Health inspection·July 26, 2024

F580 Patient Rights/Exercise of Rights §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the patient; consult with the Patient’s physician; and notify, consistent with his or her authority, the patient representative(s) when there is (B) A significant change in the Patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the patient from the facility as specified in §483.15(c)(1)(ii).

F684

F684 Quality of Care § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices, including but not limited to the following:

F697

F697 Pain Management §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. 22 CCR § 72315 (e) Nursing Service - Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 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. 22 CCR §72309. Nursing Service. Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. 22 CCR § 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. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. Findings On 6/7/24 at 6pm, California Department of Public Health (CDPH) conducted an unannounced visit to conduct an annual recertification survey. During the survey, the CDPH conducted a closed record review and interview regarding the quality of life, quality of care and death of a patient (Patient 1). Based on observation, interview, and record review, the facility failed to ensure Patient 1, who was recently hospitalized for a change in mental status and diagnosed with Transient Ischemic Attack (TIA a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain) and cerebral vascular accident (CVA-or stroke also called ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced), received treatment and care in accordance with professional standards of practice, facility's policy and procedure by ensuring the physician was immediately notified when Patient 1 had a significant change of condition and exhibited new pain, moaning, fidgeting (small movements due to feeling uneasy or nervous) increased heart rate (HR), decreasing blood pressure (BP), and agitated by failing to: 1.Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 assessed and monitored Patient 1 for signs and symptoms of TIA and Stroke such as change in mental status. 2. Ensure LVN 1 assess and notify the Physician 1 and Registered Nurse (RN1) when Patient 1 was observed with decreased BP from 128/62 mm Hg (millimeter mercury) to 90/46 mm Hg and HR 82 beats per minute (BPM), increased to 106 BPM to provide necessary interventions for the significant change in VS (measurement of the BP, HR, respiratory rate [RR] and body temperature) on 5/2/2024 at 5:47 PM. 3. Ensure LVN 1 assessed Patient 1's the source of pain notified Physician 1 and Registered Nurse 1 when Patient 1 was observed fidgeting, agitated and with pain assessed at level of 7 out of 10 (pain scale 0-no pain to 10-severe pain) to determine the source of pain on 5/2/2024 at 9:03 PM. 4. Ensure LVN 2 did not wait 13 minutes before calling LVN 3 for assistance and calling the paramedics ( a medical personnel that responds to medical emergency) via 911 when Patient 1 was found without BP and unresponsive to verbal and tactile stimuli and respiratory rate decreased to 8 BPM on 5/3/2024 at 12:30 AM. 5. Develop a plan of care for Patient 1 to address how the patient will be monitored and assessed for TIA and CVA and A-Fib. As a result of these deficient practices, Patient 1 did not receive the immediate emergency interventions to ensure the mental status and vital signs (measurement of the blood pressure, heart rate, respirations, and body temperature) return to baseline status. Patient 1's vital signs and mental status continued to decline which was not reassessed and Patient 1 was pronounced dead by the paramedics on 5/3/2024 at 12:43 AM. A review of Patient 1 's Admission Record indicated patient was admitted to the facility on 3/7/2024, and readmitted on 5/1/2024 with diagnoses that included aftercare following surgery on the digestive system, insertion of gastrostomy ([G-tube] a soft tube surgically placed into the stomach for the introduction of nutrition and medication), atrial fibrillation (irregular heart rhythm and rate) and dysphagia (difficulty swallowing) following cerebral infarction (also known as stroke occurs when a blood supply to part of the brain is blocked or reduced causing altered mental status and brain cells to die). A review of Patient 1's History and Physical Examination dated 3/8/2024 indicated patient did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS a patient assessment and care screening tool) dated 3/11/2024, Patient 1 had severe cognitive (ability to process information) impairment and required set up and clean up help with eating and maximum assistance with personal hygiene. A review of Patient 1's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel knows what treatments the patient wants in the event of a medical emergency) signed by the responsible party for Patient 1 on 4/30/2024 and signed by Physician 1 but not dated, indicated do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), instead Patient 1 selected to receive care for comfort to relieve pain and suffering with medication, use oxygen, suction, and manual treatment of airway obstruction. A review of the General Acute Care Hospital (GACH) Discharge Summary dated 5/1/2024 indicated, Patient 1 was admitted to the GACH on 4/7/2024 for evaluation of patient’s altered mental status after a fall at the facility. The GACH record indicated at baseline Patient 1 was able to answer yes or no but at the time of the assessment in the GACH, Patient 1 was nonverbal (unable to talk) and unable to provide medical history. The GACH record indicated Patient 1 had acute (sudden onset) to subacute (recent of somewhat rapid onset) small infarct (blockage of blood flow to the brain) in the brain likely due to atrial fibrillation, myocardial infraction (MI) which "most likely due to hypotension (low blood pressure) causing the fall." A review of Patient 1's care plans from 5/1/2024 to 5/3/2024 indicated no documented evidence that a care plan was developed to address interventions related for cerebral infarction and atrial fibrillation and hypotension. A review of Patient' 53's Order Summary Report from 5/1/2024 to 5/3/2024 indicated the following: 1. The physician ordered on 5/1/24 at 5:22 PM for Patient 1 to receive Tylenol (Acetaminophen) 325 mg 2 tablets via G-tube every 4 hours as needed for mild pain (1-3) not to exceed 3 grams ([gm] unit of measure) every 24 hours. 2. The physician ordered on 5/1/24 at 6:13 PM for Patient 1 to receive Ativan (Lorazepam) one tablet by mouth every 4 hours as needed for anxiety (feelings of having the fear of the unknown) manifested by physical aggression towards staff. A review of Patient 1's Vitals Summary Report from 5/1/2024 to 5/3/2024 indicated Patient 1 had blood pressure and heart rate as follows: 1. On 5/1/24 timed at 4:55 AM Patient 1 BP was 128/62 and a HR of 82 bpm 2. On 5/1/24 timed at 6:27 AM Patient 1's BP was 124/65 and a HR of 61 bpm. 3. On 5/1/24 timed at 7:24 AM Patient 1's BP decreased to 115/68 and HR increased to 101 bpm. [TL1][GG2][GG3] 4. On 5/2/2024 timed at 5:47 PM, the BP decreased to 90/46 and HR increased to 106 bpm. No documented evidence in Patient 1’s clinical record that Physician 1 was notified of the Patient’s significant change in the BP and HR. 5. On 5/3/2024 timed at 4:11 AM, (ten hours after the BP and HR was last checked[TL4]) Patient 1 was found by LVN 2 to be unresponsive to tactile stimuli and no BP when checked and RR was 8 breaths per minute. After 13 minutes on 5/3/24 Patient 1 was noted without pulse and not breathing. 6. On 5/3/24 timed at 7:09 AM, Patient 1 was pronounced dead by the paramedics. LVN 2 wrote Physician 1 was notified of Patient 1's death. A review of Patient 1's Medication Administration Record (MAR) for 5/2024, indicated on 5/2/2024 at 9:03 PM, Patient 1 was given Tylenol 325 mg for a pain level of 7 out of 10. A review of the Progress Notes, dated 5/1/2024 timed at 10:51 PM, indicated Patient 1 was admitted to the facility from the GACH, awake, responsive to verbal and tactile stimuli, patient was unable to speak, oriented to name, breathing is even and unlabored, no visible distress. A review of Patient 1's Progress notes indicated on 5/2/24 timed at 3:51 AM LVN 2 wrote Patient 1 was received with eyes open and nonverbal (unable to speak), when patient’s name was called patient with frowned face and with intermittent crying like sounds, grimacing and was unable to respond to LVN 2. LVN 2 wrote Patient 1 tried to interfere with staff when attending to G-Tube, “seen putting hands out trying to keep staff from accessing G-tube. Vital Signs obtained and within normal limits, needs met and anticipated. Will reach out to Medical Doctor for stronger pain medication. Will continue to monitor." A review of Patient 1's Progress Notes indicated on 5/2/2024 timed at 4AM, LVN 2 wrote Patient 1 was administered Ativan (medication used to relieve anxiety) oral (by mouth) tablet 0.5 MG (milligrams-a unit of measurement) for anxiety manifested by physician aggression towards the staff. A review of Patient 1's Progress Notes indicated on 5/2/2024 timed at 1:18 PM indicated Patient 1 was given Tylenol 325mg, 2 tablets via G-Tube due to facial grimacing and moaning, repositioning the patient was ineffective. A review of Patient 1’s Progress Notes, on 5/2/2024 at 5:47 PM, had no documented evidence an assessment and intervention was conducted, when Patient 1’s BP decreased to 90/46 and HR increased to 106 bpm. A review of Patient 1's Progress Notes indicated on 5/2/2024 timed at 11:56 PM, LVN 2 wrote "Patient 1 received in bed, eyes open, appearing weak, no moaning during initial rounds. Per LVN 1, Patient 1 had been moaning earlier in her shift." A review of Patient 1's Progress Notes indicated on 5/3/2024 timed at 4:11 AM, LVN 2 wrote on 5/3/2024 at 12:30 AM, indicated Patient 1 noted with “diminished respirations 8 RR per minute, with an oxygen saturation (oxygen blood level) level of 95% (normal range 90-100%) in room air, both eyes not opening with tactile stimuli or verbal commands, BP could not be obtained raised foot of the bed and retook several times and was unsuccessful.” LVN 2 wrote oxygen at 2 liters via NC was applied and after 13 minutes Patient 1’s respiration ceased (stopped) and patient had no pulse. The Progress Note indicated LVN 2 "sent immediately for crash cart, applied CPR board to Patient 1's back, and began CPR (due to POLST not being signed by Physician 1, Patient 1 was still considered a full code despite it having been marked as do not resuscitate (DNR), at LVN 3 called 911." The note indicated LVN 2 continued to perform CPR until paramedics pronounced Patient 1 expired at 12:43 AM. A review of Patient 1's Progress Notes indicated on 5/3/2024 timed at 7:09 AM, LVN 2 wrote Physician 1 was notified of Patient 1's death. A review of the Death Certificate indicated Patient 1 expired on 5/3/24 at 00:43 AM, with the primary cause of death of cerebrovascular disease, atrial fibrillation, and hypertension. During a telephone interview on 6/7/2024 at 1:46 PM, LVN 2 stated on 5/3/2024 at around midnight she checked Patient 1 in her room to give her medications. LVN 2 stated she checked Patient 1's blood pressure but did not register a BP reading on the pressure gauge (the part of the blood pressure device that show the measurement of the BP reading[TL5][GG6]). LVN 2 stated Patient 1 was staring at the ceiling and was not responsive when spoken to or when touched, and she observed Patient 1’s breathing was diminished. LVN 2 stated when she could not obtain Patient 1's BP reading, so she elevated Patient 1's legs. LVN 2 stated she called LVN 3 to help, and then she placed a pulse oximeter (a non-invasive medical device to measure the amount of oxygen in the blood) on Patient 1's finger which read oxygen saturation level was 100%, and the heart rate was 70 BPM, and she observed Patient 1’s breathing continued at less than 12 breaths per min. LVN 2 stated she used another electrical and manual BP checking device to check Patient 1's BP but still could not get a BP reading. LVN 2 stated she gave Patient 1 an oxygen therapy via nasal cannula "because it was one of our (the facility's) protocols." LVN 2 stated "the biggest thing was how I could not get her blood pressure and after 13 minutes, then Patient 1's respirations ceased (stopped) and she went on full on cardiac arrest (the heart stopped beating and circulation of blood to the body stopped)." LVN 2 stated she did not immediately notify Physician 1 of Patient 1's change in condition because "I was doing my nursing interventions." During an interview on 6/7/2024 at 3:32 PM, LVN 1 stated on 5/2/2024 during the 3 PM to 11 PM shif