Other·September 15, 2023

F684 (Rev. 73, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) § 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 person-centered care plan, and the residents’ choices, § 72523(a) 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 7/24/2023 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) following a fall episode on 7/21/2023, exhibited stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts causing damage to the brain), like symptoms including drooling (including increased salivation) and was not transferred to a General Acute Care Hospital (GACH) for evaluation and treatment in a timely manner. On 8/3/2023 at 10 a.m., an unannounced visit was made to the facility to investigate the complaint allegation. Upon investigation it was determined Resident 1, who had a history of a stroke, was not transferred to the GACH until 5:16 p.m. on 7/21/2023, (3 hours and 45 minutes) after being observed having stroke like symptoms following a fall on 7/21/2023 at 1:30 p.m., and developing right sided facial drooping (when facial muscles are not aligned), drooling from the right side of the mouth, and slurred speech, which were significant signs and symptoms (s/s) of a possible cerebrovascular accident ([CVA] a stroke). The facility failed to: 1. Ensure the licensed nurses recognized the s/s of Resident 1’s possible stroke to provide Resident 1 with the care necessary to prevent severe and/or irreversible brain damage. 2. Ensure Resident 1 who exhibited s/s of a stroke was immediately transferred to a GACH for evaluation and treatment to prevent severe and/or irreversible brain damage. 3. Ensure staff followed the facility’s policy and procedure (P/P), titled “Change of Condition Notification,” to call 911 to transport Resident 1 to a GACH for rapid intervention. There failures resulted in a delay of Resident 1's evaluation and treatment and inability for Resident 1 to receive tissue Plasminogen Activator ([tPA] a medication used to dissolve intravascular [pertaining to anything inside blood vessels] clots, return the blood supply in the brain and prevent severe and/or irreversible brain damage. Time frame for treatment is approximately three hours after the onset of symptoms). A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 12/6/2020 with a diagnosis including congestive heart failure ([CHF] when the heart does not pump blood to the body as well as it should), cardiomyopathy (a condition in which the heart is unable to deliver blood to the body which can lead to heart failure), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and level of consciousness]) and a cerebral infarction (stroke). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/13/2023, indicated Resident 1's speech was clear, he was able to make himself understood, understood others, and made independent decisions that were reasonable and consistent. A review of Resident 1's Change in Condition Evaluation (CCE), dated 7/21/2023 and timed at 1:40 p.m., indicated Resident 1 was found sitting on the floor on 7/21/2023 at 1:35 p.m., with slurred speech and drooling from his mouth. The CCE indicated Resident 1's vital signs ([v/s] measurements of the body's most basic functions such as body temperature, heart rate [HR], respiration rate [RR] and blood pressure [BP]) were as follows: 1. BP of 154/88 millimeters of mercury [(mmHg) the gauge used as a unit of measurement] BP reference range is equal or less than 120/80 mmHg. 2. HR of 65 beats per minute [(bpm) a unit of measurement]. The reference range is 60 to 100 bpm. 3. RR of 16 bpm. The reference range is 12-18 bpm. 4. Temperature of 97.3 degrees Fahrenheit (F). The reference for average body temperature is 98.6 degrees F. A review of CCE dated 7/21/2023 and timed at 1:40 p.m., indicated Resident 1 was seen by his physician, following Resident 1's unwitnessed fall. The CCE indicated Resident 1's physician instructed staff to discontinue Resident 1's medication Vimpat (a medication used to treat seizures) and to schedule a neurology (study and treatment of disorders of the nervous system) consult. A review of Resident 1's Nurses Progress Notes (NPN) dated 7/21/2023 and timed at 5:16 p.m., indicated Resident 1 was transferred to a GACH by 911, as requested by Resident 1's Responsible Party (RP) for a neurology consult due to Resident 1's slurred speech and excessive drooling of saliva (a thick colorless fluid that is constantly present in the mouth of humans). A review of Resident 1's Face Sheet from the GACH indicated Resident 1 arrived in the emergency room (ER) on 7/21/2023 at 6:07 p.m., with a chief complaint of speech difficulties, right side facial droop and was admitted to the GACH at 0:28 a.m. A review of Resident 1's Emergency Department Physician Note (EDPN) dated 7/21/2023 and timed at 6:07 p.m., indicated Resident 1 was seen for a Level 1 code stroke (a code called in the emergency room when a patient is 0-8 hours LKN [last known normal] prior, and results in the Vascular Neurology team [a team that focuses on issues that involve the central nervous system, including stroke, brain hemorrhages and other kinds of brain bleeds] responds immediately) because of speech difficulties, right side facial droop and edema (puffiness caused by excessive fluid trapped in the body tissues) of Resident 1's lip and tongue, with a last known well time of 10 a.m. on 7/21/2023. The EDPN indicated Resident 1 was administered intravenous ([IV] through the vein) Solumedrol (an anti-inflammatory medication used to treat allergies) and Epinephrine (a medication to combat a severe allergic reaction) intramuscular ([IM] into the muscle). The EDPN indicated Resident 1 was not administered an IV Tissue Plasminogen Activator because Resident 1's symptom were outside of the window to treat. Resident 1 was admitted to the GACH's Telemetry Unit with a diagnosis of right facial droop rule out CVA and angioedema (painless swelling under the skin) of the lips and tongue. A review of Resident 1's GACH's Neurology Consult Note (NCN) dated 7/22/2023 and timed at 8:57 a.m., indicated Resident 1 was assessed with dysarthria (difficulty speaking due to weak muscles) with no aphasia (inability to speak) and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder) with recurring episodes of facial grimacing and crying like episodes. The NCN indicated a magnetic resonance imaging ([MRI] a scan that produces detailed images of the inside of the body) of the brain as part of a stroke workup was ordered. A review of Resident 1's MRI, dated 7/22/2023 and timed at 11:01 a.m., indicated Resident 1 had a small acute (recent onset) to subacute (falling between acute and chronic [conditions that last more than 1 and require ongoing medical attention] especially when closer to acute) infarct (a small, localized area of dead tissue) of the left side of his brain. A review of Resident 1's GACH Discharge Summary (DS) dated 7/24/2023 and timed at 1:31 p.m., indicated Resident 1 had a small vessel left frontal lobe (part of the brain that is involved with controlling language related movement) ischemic stroke (a condition that occurs when a vessel supplying blood to the brain is blocked) and angioedema of his lips and tongue. The DS indicated Resident 1 had some right sided facial droop and mild dysarthria (difficulty speaking because the muscles used for speech are weak) During an interview on 8/3/2023 at 2:17 p.m., a Certified Nursing Assistant 1 (CNA 1), stated Resident 1 was able to talk with no problem and he (CNA 1) was able to understand him (Resident1) before his fall and transfer to the GACH. CNA 1 stated Resident 1 was found sitting on the floor in his room, near the bathroom on 7/21/2023 after lunch. CNA 1 stated he assisted staff to put Resident 1 back in bed and at that time noticed Resident 1's face looked "weird," like one side of Resident 1's face was not equal to the other side of his face, saliva was coming out of Resident 1's mouth, he (Resident 1) was talking but no one could understand what he was saying. During an interview on 8/3/2023 at 2:34 p.m., the Licensed Vocational Nurse 1 (LVN 1), stated following Resident 1's fall (7/21/2023 at 1:30 p.m.), he (LVN 1) and the Registered Nurse Supervisor 1 (RNS 1) assessed Resident 1. LVN 1 stated Resident 1 was observed with increased slurring of speech and excessive drooling of saliva from his mouth. LVN 1 stated Resident 1's physician saw Resident 1 after his fall and stated Resident 1 needed a neurology consult and instructed them to discontinue Resident 1's Vimpat. LVN 1 stated 911 was called with permission from Resident 1's physician and at the request of Resident 1's RP. LVN 1 stated when the paramedics arrived at the facility at 5:02 p.m., they performed the "FAST" test (a test used to help detect and enhance responsiveness to the needs of a person having a stroke. The acronym stands for facial drooping, arm weakness, speech difficulties, and time to call emergency services). LVN 1 stated Resident 1 was transported to the GACH at 5:16 p.m., on 7/21/2023. During an interview on 8/3/2023 at 3:04 p.m., RNS 1 stated Resident 1 had an unwitnessed fall on 7/21/2023 and was found on the floor in his room at 1:30 p.m. RNS 1 stated on assessment Resident 1 had slurred speech, was drooling excessively from his mouth, and was transferred to a GACH at approximately 5 p.m., on 7/21/2023. RNS 1 stated calling 911 for immediate transfer of a resident with s/s of a stroke was important so the resident could be evaluated and treated in a timely manner to prevent permanent damage from a stroke. RNS 1 stated she did not call 911 when Resident 1 had s/s of a stroke because previously Resident 1's normal speech was slow, and his v/s were normal. RNS 1 did not respond when asked if she knew the difference between slow speech and slurred speech. During an interview and concurrent record review on 8/3/2023 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's Long Term Care Evaluation (LTCE) dated 7/15/2023 and timed at 2:44 p.m., was reviewed. The DON stated Resident 1 had slowness of speech since admission (12/6/2020) and since his v/s were within normal range following his fall on 7/21/2023 he (the DON) did not see any abnormalities that warranted calling 911. The DON stated he personally assessed Resident 1, but later acknowledged he passed Resident 1's room and only looked in, but the nurses (LVN 1 and RNS 1) who were attending to Resident 1 told him that Resident 1 was stable. The DON acknowledged Resident 1's LTCE indicated Resident 1's speech was clear, and Resident 1 was able to make himself understood and was understood by others and the documentation did not indicate Resident 1's speech was slow and/or slurred. During a telephone interview on 8/7/2023 at 3:46 p.m., Resident 1's RP stated Resident 1 was frustrated because it was a challenge for him to express himself and to be understood. During a telephone interview on 8/11/2023 at 3:04 p.m., LVN 3, who was the charge nurse for Resident 1, on 7/21/2023 during the 7 a.m. to 3 p.m. shift, stated he did not assess Resident 1 after the resident’s fall, he only checked Resident 1's v/s, but he did observe that Resident 1 was drooling a lot of saliva from his mouth. According to The National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/health-information/public-education/know-stroke/patients-and-caregivers. Ischemic strokes, the most common type, can be treated with the drug t-PA, which dissolves blood clots obstructing blood flow to the brain. The window of opportunity to start treatment is three hours, but patients need to get to the hospital within 60 minutes to be evaluated and receive treatment. A review of the facility's Policy and Procedure (P/P) titled, "Change of Condition Notification," revised 4/1/2015, indicated it is the responsibility of the licensed nurse to assess the residents during a change in condition and determine what nursing interventions are appropriate when there is a significant change in the resident's physical, mental or life-threatening conditions or clinical complications identified and to decide if a resident needed to be transferred or discharged from the facility. During an emergency such as the resident is deteriorating and/or symptoms are serious, the licensed staff are expected to call 911 for transport to GACH for rapid intervention. The facility failed to ensure: 1. Ensure the licensed nurses recognized the s/s of Resident 1’s possible stroke to provide Resident 1 with the care necessary to prevent severe and/or irreversible brain damage. 2. Ensure Resident 1 who exhibited s/s of a stroke was immediately transferred to a GACH for evaluation and treatment to prevent severe and/or irreversible brain damage. 3. Ensure staff followed the facility’s policy and procedure (P/P), titled “Change of Condition Notification,” to call 911 to transport Resident 1 to a GACH for rapid intervention. There failures resulted in a delay of Resident 1's evaluation and treatment and inability for Resident 1 to receive tissue Plasminogen Activator ([tPA] a medication used to dissolve intravascular [pertaining to anything inside blood vessels] clots, return the blood supply in the brain and prevent severe and/or irreversible brain damage. Time frame for treatment is approximately three hours after the onset of symptoms). These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.