Other·December 20, 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. §72301 - Required Services (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. §72311 - Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. §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. Resident 1 was a 63-year-old male who had continuous vomiting on 7/19/2021, becoming unresponsive, and subsequently dying in the facility on 7/19/2021 at 7:17 AM. Resident 1 died from complications of sepsis (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration (when something enters the airways by accident) of contaminated gastric contents. The facility failed to provide Resident 1 with the quality of care consistent with maintaining Resident 1’s highest practicable physical well-being, including but not limited to: a. Thoroughly assessing and evaluating Resident 1 after having episodes of vomiting (forcefully expelling the stomach's contents out of the mouth). b. Notifying the physician when Resident 1 had episodes of vomiting in accordance with the physician's orders and care plans. c. Stopping Resident's 1 oral intake until the physician was notified and determined it was safe to restart oral intake after Resident 1's episodes of vomiting. d. Monitoring Resident 1's stool for consistency, color, and characteristics. The facility originally admitted Resident 1 on 1/20/2021 and readmitted from the hospital on 4/14/2021, with diagnoses including type 2 diabetes mellitus (affects the way the body processes blood sugar), acute respiratory failure (caused by a disease or injury that affects your breathing), hyperlipidemia (abnormally high levels of fats in the blood), Alzheimer's disease (disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys, the organs that filter waste and excess fluid from blood, leading to kidney failure), and extrapyramidal and movement disorder (uncontrollable movements and muscle tremors). Resident 1 had the capacity to express ideas and wants and had a clear understanding of others. Resident 1 needed extensive assistance (resident involved in activity and staff provided one-person physical assist) with activities of daily living (ADLs, tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). The MDS indicated Resident 1 required extensive assistance when eating with one-person physical assist. During a record review of the care plan, Constipation, initiated 4/14/2021, the care plan indicated that Resident 1 will be free from fecal impaction (large, hard, immobile mass of stool that gets stuck in the colon [large intestines] or rectum). An intervention implemented to reach the goal was to observe Resident 1 closely for signs and symptoms of fecal impaction such as: watery stool, straining (difficult for stool to pass through), distended abdomen (bloating and swelling in the belly area), vomiting, and fever. During a record review of the care plan, At Risk for Fluid Volume Deficit/Complications Related to Nausea/Vomiting, dated 7/18/21, the care plan indicated Resident 1's goal was to be free from signs and symptoms or complication related to nausea and vomiting. An intervention implemented to reach the goal was to monitor for persistent nausea/vomiting and report to the physician. During a record review of Resident 1's summary of physician orders, dated 7/1/2021 through 7/31/2021, the summary of physician orders indicated that on 4/14/2021, the physician ordered Fluvoxamine (medication to treat depression, a common and serious medical illness that negatively affects how you feel, the way you think and how you act) 50 milligrams (mg, a unit of measure) by mouth three-times-a-day. The physician further ordered to monitor the side effects of Fluvoxamine every shift and that common side effects included drowsiness, insomnia (continued problems falling and staying asleep), dry mouth, nausea (urge to vomit), vomiting, tremor (involuntary shaking or movement), increased agitation (state of nervous excitement), and to notify the physician if noted. During a record review of Licensed Vocational Nurse 3's (LVN 3) licensed nurse progress notes dated 7/18/2021, at 3:45 PM, LVN 3's progress note indicated that on 7/18/2021, at approximately 3:30 PM, Resident 1 was noted to have tan colored vomitus (matter that was expelled from the stomach) on Resident 1's gown. LVN 3's note indicated, the previous charge nurse (LVN 2) also reported that Resident 1 vomited during the 7:00 AM- 3:00 PM shift on 7/18/2021. Further review indicated no documented evidence of physician or family notification of Resident 1's episodes of emesis. During a record review of Resident 1's medication administration record (MAR), for the month of July 2021, the MAR indicated that on 7/18/2021 Resident 1 had the following oral intake (after vomiting a large amount at approximately 3:30 PM): a. Routine oral medications at 5:00 PM: 1. Fluvoxamine, 50 mg one (1) tablet (tab) 2. Docusate sodium (stool softener) 100 mg 1 tab 3. Lactobacillus acidophilus (supplement to aid digestion) 1 tab 4. Ascorbic acid (vitamin C supplement) 500 mg 1 tab 5. Apixaban (blood thinner) two and one-half (2.5) mg 1 tab 6. Calcium-vitamin D (supplement) 500 mg-125 international units 1 tab b. Dinner at 5:30 PM: 1. Fifty percent (50%) of mechanical soft (texturally altered meal that allows for easier chewing and swallowing) 2. Four (4) ounces of no sugar added (NSA) Healthshake (nutritional supplement) 3. 120 milliliters (mL, a unit if measure) of Diabetic Advanced Control (AC) source (feeding formula to provide for added nutrients). c. Bedtime at 9:00 PM: 1. Snack 2. Atrovastatin (to lower cholesterol) 10 mg 1 tab 3. Ferrous sulfate (supplement) 325 mg 1 tab 4. Donepezil (to treat confusion related to Alzheimer's Disease, a brain disorder slowly destroying memory and thinking skills, and, eventually, the inability to carry out the simplest tasks) 5 mg 1 tab During a phone interview on 9/16/2021, at 2:29 PM, with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated that on 7/18/2021 at the end of the morning shift (7:00 AM through 3:00 PM), LVN 2 stated that Resident 1 vomited. CNA 2 stated she cleaned up Resident 1 and had to change the bed linen. CNA 2 stated the vomitus was brown and a large amount was all over the bed. During a phone interview on 9/16/2021, at 3:25 PM, with CNA 4, CNA 4 stated that on 7/18/2021 at 4:30 PM, during routine rounding (timely rounding to routinely meet resident's needs), CNA 4 noted that Resident 1 vomited a large amount, enough to cover the entire bed and the whole bed, requiring the bed linens to be changed. CNA 4 stated she notified LVN 3. CNA 4 stated, during the shift when she came back from break, CNA 5 reported to CNA 4 that Resident 1 vomited a smaller amount. CNA 4 stated she notified LVN 3 of the episode of vomiting reported by CNA 5. During an interview on 9/16/2021, at 4:06 PM, with the physician (MD 1), MD 1 stated that he was not notified that Resident 1 vomited on 7/18/2021 or on 7/19/2021. MD 1 stated that he should have been notified of the vomiting incident and any changes in resident condition. During a phone interview, on 9/17/2021, at 4:00 AM, with Licensed Vocational Nurse 6 (LVN 6, Resident 1's assigned nurse for 7/18/2021 11:00 PM through 7/19/2021 7:00 AM), LVN 6 stated he did not receive verbal or written report and endorsement of a completed change of condition (COC) from the two (2) previous nurses (LVN 3 and 2) that Resident 1 had vomited multiple times on 7/18/2021. LVN 6 stated that there was no documented evidence that the physician was notified of Resident 1's episodes of vomiting. LVN 6 stated he received report (on 7/18/21 at around 11:00 PM) from LVN 3 that "everything was fine" with Resident 1. LVN 6 stated on 7/19/2021 at 6:45 AM, a CNA prompted him and all the nurses to check Resident 1 because Resident 1 was unresponsive. LVN 6 immediately responded, attempted to check Resident 1's pulse (heartbeat per minute) and vital signs (respiratory rate, blood pressure [BP, force that moves blood in the body, and temperature) but was unsuccessful. LVN 6 stated cardiopulmonary resuscitation (CPR, lifesaving technique combining chest compressions and artificial ventilation [means of assisting or stimulating respiration] to help restore spontaneous blood circulation and breathing in a person who was in cardiac arrest [sudden, unexpected loss of heart function, breathing, and consciousness]) was immediately started and 911 was called. LVN 6 stated he did not observe Resident 1 vomiting but observed a small amount of vomitus on Resident 1's gown. During an interview on 9/17/2021, at 10:40 AM, with Registered Nurse 1 (RN 1), RN 1 stated Resident 1's vomiting should have been addressed by thoroughly assessing Resident 1 and notifying the physician and family. RN 1 stated there was no documented evidence Resident 1 was thoroughly assessed and that the physician was notified after the episodes of vomiting. During a record review of Resident 2's undated Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on 5/2/2021, with diagnoses including type 2 diabetes, atrial fibrillation (abnormal heartbeat), chronic kidney disease, cardiomegaly (enlarged heart), and anxiety disorder (mental health condition involves more than temporary worry or fear). A record review of Resident 2's MDS dated 5/13/2021, indicated Resident 2 had the capacity to express ideas and wants and had a clear comprehension and understanding of others. Resident 2 had clear speech and was able to hear. During a record review of the facility's census dated 7/19/2021, the census indicated Resident 1 and Resident 2 were roommates. During a phone interview on 9/18/2021, at 5:41 PM, with Resident 2, Resident 2 stated that Resident 1 was his roommate. Resident 2 stated on 7/18/2021, the day before Resident 1's death, Resident 2 heard and saw Resident 1 vomit three to four times and recalls that two certified nurse assistants (could not verbalize which CNAs) cleaned up Resident 1. On the morning of 7/19/2021, Resident 2 stated that Resident 1 was vomiting and choking. Resident 2 stated that upon hearing Resident 1 vomiting and choking, Resident 2 pressed the call light (device used in facilities to signal staff for assistance) to get help. Resident 2 stated that the staff did not respond right away. Resident 2 could not verbalize how long it took staff to respond. During a record review of the Resident 1's prehospital care report from the fire department in the county of Los Angeles, dated 7/19/21, the prehospital care report indicated paramedics arrived in the facility on 7/19/2021 at 6:54 AM and the paramedics took over CPR; automated external defibrillator (AED, a portable electronic device that automatically diagnoses the life-threatening heart problems) was applied and Resident 1's heart rhythm indicated asystole (no electricity or movement in the heart). Resident 1's record from the paramedics indicated an assessment exam performed on 7/19/2021 at 6:57 AM showed that Resident 1 had fixed and dilated pupils (pupils that do not respond to light or other stimuli). Resident 1 was unresponsive and had no blood pressure, no pulse, and no respirations. The paramedics medicated Resident 1 with epinephrine (medication give in emergencies to restore the heartbeat) at 7:02 AM, 7:07 AM, and at 7:14 AM. On 7/19/2021 at 7:17 AM the paramedics halted resuscitation efforts and Resident 1 was pronounced dead. During a record review of Resident 1 certificate of death, dated 7/24/2021, the death certificate indicated Resident 1's cause of death was acute cardiopulmonary arrest. During a record review of Resident 1's final autopsy (exam done after death to discover the cause of death) report, completed on 7/29/2021 at 5:00 AM, the final autopsy report indicated that Resident 1died from complications of sepsis (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration of contaminated gastric contents. The autopsy indicated that agonal aspiration had occurred with formed food particles present in the upper airways. The autopsy indicated significant fecal impaction with 1,800 grams (a unit of weight) of fecal material in the sigmoid colon (portion of the large intestines before reaching the rectum) and rectum (last several inches of the large intestine leading to the anus, the opening to the outside of the body), likely causing toxic megacolon (life threatening condition characterized by extreme inflammation [localized reaction that produces redness, warmth, swelling and pain], and distention [swelling] of the colon), adding to the infectious nature of the death. The immediate cause of death was sepsis and acute pneumonia due to the above conditions. During a phone interview with RN 1 on 11/4/2021 at 3:38 PM, RN 1 confirmed Resident 1 had a physician order dated 4/14/2021 for staff to monitor Resident 1's bowel movements every shift, noting the size, amount, consistency, color, frequency, and characteristics. RN 1 stated from 7/1/2021 through 7/19/2021, there were 21 missed opportunities where the CNAs did not document the consistency, color, and characteristics of Resident 1's bowel movement, were noted on the following dates: 7/1/2021 10:39 AM 7/2/2021 12:01 PM 7/5/2021 2:54 PM 7/6/2021 6:53 AM 7/6/2021 10:47 AM 7/7/2021 6:36 AM 7/7/2021 10:00 AM 7/8/2021 1:30 PM 7/9/2021 1:31 PM 7/10/2021 12:55 PM 7/11/2021 6:53 AM 7/11/2021 9:25 AM 7/12/2021 6:53 AM 7/14/2021 9:50 AM 7/15/2021 9:35