Health inspection·January 28, 2021

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. On 9/10/2020, at 10:15 a.m., an unannounced visit was made to the facility to investigate a complaint about quality of care. The facility failed to call 911 (telephone number used to request for emergency medical assistance) when Resident 1 was observed having shallow breathing on 9/5/2020 at 4:00 a.m. As a result, Resident 1’s difficulty breathing was not immediately treated and subsequently Resident 1 expired at the facility on 9/5/2020 at 4:35 a.m. when the resident went into cardiopulmonary arrest (loss of heart function, breathing and consciousness). A review of Resident 1’s Admission Record (Face Sheet) indicated a re-admission dated 8/10/2020 with diagnoses including hyperlipidemia (abnormally high concentration of fats or lipids in the blood), hypertension (abnormally high blood pressure) and Coronavirus Disease 2019 (COVID-19 a viral contagious infection that affects the respiratory system). A review of Resident 1’s Care Plan on Advance Directive initiated on 11/11/2017 indicated a Physician Orders for Life-Sustaining Treatment (POLST – form that gives resident a control over his/her end-of-life care) on file and the following requests: initiating cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped), acute care hospitalization, providing artificial feeding, administering intravenous fluids (fluids given straight into a vein), and notifying the physician of any changes to respect the resident and/or family wishes. A review of Resident 1’s POLST, dated 4/30/2018, indicated Resident 1 was to receive full treatment (code status) and was signed by Attending Physician 1 (AP 1) and Resident 1. A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 07/22/2020, indicated Resident 1’s cognition (ability to think, understand and reason) was severely impaired. Resident 1 required extensive assistance from staff with personal hygiene, transfers, and bed mobility. A review of Resident 1’s Change of Condition (COC) Assessment Form completed by Registered Nurse 1 (RN 1) dated 9/5/2020 at 4:51 a.m., indicated on 9/5/2020 at 4:00 a.m. Certified Nursing Assistant 2 (CNA 2) found Resident 1 having shallow breathing. CNA 2 informed Licensed Vocational Nurse 1 (LVN 1). LVN 1 and RN 1 obtained Resident 1’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate and blood pressure, which indicate the state of a resident’s essential body function). Resident’s 1 blood pressure was undetectable, respiration rate was three breaths per minute (normal range 12 to 16 breaths per minute), pulse rate was 60 beats per minute (normal range 60 to 100 beats per minutes), and the oxygen saturation (refers to the amount of oxygen in a person’s bloodstream) was 50 percent (%) (normal range from 95% to 100%). The COC Assessment Form indicated Resident 1’s oxygen saturation went up to 66% after placing Resident 1 on oxygen at 15 liters per minute via a rebreather mask. At 4:25 a.m., Resident 1 stopped breathing and had no pulse. LVN 1 and RN 1 started CPR. After completing two cycles of CPR, RN 1 left to inform AP 1 that CPR was not successful. Resident 1 remained unresponsive and no vital signs detected. At 4:35 a.m., Resident 1 was pronounced dead. A review of Resident 1’s plan of care dated 11/11/2017 indicated Resident 1 is at risk for cardiac distress related to hyperlipidemia and hypertension. Resident 1 is at risk for shortness of breath, irregular pulse and abnormally low blood pressure. The goal was for Resident 1 not to have unrecognized signs and symptoms of cardiac distress daily. The interventions included to observe for irregular pulse, shortness of breath, low blood pressure, altered mental status and to report to the attending physician promptly. On 9/11/2020 at 7:00 a.m., during an interview with RN 1, she stated on 9/5/2020 at 4:10 a.m., LVN 1 informed her that Resident 1 was observed having shallow breathing. RN 1 and LVN 1 assessed Resident 1 and noted abnormal vital signs. RN 1 further stated CPR was started at 4:10 a.m. (10 minutes after being notified Resident 1 was having a change in condition) and after performing CPR for five to 10 minutes RN 1 and LVN 1 stopped. RN 1 stated CPR was stopped because it was unsuccessful. There were no further interventions implemented. On 9/12/2020, at 6:57 a.m., during an interview with LVN 1, he stated that on 9/5/2020, at around 4:00 a.m., CNA 2 informed him Resident 1 was breathing irregularly. LVN 1 then notified RN 1. LVN 1 and RN 1 went to Resident 1’s room and observed Resident 1’s breaths were shallow and could not detect Resident 1’s blood pressure. LVN 1 proceeded to the nursing station to verify the code status of the resident. LVN 1 further stated, CPR was not initiated until 4:20 a.m., 20 minutes after being notified Resident 1 was having a change in condition. LVN 1 stated at 4:26 a.m. and after performing two cycles of CPR, RN 1 left Resident 1’s room to inform AP 1 that Resident 1 had a change in condition and that CPR was unsuccessful. LVN 1 stated he asked RN 1 to call 911, however, RN 1 called AP 1 instead. On 9/21/2020 at 10:00 a.m., during a phone interview with AP 1, he stated he was notified of Resident 1’s change in condition after the failed CPR attempts. AP 1 further stated the licensed nurses should have called 911. On 10/1/2020, at 7:15 a.m., during a follow-up interview with RN 1, she stated she should have called 911. A review of the facility’s policy on Change of Condition with a revision date of 1/24/2017, indicated it is the facility’s policy to ensure proper assessments and follow through for any resident with a change of condition. A change of condition is a sudden or marked difference which includes abnormal vital signs. Upon a change in condition, for any reason, nursing staff members must inform attending physician promptly. In cases of emergency, changes in the condition of the resident, the nurse may dial 911 if necessary. The facility failed to call 911 for Resident 1, who was observed having shallow breathing on 9/5/2020 at 4:00 a.m. As a result, Resident 1’s difficulty breathing was not immediately treated and subsequently Resident 1 expired at the facility on 9/5/2020 at 4:35 a.m. when the resident went into cardiopulmonary arrest. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.