Health inspection·December 1, 2023

42 CFR §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. 22 CCR § 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. 22 CCR § 72557 Equipment and Supplies (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of patients as ordered or indicated. At least the following items shall be provided and properly maintained at all times: (8) Emergency oxygen supply and equipment for administration. 22 CCR § 72303 Physician Services--General Requirements. (b) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. Physician services shall include but are not limited to: (4) Advice, treatment and determination of appropriate level of care needed for each patient. (5) Written and signed orders for diet, care, diagnostic tests and treatment of patients by others. Orders for restraints shall meet the requirements of Section 72319(b). 22 CCR § 72313 Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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 9/26/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care and resident death. The facility failed to: 1. Ensure Resident 5 received the bi-level positive airway pressure (BiPAP, a device that helps with breathing) machine therapy as ordered by the physician. 2. Develop, implement, and update a timely and comprehensive care plan for Resident 5’s use of BiPAP machine therapy, monitor Resident 5’s BiPAP use, and notify the physician of Resident 5’s refusals to use BiPAP machine therapy. 3. Ensure that the physician’s orders addressed BiPAP settings, the type of mask, and the monitoring of use and functioning of Resident 5’s BiPAP machine and failed to incorporate such input from Resident 5’s physicians into a nursing care plan for Resident 5. 4. Provide Resident 5 with functioning BiPAP equipment on numerous days. 5. Follow the facility’s policy for “Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open during sleep) / BiPAP Support and Cleaning”. As a result, Resident 5 was transferred to a hospital emergency department for respiratory care needs twice in July 2023 and then on 8/19/2023 at 6:15 a.m. Resident 5 was found unresponsive (unable to be aroused by voice, command, or to deep stimulation), cardiopulmonary resuscitation (CPR) was initiated, and paramedics pronounced Resident 5 dead at 6:20 a.m. A review of Resident 5’s Admission Record indicated the facility originally admitted Resident 5 on 3/7/2019 and re-admitted Resident 5 on 7/11/2023 and on 7/28/2023 with diagnoses including obstructive sleep apnea (OSA), nocturnal dependence on supplemental oxygen, fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), type 2 diabetes, severe obesity, and obesity hypoventilation syndrome (OHS – breathing disorder). A review of Resident 5’s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 5/29/2023, indicated Resident 5 was able to communicate, make needs known, make decisions, and remember. The MDS further indicated that Resident 5 needed extensive assistance from two staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 5’s General Acute Care Hospital 1 (GACH 1) Discharge Summary Form, dated 7/11/2023, indicated Resident 5 presented to the Emergency Room (ER) for evaluation of altered mental status, low grade fever (a body temperature between 99.5 degree Fahrenheit [°F] and 100.3°F; normal body temperature is considered to be 98.6°F), and desaturation (drop in blood oxygen levels). GACH 1 Discharge Summary Form indicated that Resident 5 “required nocturnal BiPAP and as needed; however, the compliance at the Skilled Nursing Facility (SNF) is unknown. The GACH 1 Discharge Summary Form further indicated that the paramedics found her with an oxygen saturation level (amount of oxygen in blood, normal oxygen saturation level is between 95% and 100%) of 78% on room air (without supplemental oxygen) and unresponsive.” The discharge instructions for Resident 5 included to continue BiPAP at night. A review of the Physician’s Orders for Resident 5 upon readmission to the facility on 7/11/2023, indicated the following: 1. BiPAP continuously at night and as needed for respiratory distress. The physician’s order did not indicate: the BiPAP pressure settings (for the pressure of the air going into and out the lungs), the fraction of inspired oxygen concentration (FiO2), and the type of mask (to ensure proper fitting so air does not escape). In addition, there were no physician’s orders to monitor the use and functioning of the BiPAP machine. 2. Oxygen at four (4) liters per minute (LPM) via nasal canula continuously every shift due to OSA. 3. Monitor oxygen use and placement every shift. A review of Resident 5’s Nursing Progress dated 7/18/2023, timed at 4:46 a.m., indicated Physician 1 was informed of the BiPAP machine malfunctioning with another order from the physician to monitor Resident 5’s oxygen saturation levels and to transfer Resident 5 to GACH 1 if the oxygen saturation level is below 90%. A review of Resident 5’s Respiratory Flowsheet Form (RFF) dated 7/19/2023, timed at 3:30 p.m. indicated a broken piece from the tubing was found on Resident 5’s BiPAP machine. The RFF further indicated the facility will contact the equipment company to obtain new tubing for Resident 5’s BiPAP machine. A review of Resident 5’s Nursing Progress Notes dated 7/19/2023, timed at 3:46 a.m., indicated Resident 5 was being monitored because the BiPAP machine was not working. Further review of Resident 5’s Nursing Progress Notes dated 7/20/2023, timed at 7:58 a.m. and 11:23 p.m. indicated Resident 5 was being monitored for any changes in condition because the BiPAP machine was not working. A review of Resident 5’s Nursing Progress Notes dated 7/21/2023, timed at 11:01 p.m. indicated the BiPAP machine was not yet repaired. A review of Resident 5’s Nursing Progress Notes dated 7/24/2023, timed at 3:18 p.m., indicated Resident 5 was found unresponsive, with weak, irregular pulse rate of 127 beats per minute (bpm) and shallow respirations of 16 breaths per minute. Physician 1 was notified and ordered to administer Narcan (a medication used to revive someone during an overdose from pain medications) twice prior to paramedics’ arrival. The Nursing Progress Notes indicated Resident 5 was placed on oxygen therapy at 15 LPM via oxygen tank with a non-rebreather mask (a device used to assist in the delivery of oxygen therapy). At around 3:38 p.m. the paramedics came and took Resident 5 to GACH 2. A review of the Physician’s Order for Resident 5, dated 7/24/2023, timed at 3:20 p.m. indicated to transfer Resident 5 to a GACH due to unresponsiveness and desaturation. A review of Resident 5’s Nursing Progress Notes indicated a late entry (any documentation that is recorded in a resident’s medical record beyond 24 to 48 hours of the incident) entered on 7/25/2023 for 7/24/2023 at 3:38 p.m. (before Resident 5 went to GACH 2), indicated Physician 1 provided the BiPAP settings (BiPAP of 18/5, Respiratory Rate of 24, FiO2 of 30%) and the type of respiratory mask (full mask) to use (since 7/11/2023 the order was not clarified for the type of masks and settings). During a review of Resident 5’s care plans from 7/11/2023 to 7/24/2023, there were no care plans found regarding Resident 5’s BiPAP machine that includes the use, monitoring and functioning of the BiPAP machine. A review of Resident 5’s GACH 2’s Discharge Summary dated 7/28/2023, indicated Resident 5 presented to GACH 2 for evaluation of AMS and desaturation with an oxygen level of 50%. The GACH 2’s Discharge Summary further indicated that Resident 5 needed a BiPAP machine for use at night, but the BiPAP machine had not been working for the last couple of weeks (at the SNF). A review of Resident 5’s Physician’s Order dated 7/28/2023, upon Resident 5’s readmission to the facility on 7/28/2023, indicated to resume previous orders from Resident 5’s previous admission on 7/11/2023. A review of Resident 5’s Care Plan developed on 8/8/2023 for the use of BiPAP machine indicated a goal of Resident 5 not having any complications using the CPAP/BiPAP machine. The interventions/tasks indicated that nursing staff would be instructed as needed for proper mask placement and that Resident 5 would be instructed on how to use the BiPAP machine. The care plan did not address the BiPAP settings, the type of mask, monitoring the machine’s functioning, or monitoring the resident’s refusals of BiPAP therapy. A review of Resident 5’s Nursing Progress Notes, dated 8/19/2023, indicated: - On 8/19/2023 at 2:02 a.m., Resident 5 was on Oxygen at four LPM via NC. The use of the BiPAP machine was not documented. - On 8/19/2023 at 4:40 a.m., Resident 5 was sleeping with Oxygen at four LPM via NC and did not have difficulty beathing. The use of the BiPAP machine was not documented. - On 8/19/2023 at 6:15 a.m., Resident 5 was found in her room, unresponsive, no palpable pulses (no heart rate that can be felt by touch), unable to obtain the blood pressure and no readable oxygen saturation level. Code blue (an emergency code used to describe the critical status of a patient) was called and CPR was started while paramedics arrived. Paramedics pronounced Resident 5 dead at 6:20 a.m. A review of Resident 1’s death certificate dated 8/29/2023, indicated Resident 1’s cause of death on 8/19/2023 was cardiorespiratory arrest (cessation of adequate heart function and respiration). On 10/6/2023 at 1:10 p.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated she routinely worked the night shift and provided care to Resident 5. LVN 2 stated Resident 5 receives oxygen therapy continuously via NC and the BiPAP only sometimes during the night because Resident 5 did not want to have BiPAP late night. LVN 2 stated that Resident 5 would disconnect the BiPAP machine. When LVN 2 was asked where Resident 5’s use of the BiPAP was documented, LVN 2 stated it should be documented in either the Medication Administration Record (MAR- a document of the medications administered to a resident on a day-to-day basis) or the Treatment Administration Record (TAR- a document of the healthcare treatments provided to a resident on a day-to-day basis). LVN 2 stated she did not document Resident 5’s refusal to use BiPAP machine and she did not notify Physician 1 about Resident 5’s refusal to use BiPAP machine. LVN 2 stated that she could not find documentation to indicate Resident 5’s BiPAP machine was routinely checked. On 10/6/2023 at 2:11 p.m., during an interview, Physician 1 stated that he was the attending physician for Resident 5. Physician 1 stated that residents have the right to refuse care, services, or treatments, however, the licensed nurses should have informed the resident’s physician of the refusal of treatment. Physician 1 stated that he had not been made aware by the licensed nurses that Resident 5 was refusing to use the BiPAP machine. Physician 1 further stated that had he known that Resident 5 refused to use BiPAP during the night, he would have transferred Resident 5 to a GACH. During a concurrent interview and record review with the Director of Nursing (DON) on 10/6/2023 at 3:00 p.m., Resident 5’s Physician Orders dated 7/11/2023 and 7/25/2023 for Resident 5’s BiPAP were reviewed. The DON stated that she reviewed Resident 5’s Nursing Progress Notes, MAR, TAR, and Respiratory Notes including RFF from 7/11/2023 to 8/19/2023.The DON stated that there were no documented evidence indicating that the licensed nurses monitored Resident 5’s BiPAP use during the night. The DON stated that there was no documented evidence of Resident 5’s BiPAP refusal, and there was no documented evidence that Physician 1 was made aware of Resident 5’s noncompliance with the prescribed BiPAP usage. During a concurrent interview and record review with Case Manger (CM) on 10/6/2023 at 3:31 p.m., Resident 5’s Physician Orders dated 7/11/2023 and 7/25/2023 for BiPAP use were reviewed. CM stated that the licensed nurses did not select the option in the electronic medical records that would allow for Resident 5’s BiPAP order to be placed in Resident 5’s MAR or TAR to monitor the residents BiPAP usage. CM stated that as a result, it was not transcribed or carried out in Resident 5’s MAR or TAR to monitor and document Resident 5’s BiPAP usage at night, the resident’s response to oxygen therapy, and to monitor the functioning of the BiPAP. During a concurrent interview and record review with the DON on 10/10/2023 at 3:41 p.m., Resident 5’s care plans related to Risk for Altered Respiratory Status with a revised date of 5/8/2023 and the care plan for the BiPAP machine use initiated on 8/8/2023 were reviewed. The DON stated that there was no care plan developed for Resident 5’s non-compliance of BiPAP usage. On 10/18/2023 at 6:15 p.m., during an interview, Registered Nurse 2 (RN 2) stated she was the RN who re-admitted Resident 5 on 7/11/2023. RN 2 stated she did not clarify Resident 5’s BiPAP setting levels and type of mask to be used with Physician 1. RN 2 stated she forgot and that she should have verified with Physician 1 Resident 5’s BiPAP setting levels including the type of mask to prevent Resident 5 from having a change in condition such as respiratory issues that could lead to hospitalization. A review of the facility’s policy and procedure (P&P) titled, “Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open during sleep) / BiPAP Support and Cleaning,” last reviewed on 2/16/2023, indicated that the purpose of the policy is to improve arterial (involving or relating to the arteries and the movement of blood through the body) oxygenation in residents with respiratory insufficiency (when something oxygen from getting into the blood), obstructive sleep apnea, or restrictive/obstructive lung disease (conditions that make it hard to exhale all the air in the