Health inspection·January 3, 2025

F580 §483.10(g)(14) Notification of Changes. (i)A facility must immediately inform the resident; consult with the resident’s physician; andnotify, consistent with his or her authority, the Patient representative(s) when there is: (B)A significant change in the resident’s physical, mental, or psychosocial status (that is, adeterioration in health, mental, or psychosocial status in either life-threatening conditions orclinical 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).

F695 §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a Patient who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the patients’ goals and preferences, and 483.65 of the subparts. On 12/3/2024 at 8:30 AM, an unannounced visit was made to the facility to conduct the facility’s Annual Recertification Survey. During the investigation, the California Department of Public Health (CDPH) conducted a closed record review regarding the quality of life and quality of care and death of Patient 1. As a result of the investigation, it was determined that the facility failed to provide the necessary respiratory care and implement interventions in accordance with the patient's needs, care plan, facility policy and the physician's order for Patient 1 who had a diagnoses of chronic obstructive pulmonary disease exacerbation [COPD, sudden worsened or severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath (SOB), difficulty breathing and respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty, breathing)]. The facility failed to: 1. Monitor and evaluate if the oxygen provided was effective to relieve the patient's respiratory distress and oxygenation in accordance with the patient's care plan for COPD and physician's orders, when Patient 1 experienced shortness of breath (SOB), labored breathing (taking more effort to breath than usual), and oxygen saturation (blood oxygen level) decreased to 72% (normal range 90-100%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 liters per minute (L/min) on 11/14/2024 at 11:05 PM. 2. Follow physician orders to titrate (adjust) Patient 1's oxygen therapy at 2-5 L/min to maintain oxygen blood levels of 92% when Patient 1's oxygen saturation decreased to 72% on 11/15/2024 at 12:10 AM, while receiving 2 L/min of oxygen via NC. 3. Ensure Licensed Vocational Nurse (LVN) 6 monitored and documented Patient 1's respiratory distress, treatments provided, and report Patient 1's change in respiratory condition to the physician, in accordance with the physician orders and the facility's policy and procedure. 4. Notify the physician and call 911 emergency services immediately, when Patient 1 complained of not being able to breathe and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on 11/15/2024 at 12:10 AM. 5. Ensure the physician was informed that Patient 1 refused to go to the hospital while complaining of not being able to breathe and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on 11/15/2024 at 12:10 AM. As a result of these deficient practices, Patient 1 did not receive immediate respiratory care and interventions on 11/14/2024 from 11:05 PM when the patient was initially observed with respiratory distress, labored breathing, and decreased level of oxygenation, until 11/15/2024 at 2:29 AM when the paramedics pronounced Patient 1 dead after providing unsuccessful CPR [cardiopulmonary resuscitation, an emergency treatment for someone who stopped breathing or heartbeat has stopped by providing chest compression (pressing on the chest over the heart), and rescue breathing (mouth-to-mouth resuscitation)]. A review of Patient 1's "Admission Record (AR)," indicated Patient 1 was a 77-year-old male who was admitted to the facility on 9/4/2024 and readmitted on 10/6/2024 with diagnoses that included COPD with exacerbation pneumonia, hypertensive heart disease (a condition of having high blood pressure), and type 2 diabetes mellitus (condition of having high blood sugar) and septic shock. A review of Patient 1's "Physician Orders for Life-Sustaining Treatment (POLST- a medical order that documents a patient's preferences for end-of-life care)," dated 9/5/2024, indicated if the patient was found with a pulse and/or was breathing, full treatment was ordered for medical interventions including intubation (a tube placed in the mouth to the airway to provide oxygenation), advanced airway interventions (a tube place in the airway), mechanical ventilation (assisted breathing provided with the use of a machine), and cardioversion (a medical procedure that restores a normal heart rhythm by using electricity or medication to treat an abnormal heart rhythm). A review of Patient 1's "Order Summary Report (OSR)," indicated on 10/6/2024 Patient 1 had physician orders to monitor for signs and symptoms of respiratory distress that included monitoring for pulse oximetry (a device used to monitor oxygen blood level), lethargy (a state of unusual drowsiness, fatigue, and lack of energy and mental alertness), accessory muscle usage (breathing using muscles other than those typically used for breathing to take in and expel air) and to document with hashmarks in the clinical record of the patient if present and report to the physician. The physician also ordered to titrate oxygen at 2-5 L/min via NC continuously to maintain oxygen saturation at 92 % or above, and to notify the physician if oxygen saturation was below 92% for SOB. The OSR indicated "in the event of an emergency, the Medical Director may be called if the attending physician or alternate physician are not available." A review of Patient 1's "History and Physical Examinations," dated 10/7/2024, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's OSR, indicated on 10/22/2024, Patient 1 had a physician order for "Full Code" [a medical order that instructs the health care team to perform all possible life-saving measures if the patient goes into cardiac or respiratory arrest (when the heart stopped beating or the patient stopped breathing)]. A review of Patient 1's "Physician Progress Note," dated 11/7/2024, indicated Patient 1 "exhibited alertness and cognitive ability to effectively communicate needs and his language comprehension and response during assessments were appropriate." The notes indicated Patient 1 "continued under monitoring for anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) and has declined hospitalization despite the recommendation, understanding the associated risks and benefits." A review of Patient 1's "Physician Progress Note," dated 11/7/2024, indicated when confronted with acute medical symptoms or conditions necessitating immediate attention for Patient 1, the staff has received explicit instructions to promptly trigger emergency medical services (EMS- a system that provides emergency medical care to patients after an incident of serious illness or injury) via 911 and direct the patient to the emergency department. These symptoms and conditions encompass, though are not confined to exacerbation (severe symptoms) of asthma. A review of Patient 1's Care plan, dated 11/8/2024, indicated Patient 1 had exacerbation (worsened symptoms) of COPD manifested by wheezing (a high-pitched, whistling sound that occur during breathing when the airways in the lungs become narrowed or blocked) with the goal that the patient would display optimal breathing patterns daily. The care plan interventions included to give aerosol (a substance released in very fine mist) or bronchodilations [a medication that makes breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)] as ordered by the physician and monitor/document any side effects and effectiveness, to monitor for difficulty breathing on exertion, and to administer oxygen via nasal cannula at 2 L/min. A review of Patient 1's OSR, indicated on 11/10/2024, Patient 1 had a physician order for Ipratropium-Albuterol (a medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing) 3 ml inhale orally every 6 hours as needed for shortness of breath/wheezing for 14 days. A review of Patient 1's "Progress Notes," dated 11/15/2024, indicated on 11/14/2024 at 11:05 PM, during an initial assessment Licensed Vocational Nurse (LVN) 6 noted Patient 1 was in bed asleep but responsive to verbal stimuli with no complaint of pain or discomfort. The note indicated on 11/15/2024 at 12:10 AM, Patient 1 was sitting on his bed and verbalized "I can't breathe, I need a breathing treatment," breathing was labored with oxygen saturation was at 72%. The note indicated LVN 6 administered a breathing treatment and offered to transfer the patient to the hospital of which Patient 1 declined and on 11/15/2024 at 12:30 AM, Patient 1 verbalized "thank you, I'm feeling better." The Progress Notes indicated on 11/15/2024 at 1 AM, Patient 1 was asleep with eyes closed and receiving continuous oxygen at 2 L/min, then at 1:55 AM, LVN 6 was alerted to Patient 1's room by Certified Nurse Assistant (CNA) 4, that Patient 1 was unresponsive without chest movement and no pulse, CPR was initiated and 911 was called. The Progress Notes indicated on 11/15/2024 at 2:10 AM, the paramedics arrived and took over the CPR and Patient 1 was pronounced dead at 2:29 AM, and the physician was notified via telephone text on 11/15/2024 at 3:16 AM. A review of Patient 1's "Medication Administration Record (MAR)" for November 2024, indicated on 11/15/2024 at 12:10 AM, Ipratropium-Albuterol Inhalation Solution medication was given to Patient 1 for SOB (shortness of breath/wheezing). A review of "Paramedic Run Report," dated 11/15/2024, indicated Patient 1 "presented warm, pupils were fixed (indication of no brain activity), in asystole (no heart rhythm) and for the duration of CPR." The report indicated, Patient 1 "remained in asystole with no changes after given 3 Epinephrine (the primary drug administered during CPR to reverse cardiac arrest) doses and was pronounced dead at 2:29 AM after 20 minutes of high-quality CPR." The report indicated, "staff stated the patient (Patient 1) is being seen at this facility for COPD and possible pneumonia. Pt (patient) was advised to go to the hospital by staff numerous times for better care and treatment but declined for a week. Patient 1 was given a breathing treatment by staff at midnight with no improvement and was found not breathing at around on 11/15/2024 at 2 AM. Staff immediately began CPR and called 911. CPR taken over by EMS on 11/15/2024 at 2:09 AM." During an interview on 12/4/2024 at 4:37 PM , CNA 4 stated, when she came to work on 11/14/2024 at around 11:06 PM and did her facility round (the practice of checking in on all patients under the CNA’s care), Patient 1 did not respond when she tried to greet him, his eyes were closed, and he was "breathing very fast." CNA 4 stated, Patient 1 was receiving oxygen supplement "with a tube in his nose." CNA 4 stated, LVN 6 told her that Patient 1 was not feeling well and that she should keep an eye on Patient 1. CNA 4 stated, she checked Patient 1 "several times" and observed Patient 1's breathing "was getting loose and loose to the point of no breathing anymore," and his facial expression was flat. CNA 4 stated, she did not monitor for Patient 1's vital signs (measurement of the blood pressure, heart rate, respiratory rate, and body temperature) or oxygen saturation because it was the charge nurse's responsibility. CNA 4 stated, she asked LVN 6 to come and check on Patient 1 because she had to attend another patient. CNA 4 stated, LVN 6 went to see Patient 1 and she went to another patient's room to give care. CNA 4 stated, when she came out of the other patient's room, she saw LVN 4 bringing in "a big oxygen tank" to Patient 1's room. When she looked in Patient 1's room, LVN 4 told her that the patient was "dead." CNA 4 stated she recalled LVN 4 performing CPR on Patient 1, CNA 4 did not assist in Patient 1's room because she was busy with the other resident. During an interview on 12/4/2024 at 5:09 PM , LVN 6 stated, when he first checked on Patient 1 at the start of his shift on 11/14/2024 at around 11 PM, Patient 1's vital signs including the oxygen saturation was around 94-95% while Patient 1 was receiving 2 L/min oxygen via NC. LVN 6 stated, Patient 1 was breathing "heavily, and very labored." LVN 6 stated, about an hour later, Patient 1 told him "I can't breathe, I want my breathing treatment." LVN 6 stated he checked Patient 1's oxygen saturation, and it was at 72%. LVN 6 stated, he asked Patient 1 if he wanted to be transferred to the hospital, but Patient 1 stated "No," meaning he didn't want to go the hospital, so LVN 6 gave Patient 1 Albuterol breathing treatment as ordered by the physician. LVN 6 stated, after the treatment, Patient 1's oxygen saturation went up, "but not that high, to 75-78%." LVN 6 stated, he asked Patient 1 again if Patient 1 wanted to be transferred to the hospital, Patient 1 stated "No." LVN 6 stated, after the breathing treatment was given, he put Patient 1 back to continuous oxygen at 3 L/min via NC. LVN 6 stated, he did not recheck Patient 1's vital sign when Patient 1 had an episode of decreased oxygen saturation of 72%, and he did not recheck and monitor Patient 1's oxygen saturation after giving Patient 1's breathing treatment when the oxygen saturation increased to 75-78%. LVN 6 stated, at nighttime, the staff does not call the physicians if there are concerns or significant change of conditions (COC) with the patient, rather the staffs communicate with the physicians by texting messages on the phone, then wait for the physicians to call back. LVN 6 stated he did not document Patient 1's significant change of condition, and notify the physician via text or call, or call 911 regarding Patient 1's labored breathing, low oxygen level, changes in the respiratory and refusal to go to the hospital because Patient 1 had a behavior of refusing to be transferred to the hospital and because LVN 6 believed tha