Other·June 4, 2021

F580 (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’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 resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is— (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9). F-656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. § 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 3/11/2021 an unannounced visit was made to the facility to investigate two complaints about quality of care. The facility failed to develop and implement a comprehensive person-centered care plan for Resident 1 in violation of its policies and procedures by failing to do the following: 1. Develop and implement a care plan when Resident 1 got a positive laboratory result for Coronavirus Disease 2019 (COVID-19, a highly contagious respiratory disease that spreads from person to person) on 2/5/2021. There was no care plan developed on 2/5/2021 to 2/10/2021. 2. Implement Resident 1's care plan to monitor, document, and report change of condition to physician when Resident 1 had a blood pressure of 80/49 millimeter of mercury (mmHg - unit of pressure; normal range of 90 to 120/60 to 80 mmHg) and heart rate of 52 beats per minute (bpm - normal range of 60-100 bpm) on 2/7/2021 at 5:54 pm. 3. Implement Resident 1's care plan to observe for signs and symptoms of decline and change in condition, and report to physician. 4. Implement Resident 1's care plan to monitor abnormal signs and symptoms every four hours if positive for COVID-19 on 2/5/2021 to 2/10/2021. As a result, Resident 1’s medical condition deteriorated and the resident expired on 2/10/2021 at 5:50 pm at the facility due to cardiopulmonary arrest (the heart suddenly stops beating) and COVID-19. A review of the Admission Record indicated the facility admitted Resident 1 on 1/17/2021 with diagnoses that included acute cystitis (sudden inflammation of the bladder), type 2 Diabetes Mellitus (high sugar in the blood), and a history of falling. A review of Resident 1's Initial History and Physical (a reference document that provides concise information about a patient's history and exam findings at the time of admission), dated 1/17/2021, indicated Resident 1 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 1/24/2021, indicated Resident 1 had the ability to make herself understood and the ability to understand others. The MDS indicated Resident 1 needed extensive assistance and one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 1's Patient Report indicated Resident 1's laboratory specimen for COVID-19 was collected on 2/4/2021 and results reported 2/5/2021 as positive for COVID-19. A review of Resident 1's Weights and Vitals Summary indicated that on 2/7/2021, at 5:54 pm, Resident 1 had a blood pressure of 80/49 mmHg and heart rate of 52 bpm. During an interview on 3/11/2021, at 3:59 pm, the Infection Preventionist (IP) stated that signs and symptom monitoring and vital signs were taken every four hours in the red zone (area with confirmed COVID-19 positive residents) and yellow zone (area with unknown COVID-19 viral status) which included Resident 1. The IP stated, "I am not sure why it was not done for this resident." During an interview and concurrent record review on 3/11/2021, at 4:29 pm, the Assistant Director of Nursing (ADON) stated vital signs were taken every four hours in the red zone and yellow zone but the ADON was unsure why it was not done for Resident 1. The ADON stated the following Weights and Vitals Summary of Resident 1 from 2/5/2021-2/10/2021: 2/5/2021- monitored/documented three times 2/6/2021- monitored/documented two times 2/7/2021- monitored/documented two times 2/8/2021- monitored/documented once 2/9/2021- monitored/documented two times 2/10/2021 - monitored/documented once, at 10:03 am. During an interview on 3/11/2021, at 4:45 pm, and concurrent record review, the Director of Nursing (DON) stated that on 2/7/2021 there was no Change of Condition (COC) nor progress notes done for Resident 1 regarding the low blood pressure and low heart rate. The DON stated there was no documented evidence that Resident 1 had a care plan for being positive for COVID-19. During a phone interview on 4/1/2021, at 3:00 pm, and concurrent record review, the DON stated that looking at Resident 1's trend, a blood pressure of 80/49 mmHg and a heart rate of 52 bpm were abnormal, and therefore the physician should have been notified. The DON stated there was no documented evidence that the physician was notified or that interventions were implemented regarding the low blood pressure and low heart rate on 2/7/2021. During a phone interview and concurrent record review on 4/2/2021, at 12:48 pm with Medical Doctor 1 (MD 1), MD 1 stated she was not notified of the abnormal values on 2/7/2021. MD 1 stated she had no documented evidence to show she was notified of Resident 1's COVID-19 positive status on 2/5/2021. MD 1 stated that for a resident who was newly diagnosed with COVID-19 with or without symptoms, she would order medications, laboratory works, and a chest x-ray. During an interview on 5/6/2021, at 1:45 pm, the DON stated when Resident 1 became positive with COVID-19, there was no plan of care developed. The DON stated that the resident was supposed to have a care plan that addressed the COVID-19 diagnosis. A review of Resident 1's Order Summary indicated an order started on 1/17/2021 to: Monitor abnormal signs and symptoms every shift or if COVID-19 positive every four hours: temperature, chills, respiratory rate, oxygen saturation (amount of oxygen carried in the blood), headache, change in mental status, shortness of breath, heart rate, cough, sore throat, rhinorrhea (runny nose), chest pain, diarrhea, nausea, vomiting, loss of taste and smell, fatigue, and muscle ache. If one of the following, altered mental status, respiratory rate above 22, systolic (the top number) blood pressure below 100, oxygen saturation below 92%, bluish lips/face: increase monitoring to every four hours. Report change to physician immediately. If two or more of the situations above, call the physician every shift to be done until COVID requirement ends. A review of Resident 1's care plan titled, "Code Status-Resident chose attempt resuscitation, full treatment," initiated on 1/21/2021 indicated a list of interventions including, "Monitor/document/Report prn (as needed) change of condition to physician and responsible party .... Observe for signs and symptoms of decline/change in condition and report to physician." A review of Resident 1's care plan titled, "Resident has had exposure to Coronavirus 19," initiated on 1/29/2021 indicated that the goal was for Resident 1 to receive monitoring and care per Centers of Disease Control and Prevention (CDC) guidelines and resident wishes. Identified interventions included " ...if COVID positive, monitor every 4 hours: temperature, chills, respiratory rate, oxygen saturation, headache, change in mental status, shortness of breath, heart rate, cough, sore throat, rhinorrhea, chest pain, diarrhea, nausea, vomiting, loss of taste/smell, fatigue, muscle ache." A review of the Nursing Progress notes, dated 2/10/2021, indicated Resident 1 was pronounced dead by paramedics on 2/10/2021, at 5:50 pm at the facility. A review of the death certificate, issued on 3/31/2021, indicated Resident 1 died on 2/10/2021 at 5:50 pm due to cardiopulmonary arrest (the heart suddenly stops beating) and COVID-19. A review of facility's policy titled, "Change of condition, Resident," revised 11/2017 indicated that it is the policy of the 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 procedure to follow has six steps. Number two indicates "after assuring the resident's safety, notify the resident's physician of the clinical findings and note/implement new orders given by the physician ... number five indicates document assessments and interventions on the clinical record...." A review of the facility's policy titled, "Care Plan, Baseline and Comprehensive" revised 11/2017, indicated it is the policy of the facility to develop, upon admission and following completion of the Admission Nursing Assessment, an interim and comprehensive care plan for the resident. A comprehensive person-centered care plan consistent with residents’ rights will include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to develop and implement a comprehensive person-centered care plan for Resident 1 by failing to do the following: 1. Develop and implement a care plan when Resident 1 got a positive laboratory result for COVID-19. There was no care plan developed on 2/5/2021 to 2/10/2021. 2. Implement Resident 1's care plan to monitor, document, and report change of condition to physician when Resident 1 had a blood pressure of 80/49 mmHg and heart rate of 52 bpm on 2/7/2021 at 5:54 pm. 3. Implement Resident 1's care plan to observe for signs and symptoms of decline and change in condition and report to physician. 4. Implement Resident 1's care plan to monitor abnormal signs and symptoms every four hours if positive for COVID-19 on 2/5/2021 to 2/10/2021. As a result, Resident 1’s medical condition deteriorated and the resident expired on 2/10/2021 at 5:50 pm at the facility due to cardiopulmonary arrest and COVID-19. The above violations, jointly or separately, 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 1.