Other·June 28, 2024

§483.10(g)(14) Notification of Changes. (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). §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident 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 residents’ goals and preferences, and 483.65 of this subpart. §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. §483.35(d) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. 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 5/7/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate an allegation of a resident death. The facility failed to: 1. Follow its policy and procedure (P&P) titled, "Change of Condition (COC - a major decline in a resident's status)," and notify the physician for Resident 1 who had a significant COC that started on 5/4/2024 at 4 a.m. 2. Ensure Resident 1 who had a COC on 5/4/2024 at 4 p.m. received tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) care. 3. Ensure Registered Nurse 1 (RN 1) had the skills and knowledge to provide nursing services to Resident 1. RN 1 failed to follow the facility's P&P titled, "Change of Condition," and failed to call Resident 1's Medical Doctor 1 (MD 1) to secure orders or request for interventions from MD 1 to address Resident 1's COC on 5/4/2024 at 4 a.m. 4. Ensure RN 1 followed the facility's P&P titled, "Cardiopulmonary Resuscitation, (CPR- an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped)" and immediately called the paramedics (health professionals certified to perform advanced life support procedures) on 5/4/2024 at 5:55 a.m. upon finding Resident 1 with vital signs (clinical measurements, specifically pulse rate/heart rate, temperature, respiration rate [number of breaths a person takes per minute], and blood pressure [the force of the blood pushing against the walls of the arteries], that indicated the state of a patient's/resident's essential body functions) unappreciated (not located, felt, or heard). RN 1 called the paramedics at 6:01 a.m. (6 mins after). On 5/4/2024, at 4 a.m., Resident 1's tracheal tube (trach tube, a two-inch-to three-inch-long curved metal or plastic tube placed in a surgically created opening [tracheostomy] in the windpipe to keep it open) was partially (not completely) displaced (removed from the usual or proper place). Respiratory Therapist 2 (RT 2) was unable to replace the tracheal tube with the same size (7.5 millimeter (mm, one thousandth of a meter) but was able to replace the tracheal tube with a smaller-sized tube (6 mm). RT 2 noted Resident 1 with bilateral (both lungs) diminished (decreased) breath sounds and minimal airflow from the airway (a passageway for air into or out of the lungs). RT 2 endorsed (to report or note the presence of a symptom) to Registered Nurse 1 (RN 1) to notify Resident 1's Medical Doctor (MD 1), but RN 1 did not notify MD 1 regarding Resident 1's COC and that RT 2 replaced Resident 1's tracheal tube with a different sized tracheal tube. As a result, on 5/4/2024 at 5:55 a.m., RN 1 and Licensed Vocational Nurse 2 (LVN 2) found Resident 1 with breathing difficulty, vital signs unappreciated, and Resident 1 starting to turn blue. The paramedics arrived at the facility at 6:08 a.m. The paramedic found Resident 1 lying in bed with rigor (stiffening of the body muscles due to chemical changes after death) and lividity (the bluish-purple discoloration of skin after death) and pronounced Resident 1 dead on 5/4/2024, at 6:13 a.m. A review of Resident 1's Admission Record indicated the facility admitted the 61-year-old male resident on 4/14/2024 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs), dysphagia (swallowing difficulties), encephalopathy (a group of conditions that cause brain dysfunction ), and respiratory (pertaining to the lungs) failure. A review of Resident 1's Care Plan titled, "Tracheostomy tube care with risk for accidental decannulation and associated respiratory distress," developed on 4/20/2024, indicated Resident 1 needed special treatments for tracheal tube care with risk for accidental decannulation and associated respiratory distress. The approached interventions included when decannulation occurs RT (any RT) or RN (any RN) to replace the tracheostomy tube with the same size or smaller size ASAP (right away), observe and monitor vital signs, notify physician and responsible party of change of condition, and keep extra trach tubes with the same size or smaller size at the resident's bedside with other tracheostomy supplies. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/21/2024 indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent on staff on oral care, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. A review of the Physician's Orders for Resident 1, dated 4/27/2024 at 1:47 p.m., indicated to place Resident 1 on a T-bar (T-shaped tubing connected to an endotracheal tube [a small, usually plastic tube inserted into the trachea through the mouth or nose to maintain an unobstructed passageway especially to deliver oxygen to the lungs] used to deliver oxygen therapy in an intubated patient who does not require mechanical ventilation [a type of therapy that helps the patient/resident breathe or breathes when the patient/resident cannot breathe]) as tolerated 24/7 (24 hours a day, seven days a week) on oxygen, every shift. A review of Resident 1's Respiratory Daily Notes entered by RT 2, dated 5/3/2024 at 11:36 p.m., indicated Resident 1 was on a T-bar, at 5 liters of oxygen per minute (LPM-unit of measurement), with thick white sputum (a mixture of saliva and mucus coughed up from the respiratory tract), and bilateral rhonchi ("large airway sounds," are continuous gurgling or bubbling sounds typically heard during both inhalation [breathe in] and exhalation [breathe out]). The notes indicated Resident 1's tracheal tube was midline (refers to the imaginary line that divides the body into symmetrical left and right halves) and intact, airway was patent (open) and secured. During a review of Resident 1's Tracheostomy Tube Change form, dated 5/4/2024 at 3:32 a.m. and an interview with RT 2 on 5/9/2024 at 1:07 p.m., RT 2 stated on 5/4/2024, at 3:32 a.m. Resident 1's original tracheal tube was the Bivona 75HA60 (type of tracheal tube) which was 7.5 mm in size, and it was decannulated outside of Resident 1's stoma (an opening made during surgery). RT 2 stated, "It appeared" that Resident 1 was on his (Resident 1's) side and his position may have caused his Bivona to come out of his stoma. RT 2 stated the Portex 7 mm (a type of tracheal tube) uncuffed (not cuffed) was not successfully inserted by RT2. RT 2 stated a Portex 6 mm uncuffed was inserted by RT 2 and a catheter (a flexible tube) was able to pass through Resident 1's tracheostomy with little resistance. RT 2 stated Resident 1's breath sounds were diminished with minimal airflow noted from the airway. RT 2 stated RT 2 recommended/endorsed RN 1 to obtain an order from MD 1 for an x-ray (a type of medical imaging that creates pictures of the bones and soft tissues) to confirm Resident 1's new tracheal tube (Portex 6 mm) placement. A review of the Tracheostomy Tube Change form indicated for staff (in general) to notify the physician (MD 1) if a smaller size tracheal tube was used. A review of Resident 1's Change of Condition notes entered by RN 1, dated 5/4/2024 and documentation started at 5:14 a.m., indicated Resident 1 "expired (died)." The notes indicated (on 5/4/2024), at 4 a.m., during rounds, charge nurse (LVN 2) noted that Resident 1's tracheal tube was not fully secured (not attached firmly so that it cannot be moved). RT 2 and RN 1 were notified immediately. Vital signs checked after RT 2 replaced Resident 1's displaced tracheal tube. The notes indicated (on 5/4/2024), at "around" 5:55 a.m. Resident 1 was noted with breathing difficulty, Resident 1's vital signs were unappreciated (unrecognized), and MD 1 was notified. The notes indicated on (5/4/2024) at 6:08 a.m., the paramedics arrived and took over the care and the paramedics pronounced Resident 1 expired at 6:13 a.m. A review of the Los Angeles Fire Department (LAFD) Care Report for Resident 1, dated 5/4/2024, at 6:01 a.m., indicated LAFD received dispatch notification (on 5/4/2024), at 6:01 a.m. with dispatch complaint as cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping). The report indicated the paramedics arrived on scene (at the facility) at 6:08 a.m. and at 6:12 a.m., exam indicated Resident 1 was unresponsive, pale, with bilateral eyes fixed (did not react to light) and dilated (became wider/larger). The report indicated Resident 1 was lying in hospital bed of nursing home "obviously dead." The report indicated Resident 1 had rigor and lividity. Resident 1 was determined dead at 6:13 a.m. During an interview on 5/7/2024 at 2:29 p.m., RN 1 stated that (on 5/4/2024) at "around" 4 a.m. LVN 2 and RT 2 told RN 1 that Resident 1's tracheostomy tube was partially displaced, and RT 2 replaced Resident 1's tracheostomy tube. RN 1 stated at 5:55 a.m. LVN 2 and RN 1 walked into Resident 1's room and saw Resident 1 was gasping for air like he (Resident 1) could not breathe. RN 1 stated he (RN 1) yelled for help. RN 1 stated RT 3 who was close by arrived and asked RN 1 to call "code blue, (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest [occurs when the heart suddenly and unexpectedly stops pumping])" and RT 3 came into Resident 1's room and started CPR. RN 1 stated the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was nearby and “it (the crash cart) was pulled into Resident 1’s room. RN 1 stated there was a phone on top of the crash cart and he (RN 1) called 911 at 6:01 a.m. RN 1 stated RT 3 checked Resident 1’s tracheostomy tube and changed the oxygen via artificial manual breathing unit (ambu bag - a type of device known as a bag valve mask, which is used to provide respiratory support to patients) to a full-face mask. RN 1 stated he did not assist with the CPR as it was all done by RT 3. During an interview on 5/7/2024 at 3 p.m., LVN 2 stated (on 5/4/2024) at 4 a.m., she (LVN 2) found Resident 1's tracheostomy tube "was out (displaced)" and called RT 2. LVN 2 stated RT 2 placed Resident 1's tracheal tube, and Resident 1's vital signs were taken and were "within normal ranges (the results were normal, and no further investigation or treatment is needed). LVN 2 stated (on 5/4/2024), at 5:55 a.m. RN 1 called LVN 2 for help when RN 1 saw Resident 1 was having difficulty breathing/labored breathing (breathing that requires observed effort or an increased amount of energy). LVN 2 stated she (LVN 2) tried to obtain Resident 1's vital signs, but she was not able to get the vital signs reading. LVN 2 stated Resident 1 started to turn blue. LVN 2 stated RN 1 called the code blue and RT 3 then came inside Resident 1's room. LVN 2 stated Resident 1 lost consciousness and RT 3 started CPR on Resident 1. LVN 2 stated the paramedics arrived at the facility (on 5/4/2024) at "around" 6:08 a.m., and the paramedics took over Resident 1's care. During an interview on 5/7/2024 at 3:30 p.m., RT 2 stated that (on 5/42024) at "around" 3:30 a.m. Resident 1's tracheostomy tube came out (displaced) while Resident 1 was lying on Resident 1's side (did not indicate which side). RT 2 stated when he (RT 2) asked Resident 1 how long the tracheostomy tube had been out Resident 1 stated he (Resident 1) did not know. RT 2 stated he (RT 2) then did an emergency tracheostomy tube change. RT 2 stated emergency tracheostomy tube change meaning he must insert a new tracheal tube. RT 2 stated Resident 1's tracheal tube was a size 7.5 mm and he tried to insert a size 7 mm, but it (the new tracheal tube size 7 mm) did not go through. RT 2 stated he then inserted a smaller tracheostomy tube size 6 mm and Resident 1's oxygen saturations (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher) went from 95% to 98%. RT 2 stated he informed RN 1 to get an x-ray to confirm the new tracheal tube placement. RT 2 stated Resident 1's breath sounds were diminished with minimal airflow due to a smaller size of the new tracheal tube. During an interview on 5/7/2024 at 4:30 p.m., RN 1 stated RT 2 did ask RN 1 to obtain an order for an x-ray on Resident 1 to confirm the new tracheal tube placement, but RT 2 said Resident 1 was "okay." RN 1 stated RT 2 mentioned "it casually" and he (RN 1) did not call MD 1 to obtain a new order for the x-ray to confirm Resident 1's new tracheal tube placement as requested by RT 2. RN 1 stated he (RN 1) informed MD 1 when Resident 1 was having distress on 5/4/2024 at 5:55 a.m. RN 1 stated there were no prior notifications made to MD 1. Du