Other·November 23, 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 resident’s choices.

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 1, who was unable to make safe decisions due to poor judgement, had impaired sensitivity to heat, used a wheelchair for mobility, and needed staff assistance with activities of daily living (ADLs, such as: transfers, locomotion, personal hygiene, eating, and dressing) had the right to be free from neglect (the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress); was provided with supervision and assistance while in the patio, in the heat (a recorded high temperature of 88 degrees for that day according to Weather.com), and received prompt emergency care and treatment by calling paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) instead of waiting 42 minutes when the resident was unresponsive. As a result, on 6/20/2021, Resident 1 was found at 4:25 p.m., unresponsive to stimuli (not reacting or able to react in a normal way when touched, spoken to, etc.), was transported to General Acute Care Hospital 1 (GACH 1), where he was diagnosed with acute respiratory distress (condition in which fluid collects in the tiny, elastic air sacs in the lungs, depriving organs of oxygen), and second-degree burns (which often looks wet or moist, affects the first and second layers of the skin, blisters may develop, and pain can be severe) on the left shoulder and abdomen. Resident 1 was transferred to the intensive care unit (ICU, is a specialized section of a hospital with specially trained health care staff that provide comprehensive and continuous care to persons with life-threatening injuries and illnesses). A review of Resident 1's Admission Record (Face Sheet) indicated the resident was an 81-year-old male, with an initial admission to the facility dated 9/18/2018, with the last re-admission dated 5/22/2021. Resident 1’s diagnoses included polyneuropathy (is the damage to multiple nerves outside of the brain and central nervous system. This can cause inability to feel pain, heat intolerance, pain, discomfort, and mobility difficulties), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems, diabetes (a chronic disease characterized by elevated levels of blood glucose [or blood sugar], which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves), and major depressive disorder (persistently depressed mood [or emotional state] marked by feelings of low self-worth or guilt, and long-term loss of pleasure or interest in life). Family Member 1 (FM 1) was listed as Resident 1’s responsible party (for healthcare decisions). A review of Resident 1’s Physician's Orders for Life-Sustaining Treatment (POLST, is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures [such as a ventilator or feeding tube] and CPR [cardio-pulmonary resuscitation]. It is signed by both the patient or patient’s representative and the physician) dated 10/3/2018, indicated DNR (do not resuscitate or no CPR) and DNI (do not intubate). Resident 1’s POLST did not indicate no hospitalization or no IV fluids. A review of Resident 1’s Care Plan with a revision date of 6/19/2020, indicated Resident 1 was at risk for falls and injury related to history of falling, diagnosis of diabetes, anemia (low number of red blood cells to carry adequate oxygen to the body), congestive heart failure (a serious condition in which the heart doesn’t pump blood as efficiently as it should) and chronic kidney disease (gradual loss of kidney function). The interventions included to visibly observe resident frequently and provide a safe environment. A review of Resident 1’s Care Plan developed for the resident’s self-care deficits related to extensive assistance with locomotion in wheelchair, with a revision date of 9/6/2020 included in the interventions providing Resident 1 assistance as needed and a safe environment. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 6/4/2021, indicated the resident had severe cognitive impairment (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 required extensive assistance with one-person physical assist with bed mobility, locomotion on/off unit, eating, and personal hygiene. Resident 1 used a wheelchair as a mobility device. A review of Resident 1's SBAR (Situation - Background - Appearance – Recommendation, is a technique that provides a framework for communication between members of the health care team about a resident's condition) Change of Condition (COC) form, dated 6/20/2021, documented by Licensed Vocational Nurse 3 (LVN 3), indicated Certified Nursing Assistant 1 (CNA 1) found Resident 1 at 4:25 p.m. in the patio with an altered level of consciousness (ALOC) unresponsive to stimuli. At 4:25 p.m., Resident 1’s tympanic temperature (taken in the ear) was 98.2 °F (normal), the oxygen saturation (O2 Sat, indicates the amount of oxygen traveling through the body with the red blood cells. Normal range is between 95% and 100% for most healthy adults) was 94%, the respiration rate was even and unlabored (normal) but had tachycardia (rapid heartbeat) and had low blood pressure (hypotension or low blood pressure [the force of the blood as it presses against the blood vessel walls]). The actual reading of the heart and respiratory rates, and the blood pressure, were not documented as taken until 4:45 p.m. LVN 3 documented that at 4:45 p.m. Resident 1’s pulse (heart rate) was 138 beats per minute (bpm, the normal heart rate for an adult range between 60 -100 bpm), the respiratory rate was 20 breaths per minutes (the normal respiration rate for an adult at rest range from 12 to 16 breaths per minute), and the blood pressure was 94/66 millimeters of mercury (mmHg - normal blood pressure between 90/60 mmHg and 120/80 mmHg). LVN 3 documented Registered Nurse 2 (RN 2) was notified and a Code Blue (means there is a medical emergency occurring within the facility. Healthcare providers activate a code blue, if they feel the life of the person they are treating is in immediate danger) was called at 4:30 p.m. Resident 1 was brought inside the hallway, in his wheelchair, was warm to touch and a cold towel was placed on the resident’s forehead and neck. Resident 1 was given oxygen (O2) at 15 liters per minute (L/min) with the use of a non-rebreather mask (NRBM, is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that is filled with a high concentration of oxygen. The reservoir bag is connected to an oxygen tank. The mask covers both the nose and mouth. One-way valves prevent exhaled air from reentering the oxygen reservoir. A NRBM is used in emergency situations to prevent hypoxemia, also known as low blood oxygen). At 4:50 p.m., Resident 1’s clothes were removed and was noted with blisters on both shoulders and left lower abdomen. Resident 1’s upper and lower extremities (arms and legs) were red and warm to touch and ice packs were applied to head, upper and lower extremities. At 4:55 p.m., RN 2 called FM 1 to inform him of Resident 1’s condition and DNR and FM 1 instructed RN 2 to transfer Resident 1 to an Emergency Room (ER). At 5:00 p.m., RN 2 called 911 and Resident 1’s vital signs (temperature, respiratory and heart rate, blood pressure, O2 Sat, etc.) were re-checked, the blood pressure was 80/54 mmHg, the heart rate was 151 bpm, the temperature was 98.2 °F, and the O2 Sat was 98% with O2 via NRBM at 8L/min. At 5:23 p.m., EMS arrived at Resident 1’s room. A review of the EMS Report titled, “Prehospital Care Report Summary” dated 6/20/2021, with a dispatch (called received) time of 5:12 p.m., and an arrival at Resident 1’s room at 5:20 p.m. and a departure from the facility to GACH 1 at 5:36 p.m., indicated that upon arrival, EMS found Resident 1 in bed with ALOC, a Glasgow Coma Score of 3 (GCS, is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. A GCS of 3 is the lowest score possible indicating coma or unresponsiveness) with labored breathing (difficulty breathing), shallow respiration, abnormal lung sounds on both lungs, hot to the touch with flushed red sunburns skin with some blistering, and diaphoretic (sweating heavily). EMS administered IV fluids, initiated active cooling measures with ice packs under armpits and groin area, and documented that per nursing staff, Resident 1 was sitting outside in his wheelchair in the patio, in the heat for several hours. Nursing staff waited an hour to activate 911 system. A review of Resident 1's ED Physician Notes at GACH 1 dated 6/20/2021, indicated the resident was received at 5:52 p.m. with heat stroke and ALOC with an onset earlier in the day. Resident 1 was left outside in the heat, in a wheelchair, for four hours when nursing staff found him. The resident had second degree burns on his left shoulder and abdomen. Resident 1’s rectal temperature was 107.03 °F (hyperthermia, dangerously overheated body, usually in response to prolonged hot weather). Patient was cooled with cooling blanket, cool IV fluids, three-way Foley catheter (thin, flexible tube placed in the bladder) with bladder irrigation with cool fluids. Ice packs were also applied to the groin and axilla (armpit). At 6:21 p.m. Resident 1’s temperature was 105.8 °F. At 7:03 p.m., Resident 1 vomited, FM 1 at bedside and the physician explained the resident’s critical condition. At 7:47 p.m., FM 1 requested intubation (oral or tracheal [windpipe] intubation, is the placement of a flexible plastic tube into the trachea to maintain an open airway). Resident 1 remained obtunded (ALOC) and not protecting airway despite normal temperature. Resident 1 was intubated in the ED and at 8:02 p.m. was transferred to ICU. Resident 1’s diagnoses included acute renal failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), acute respiratory failure, heat stroke, second degree sunburn, and severe dehydration. A review of the facility’s Administrator letter, dated 6/28/2021, notifying the State Survey Agency (SSA, the Department) of the incident of Resident 1 hyperthermia on 6/20/2021, indicated that based on interviews with the staff and residents, the incident was unavoidable because the resident was alert and could independently wheel himself around the facility which was demonstrated in the video footage. Resident 1 was able to go to the patio on his own which was accessible with automatic motion sensor which allow the resident to go out (to the patio) and enter the facility (return inside). The smoking break at the patio was at 2 p.m., the last staff interaction, or visual contact with the resident was at 3:25 p.m. which was an hour before he was found unresponsive in the patio. On 6/30/2021, at 1:52 p.m. during a review of the security video footage with the Director of Nursing (DON), Resident 1 was last seen in the video recording on 6/20/2021 at around 1:17 p.m. leaving the Sunroom (dining room), wheeling himself towards the hallway. There were no further sightings of Resident 1 in the surveillance video. On 8/18/2021 at 5:15 p.m. during an interview, Licensed Vocational Nurse 1 (LVN 1) stated nursing staff do not normally check the patio and residents should not be out in the patio unattended. On 8/18/2021 at 5:18 p.m. during an interview, Registered Nurse 1 (RN 1) stated residents going to the patio should always be supervised for their safety. RN 1 stated there was no schedule for nursing staff to check the patio for residents. On 8/18/2021 at 7:02 p.m. during an interview, CNA 1 stated he worked the 3:00 p.m. to 11:00 p.m. shift on 6/20/2021, he came late (at 3:20 p.m.) to work and was assigned to care for Resident 1. CNA 1 stated that at around 4:20 p.m. he found Resident 1 outside in the patio alone without any staff supervising him. CNA 1 stated Resident 1 was wearing a beanie (head covering), a long-sleeved shirt, long pants, and shoes. CNA 1 stated it was a very hot that day. CNA 1 stated there are no staff outside the patio on regular bases, only during smoking break. On 8/26/2021 at 1:26 p.m. during an interview, Assistant Administrator (AA) stated Resident 1’s incident of hyperthermia and sunburns was avoidable if proper supervision and assistance was provided. Staff should have been with Resident 1 while he was in the patio. On 9/7/2021 at 10:52 a.m. during a telephone interview, the facility’s Medical Director stated not knowing how the facility managed residents that went out on the patio or if there was a policy on supervision of residents on the patio. Medical Director stated Resident 1’s incident of hyperthermia was avoidable. On 10/21/2021, at 7:30 p.m. during an interview, LVN 3 stated she worked the 3 p.m. to 11 p.m. shift on 6/20/2021 and she took Resident 1’s vital signs. When asked about Resident 1’s normal body temperature reading of 98.2 °F at 4:25 p.m. but warm to the touch and needing cooling measures, LVN 3 explained it was because she had placed a cold towel first on Resident 1’s forehead and then, used the temperature probe (which is a forehead gun thermometer) but LVN 3 documented the resident’s temperature was taken from the ear. LVN 3 stated she administered O2 at 15 L/min via NRBM but could not explain its need when she documented Resident 1 was not in a respiratory distress. LVN 3 stated RN 2 instructed her to remove Resident 1’s clothes to assess the resident’s skin. On 10/21/2021, at 7:51 p.m. during an interview, RN 2 stated the delay in calling paramedics was due to Resident 1’s POLST and she had to call FM 1 first. RN 2 confirmed Resident 1’s POLST did not say to call the family first in an emergency and did not say no to hospitalization. RN 2 acknowledged giving paramedics the verbal report but denied saying Resident 1 was left in the heat for several hours. RN 2 stated paramedics were not called immediately because Resident 1 was DNR, was not in distress, had vital signs and was just unresponsive. On 10/22/2021, at 3:10 p.m. during an interview, Administrator stated once the staff found Resident 1 unresponsive, they should have called 911 immediately. On 10/22/2021, at 3:17 p.m. during an interview, DON stated since Resident 1’s POLST was DNR/DNI with selective measures, she believed the licensed nurses did the right thing by calling the FM 1 to ask permission to call 911. DON could not explain the delay of 47 minutes in calling EMS from 4:25 p.m. to 5:12 p.m. (per EMS report) and of 3