Other·February 2, 2023

42 CFR § 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 42 CFR § 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. 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 11/15/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care, abuse, and the death of Resident 1. The facility failed to ensure Resident 1 was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) on 11/4/2022 at 6:30 a.m. when Resident 1 exhibited signs (physical forms of disease, illness, and injury) and symptoms (a subjective experience that cannot be identified by anyone else) of decompensating (a sudden worsening of a resident’s medical condition) and the licensed nurses did not immediately call paramedics (healthcare staff trained to give emergency medical care to people who are injured or ill) as per facility’s policies and procedures. As a result, Resident 1’s episode of decompensating, as evidenced by a blood pressure of 75/55 millimeters of mercury (mmHg-unit of measure, normal blood pressure is 120/70mmHg); Oxygen Saturation level (O2 sat- the amount of oxygen in the blood) of 77 percent (%); normal level is 95% or higher); pulse (heart rate) of 111 beats per minute (BPM; normal range is 60 to 100 bpm); and respiration (beathing) rate of 26 breaths per minute (normal range is 16 to 20 breaths per minute) on 11/4/2022 at 6:30 a.m., went without the immediate medical treatment needed. Staff did not call paramedics until 7:56 a.m. (one hour and 26 minutes after Resident 1 was initially identified as in distress) when the oncoming shift nurse (Registered Nurse 2 [RN 2]) went to assess Resident 1 during her morning rounds (when the nurse first checks on all their assigned residents at the start of their shift). RN 2 noted that Resident 1 appeared to be in distress. Paramedics took over Resident 1’s care and transferred the resident to general acute care hospital 1 (GACH 1) Emergency Department (ED). While at the ED, Resident 1 expired at 10:19 a.m. A review of Resident 1’s Admission Record (Face Sheet) indicated the resident, a 76-year-old male, was admitted on 5/20/2021 with diagnoses including hypertension (high blood pressure [BP - a measure of the force the heart uses to pump blood around the body]), diabetes mellitus type II (impairment in the way the body regulates and uses glucose [sugar]), and thrombocythemia (occurs when the bone marrow does not make enough platelets; platelets form blood clots to help stop bleeding). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 8/28/2022, indicated the resident was able to communicate, understand, make decisions, and needed extensive assistance from staff with mobility, transfer, toilet use, dressing, and personal hygiene. A review of the Physician’s Order for Resident 1, dated 5/5/2022, for Life-Sustaining Treatment (POLST - form that gives residents control over their end-of-life-care) indicated do not resuscitate (DNR - if the resident is found without heartbeat and not breathing, staff is not to perform cardiopulmonary resuscitation [CPR - an emergency life-saving procedure done when someone's breathing or heartbeat has stopped]) with selective treatment (a goal of treating a medical condition without invasive [aggressive] medical procedures) including use of medical treatment, intravenous (IV - into a vein) antibiotics (medicines that fight bacterial infections), and IV fluids. The POLST form was signed by the physician and Resident 1 on 5/5/2022. A review of Resident 1’s Change of Condition (COC - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Assessment form completed by RN 4 dated 11/4/2022 and timed at 8:46 a.m., indicated the following: - At approximately around 6:30 a.m., Resident 1 complained of shortness of breath (SOB). Resident 1’s initial vital signs (measurements of the body's most basic functions) were: 1. Blood pressure was 75/55 mmHg. 2. O2 sat of 77 %. - Resident 1’s legs were elevated (elevating one’s legs above the heart allows the blood to circulate back to the heart without fighting gravity) and was provided with supplemental oxygen (treatment in which a tank of oxygen is used to give oxygen to people with breathing problems) of five (5) liters (L - unit of measure) via nasal canula (NC - a device that has two prongs and sits below the nose that delivers oxygen directly into one’s nostrils). - Upon reassessment (time not indicated), Resident 1’s vital signs were: 1. Pulse was 111 beats per minute. 2. Respiration rate was 26 breath per minute. 3. Blood Pressure was 103/84 mmHg 4. Temperature was 97.3 degrees Fahrenheit (°F - normal temperature range is 97 to 99°F). 5. O2 sat was 94% - Resident 1 was noted with bloody urine (time not indicated) from an in and out catheterization (a tube is inserted in a person’s bladder to drain urine). - A message was left with Resident 1’s physician (no time specified). - RN 4 received a call back (time not specified) with instructions to transfer Resident 1 via emergency medical services (EMS - paramedics) which staff called around 8:00 a.m. - At 8:05 a.m., paramedics arrived at the facility and took over Resident 1’s care. - At 8:13 a.m., paramedics took Resident 1 to GACH 1 ED. A review of Resident 1’s Paramedic Patient Care Report, dated 11/4/2022, indicated paramedics were called at 7:56 a.m. and arrived at the facility at 8:02 a.m. Upon the paramedic’s arrival to the facility, Resident 1 had an O2 sat of 78% and was noted to be in a moderate level of distress with the chief complaint of shortness of breath. A review of GACH 1’s Daily Focus Assessment Report, dated 11/28/2022, indicated that on 11/4/2022 at 8:39 a.m., Resident 1 was admitted to the ED for SOB, with labored breathing (having a hard time breathing), slurred speech, hypothermia (dangerously low body temperature), oriented (level of awareness) to self and place, and unable to complain of pain. Resident 1 had abdominal tenderness (pain or discomfort) on palpation (upon touching). Resident 1 was pronounced dead on 11/4/22 at 10:19 a.m. A review of Resident 1’s Certificate of Death, dated 12/20/2022, indicated the resident expired on 11/4/2022 at 10:19 a.m. The immediate cause of death was cardiac arrest (the heart suddenly and unexpectedly stops pumping), followed by congestive heart failure (a weakened heart condition that causes fluid buildup). During an interview on 12/16/2022 at 12:06 p.m., RN 2 stated that on 11/4/2022, RN 2 was the incoming morning shift (7 a.m. to 3:30 p.m.) nurse supervisor and arrived late at approximately 7:45 a.m. RN 2 stated that RN 4 informed her Resident 1 had experienced a COC at 6:30 a.m. that same morning. RN 2 stated she immediately rushed into Resident 1’s room. RN 2 asked RN 4 if 911 had been called, to which RN 4 responded she did not call 911 because Resident 1 was a DNR. RN 2 corrected RN 4 that paramedics should be still called as Resident 1 appeared to be in distress. RN 2 stated paramedics took Resident 1 to GACH 1. RN 2 stated that Resident 1 should have been transferred to a GACH when he first exhibited signs and symptoms of desaturation (low levels of oxygen in the blood), hypotension (low blood pressure), rapid respiratory rate, and tachycardia (heart rate greater than 100 beats per minute). On 12/16/2022 at 2:57 p.m., during an interview, the Director of Nursing (DON) stated the licensed nurses should have immediately called 911 if Resident 1 exhibited signs and symptoms of desaturation, hypotension, and tachycardia so that the resident could have gotten the help and care he needed On 12/16/2022 at 5:25 p.m., during an interview, RN 4 stated she was the RN Supervisor on 11/4/2022. RN 4 stated that at approximately 6:30 a.m., RN 5 called her to Resident 1’s room because the resident was in distress. RN 4 stated that since Resident 1 was complaining of abdominal pain, she asked RN 5 and Licensed Vocational Nurse 3 (LVN 3) to perform an in and out catheterization (to remove urine from the bladder) and Resident 1 had hematuria (blood in the urine). RN 4 stated Resident 1’s blood pressure and O2 sat level improved and left a message with Resident 1’s physician regarding the COC. On 12/17/2022 at 9:25 p.m., during an interview, LVN 3 stated that on 11/4/2022 at approximately 6:30 a.m., RNs 4 and 5 called her to Resident 1’s room and the resident was complaining of abdominal pain. RNs 4 and 5 were having difficulty with obtaining Resident 1’s blood pressure because the machine was not getting a reading (occurs when the blood pressure is too low). Resident 1 appeared to be in distress and LVN 3 told RNs 4 and 5 to send him to a GACH as Resident 1 continued to have unrelieved pain. On 12/18/2022 at 10:04 a.m., during an interview, RN 5 stated that on 11/4/2022, Resident 1 was under her direct care. RN 5 stated that at approximately 6:30 a.m. on 11/4/2022, she checked Resident 1’s blood pressure and O2 sat level and noted the blood pressure reading was 75/55 mmHg with an O2 sat level at 77%. RN 5 stated that because Resident 1 had a low blood pressure, the resident’s legs were elevated, and he was started on O2 at 5 Liters per minute (LPM -unit of measure) via NC. RN 5 stated Resident 1’s O2 sat increased to 94% and the blood pressure increased to 103/84 mmHg. RN 5 stated she did not monitor Resident 1 any further. RN 5 acknowledged Resident 1 should have been transferred to a GACH via paramedics given the resident’s initial blood pressure and O2 sat. On 12/29/2022 at 12:40 p.m., during an interview, RN 2 stated she was familiar with Resident 1 because the resident resided in the facility for a long time and on 11/4/2022, when she first observed Resident 1, he “looked different.” RN 2 stated Resident 1 looked pale and complained of abdominal pain. RN 2 stated she could tell the resident needed emergent transfer to a GACH. RN 2 stated that it was important to call paramedics because the resident was in distress. On 12/29/2022 at 1:38 p.m., during an interview with the DON and concurrent review of Resident 1’s COC form dated 11/4/2022 timed at 8:46 a.m., the DON stated that from her investigation of the event that occurred on 11/4/2022 regarding Resident 1’s change of condition, the resident was stabilized and did not require emergent transfer to a GACH. The DON acknowledged that while Resident 1’s blood pressure improved to 103/84 mmHg and the O2 sat level was 94% on 5 LPM via NC, the resident continued to have elevated heart and respiratory rates. When the DON was asked if Resident 1 had been reassessed, the DON stated there was no documentation. On 12/29/2022 at 2:17 p.m. during an interview with RN 5 and concurrent review of Resident 1’s COC form dated 11/4/2022 at 8:46 a.m., RN 5 was unable to find documentation she reassessed and monitored the resident to ensure the resident’s condition had stabilized. RN 5 stated she should have reassessed Resident 1. When asked if she acted neglectful by not reassessing or re-evaluating Resident 1 during his COC on 11/4/2022, RN 5 stated "Yes" it was neglectful. A review of the facility’s policy and procedures titled, “Change of Condition Notification”, revised 1/1/2017, indicated: 1. If the resident deteriorates, the resident’s symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, the facility is to call 911 for transport to hospital. 2. COC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death. A review of the facility’s policy and procedures titled “Emergency Care-General,” revised 7/1/2015, indicated that for Emergency - Serious but Not Life Threatening, staff is to summon help and request that someone call 911 if indicated. The resident's vital signs including blood pressure, pulse, respirations, and temperature is to be documented. A review of the facility's policy and procedures, titled “Abuse Prevention and Prohibition Program,” revised 10/24/2022, indicated: 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Resident assessments and care planning are performed to monitor resident needs. The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect including leaving someone unattended who needs supervision. The facility failed to ensure Resident 1 was free from neglect on 11/4/2022 at 6:30 a.m. when Resident 1 exhibited signs and symptoms of decompensation and the licensed nurses did not immediately call paramedics as per facility’s policies and procedures. As a result, Resident 1’s episode of decompensating, as evidenced by a blood pressure of 75/55 mmHg; O2 Sat of 77 percent; pulse of 111 beats per minute; and respiration rate of 26 breaths per minute on 11/4/2022 at 6:30 a.m., went without the immediate medical treatment needed. Staff did not call paramedics until 7:56 a.m. (one hour and 26 minutes after Resident 1 was initially identified as in distress) when the oncoming shift nurse (RN 2) went to assess Resident 1 during her morning rounds. RN 2 noted that Resident 1 appeared to be in distress. Paramedics took over Resident 1’s care and transferred the resident to GACH 1 ED. While at the ED, Resident 1 expired at 10:19 a.m. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a substantial factor in the death of Resident 1.