed watching television. LVN 1 stated that on 7/16/2022 between 10:35 p.m. to 10:50 p.m., CNA 1 told LVN 1 to check on Resident 4. LVN 1 stated that CNA 1 and LVN 1 went to check on Resident 4 and saw Resident 4 in a sitting position with upper body leaning forward and the resident was not responding to CNA 1 and LVN 1 calling Resident 4's name and patting Resident 4's shoulders. LVN 1 stated he then left the room to get blood pressure machine and pulse oximeter machine (a device used to measure oxygen saturation) and told another staff to call 911. LVN 1 stated he went back to Resident 4's room and checked Resident 4's blood pressure and oxygen saturation. LVN 1 stated Resident 4 had no carotid pulse (pulse felt on a person ' s neck), no blood pressure, and no oxygen saturation. LVN 1 stated that LVN 1 and CNA 1 then transferred Resident 4 to Resident 4's bed. LVN 1 stated that RN 1 came into the room and checked Resident 4's pulses and did not feel any pulses. LVN 1 stated LVN 1 called and informed Physician 1 of Resident 4's condition and Physician 1 pronounced Resident 4 dead on 7/17/2022 at 12 a.m. LVN 1 stated that when the paramedics arrived, LVN 1 informed the paramedics that Resident 4 was pronounced dead by Physician 1. LVN 1 stated that LVN 1 did not check Resident 4's POLST and assumed Resident 4 was DNR. LVN 1 stated that staff did not do CPR. LVN 1 stated that if CPR was not done it meant that staff did not try to revive Resident 4. During an interview on 8/5/2022 at 4:15 p.m., and concurrent record review of the POLST (dated on 6/1/2019) and Advance Directive Acknowledgment form (signed on 2/19/2020), Medical Records Director (MRD) stated staff could have crossed out the old POLST. The MRD stated there was no documented evidence there was a correction made for the inconsistencies of the POLST and Advance Directive Acknowledgment. During an interview on 8/6/2022 at 8:12 a.m., and concurrent record review of the POLST (dated on 6/1/2019) and Advance Directive Acknowledgment form (signed on 2/19/2020), RN 2 stated whoever did the Advance Directive Acknowledgment form did not create an updated POLST. RN 2 stated medical records staff should have audited (physically checking records to ensure accuracy) the chart and if the discrepancy was found, should have clarified the conflicting information with Resident 4. During an interview on 8/7/2022 at 12:02 p.m., the DON stated Resident 4 got COVID-19 on 7/11/2022 and Resident 4 was asking to be sent to GACH 1. The DON stated the facility transferred Resident 4 to GACH 1 on 7/11/2022 but discharged against medical advice and was readmitted back at the facility on 7/13/2022. The DON stated this readmission was a missed opportunity to clarify with Resident 4 her code status as to whether resident was DNR or full code. A review of the facility's current policy and procedures (P&P), dated 12/2016, titled, "Advance Directives," indicated, "Advance directives will be respected in accordance with state law and facility policy ... 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so ... 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives ... 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive ...11. A resident will not be treated against his or her own wishes ... 18. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS) ... 20. The director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care...." A review of facility's current P&P, dated 2/2018, titled, "Emergency Procedure - Cardiopulmonary Resuscitation," indicated, "1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system code (code) and call 911; b. Instruct a staff member to retrieve the automatic external defibrillator (AED - sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm); c. Verify or instruct a staff member to verify the DNR or code status of the individual; d. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as "C-A-B" (chest compressions, airway, breathing)