Other·February 9, 2024

F580 §483.10(g)(14) Notification of Changes. (i)A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). § 72311. Nursing Service--General. (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. (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. (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. On 12/8/2023, the California Department of Public Health (CDPH) received a complaint regarding Resident 1’s transfer to a General Acute Care Hospital for increased shortness of breath and hypoxia (oxygen levels in the blood lower than normal) due to the facility not administering Resident 1’s Continuous Positive Airway Pressure ([CPAP] a machine that uses mild air pressure to keep breathing airways open while a person sleeps) device every night as ordered by Resident 1’s physician. On 12/8/2023, CDPH conducted an unannounced visit to the facility to investigate the complaint. The facility failed to ensure Resident 1 received oxygen and respiratory care with his CPAP machine as ordered by Resident 1’s physician. The facility failed to: 1. Ensure the licensed nurses administer oxygen to Resident 1 at 5.0 liters per minute ([L/min]) via nasal cannula ([NC] a device that delivers oxygen through two thin plastic tubes inserted into the nose) continuously every shift to keep oxygen saturation (amount of oxygen in a person’s blood) above 92 % in accordance with the physician’s order. 2. Ensure the licensed nurses provided Resident 1 with CPAP machine every night as ordered by the physician. 3. Ensure the licensed nurses notified Resident 1’s physician when Resident 1’s oxygen saturation fell below 92%. 4. Ensure the licensed nurses did not remove Resident 1’s CPAP machine and did not administer oxygen at 2.0 L/min via NC when Resident 1’s oxygen saturation was below 92% on 11/21/2023. 5. Ensure the licensed nurses followed the facility’s policy and procedure titled, “CPAP/BiPAP (a non-invasive ventilation machine that is capable of generating two adjustable pressure levels) Support,” to provide Resident 1 with a CPAP machine to ensure Resident 1 was spontaneously breathing, improve the resident’s blood oxygenation due to Resident 1’s obstructive sleep apnea and diagnosis of COPD, and to promote the resident comfort and safety. As a result, on 11/22/2023 Resident 1 was transferred to a General Acute Care Hospital [GACH] for evaluation and treatment due to shortness of breath and out of range oxygen saturation of 89% (oxygen saturation reference range is 95% -100%). Resident 1 was admitted to the intensive care unit ([ICU] a unit in a hospital providing care for critically ill or injured patients) from 11/22/2023-12/7/2023, for a total of 15 days and readmitted to a GACH a second time from 12/8/2023 to 12/23/2023, a total of 15 days. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, a 78-year-old male, was admitted to the facility on 11/15/2023, with diagnoses including obstructive sleep apnea (a sleep-related breathing disorder which occurs when the throat muscles relax and blocks the airway) and chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1’s Minimum Data Sheet ([MDS]- a comprehensive standardized assessment and care screening tool) dated 11/18/2023, indicated Resident 1 had intact cognitive (ability to learn, understand, and make decisions), skills for daily decision making. The MDS indicated Resident 1 required maximum assistance from staff with toilet hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 was on continuous oxygen therapy and non-invasive mechanical ventilator (CPAP). A review of Resident 1’s care plan titled, “Needs Special Care Related to CPAP Machine Use” dated 11/16/2023, indicated the care plan interventions for use of the CPAP machine included to monitor the resident for episodes of shortness of breath, monitor the CPAP for use/function at nighttime and hours of sleep. A review of Resident 1’s care plan titled, “At risk for Altered Respiratory Status/Difficulty Breathing Related to Pneumonia (lung infection), COPD and Obstructive Sleep Apnea” dated 11/16/2023, indicated the care plan interventions included to observe and document changes in Resident 1’s orientation, air hunger (a sensation of a strong urge to breathe or a feeling of severe breathlessness), observe for signs and symptoms of respiratory distress (and report to a physician for increased respiration rate (respiration rates reference for an adult person at rest range from 12 to 16 breaths per minute), observed for decreased pulse oximetry (oxygen saturation), administer oxygen as ordered and provide Resident 1 with a CPAP machine every night with preset settings as ordered by a physician. Review of Resident 1’s Physician’s order dated 11/15/2023, contained an order for oxygen at five (5) L/min via NC continuously every shift for COPD exacerbation. Review of Resident 1’s Physician’s order dated 11/15/2023, contained an order for use of CPAP machine at bedtime. During a concurrent interview and record review on 12/26/2023 at 1:20 p.m. with the Director of Nursing (DON), Resident 1’s Licensed Nursing Progress Notes dated 11/17/2023 timed at 11:32 p.m. were reviewed. The DON stated the Licensed Nursing Progress Notes indicated Resident 1 was administered 4.0 L/min of oxygen via NC without a Physician’s order. The DON stated the Licensed Nursing Progress Notes contained physician orders for administration of 5 L/min not 4 L/min. The DON stated Resident 1’s physician was not informed of Resident 1’s desaturation (low oxygen saturation level between 87-90 % with a use of accessory muscles to breathe). The DON stated the licensed nurses removed the CPAP machine and administered oxygen via nasal cannula at 4.0 L/min. During a concurrent interview and record review on 12/26/2023 at 1:29 p.m. with the DON, Resident 1’s Licensed Nursing Progress Notes dated 11/18/2023 timed at 1:08 p.m., and 7:12 p.m. were reviewed. The DON stated the Licensed Nursing Progress Notes indicated Registered Nurse (RN 3) administered oxygen to Resident 1 via NC at 3L/min without a physician’s order. During a concurrent interview and record review on 12/26/2023 at 1:37 p.m. with the DON, Resident 1’s Licensed Nursing Progress Notes dated 11/18/2023 and timed at 10:53 p.m., and 11:06 p.m. were reviewed. The DON stated the Licensed Nursing Progress Notes indicated Licensed Vocational Nurse 3 (LVN 3) attempted to have Resident 1 use the CPAP machine, but Resident 1’s oxygen saturation was 82%. Oxygen saturation reference range is 95% to 100 %. The DON stated the Licensed Nursing Progress Notes indicated LVN 3 did not inform Resident 1’s physician Resident 1’s oxygen saturation level was 82 % (out of range) on 11/18/23 at 10:53 p.m., and that a CPAP machine was not used. The DON stated the Licensed Nursing Progress Notes did not contain any documentation for Resident 1’s change of condition or notification of the resident’s physician of the change of condition. During a concurrent interview and record review on 12/26/2023 at 1:49 p.m. with the DON, the Licensed Nursing Progress Notes dated 11/19/2023 and timed at 6:43 a.m. were reviewed. The DON stated the Licensed Nursing Progress Notes documented LVN 9 administered oxygen to Resident 1 at 5.0 L/min continuously via NC and a CPAP machine was not used. The DON stated the Licensed Nursing Progress Notes revealed LVN 9 did not notify Resident 1’s physician that he was not being treated as ordered with a CPAP machine. A review of Resident 1’s Licensed Nursing Progress Notes dated 11/19/2023, at 1:41 p.m. documented RN 3 administered oxygen to Resident 1 at 3L/min via NC. A review of Resident 1’s Licensed Nursing Progress Notes dated 11/20/23 timed at 8:34 a.m. documented LVN 7 administered oxygen to Resident 1 at 3L/min via NC. A review of Resident 1’s Licensed Nursing Progress Notes dated 11/20/23 and timed at 1:04 p.m. documented RN 3 administered oxygen to Resident 1 at 3L/min via NC. During a concurrent interview and record review on 12/26/2023 at 1:49 p.m. with the DON, Resident 1’s Licensed Nursing Progress Notes dated 11/21/23 and timed at 2:10 a.m. and 8:23 p.m. were reviewed. The DON stated the Licensed Nursing Progress Notes documented on 11/21/2023 at 2:10 a.m. LVN 6 administered oxygen to Resident 1 at 2 L/min via NC and at 8:23p.m. and LVN 6 administered oxygen to the resident at 5 L/min via NC on 11/21/2023 at 8:23 p.m. The DON stated there was no documentation in the chart that Resident 1 was placed on the CPAP machine on 11/21/2023. The DON stated there was also no documentation in the chart notating Resident 1’s physician was notified Resident 1 was receiving oxygen at 2 L/min or that Resident 1 was not placed on a CPAP machine during the nightshift (11 p.m-7 a.m.) on 11/21/2023. A review of Resident 1’s Licensed Nursing Progress Notes dated 11/22/2023 and timed at 6:17 p.m. indicated Resident 1 was not able to breathe and Resident 1’s oxygen saturation was 80% while the resident was receiving oxygen at 5.0 L/min via nasal cannula. The Licensed Nursing Progress Notes documented Resident 1 was provided with oxygen via non-rebreather mask (special medical device that helps provide with higher concentration of oxygen in emergencies) and Resident 1’s oxygen saturation increased to 89%. The Licensed Nursing Progress Notes documented Resident 1’s oxygen saturation was 81% to 87% via NC. Resident 1 was transferred to GACH on 11/22/23 at 7:46 p.m. A review of Resident 1’s Admission Record (Face Sheet), indicated the Resident 1 was re-admitted to the facility from the GACH on 12/8/2023. A review of Resident 1’s Licensed Nursing Progress Notes dated 12/8/23 timed at 5:27 a.m. revealed Resident 1’s oxygen saturation was 85% one hour after the CPAP was removed by LVN 7. The Licensed Nursing Progress Notes further documented Resident 1 was receiving 5.0 L/min of oxygen via nasal cannula and had a heart rate of 130 beats/min (reference range 60 to 100 beats per minute). Resident 1 was transferred to a GACH on 12/8/2023 (no time indicated) after eight and half hours post re-admission to the facility. During a telephone interview on 12/26/2023 at 1:56 p.m., RN 3 stated the licensed staff should have followed Resident 1’s physician’s orders to administer oxygen at 5L/min via nasal cannula continuously. RN 3 stated if a licensed nurse administers less or more oxygen than the physician ordered, Resident 1’s physician should have been notified. RN 3 further stated the licensed nurses should have obtained a physician’s order prior to adjusting the amount of oxygen administration. RN 3 stated administering a higher amount of oxygen than ordered could place the resident at risk for oxygen toxicity (harmful effects that can occur when a resident was exposed to high levels of oxygen). RN 3 stated administering a smaller amount of oxygen could also create a risk the Resident will experience desaturation (low oxygen levels). During a telephone interview on 12/26/2023 at 2:15 p.m., Resident 1’s physician stated a resident diagnosed with COPD can receive 5.0 L/min of oxygen via NC to keep the resident’s oxygen saturation level at or above 92%. The physician stated the facility did not inform him when Resident 1’s oxygen saturation level dropped below 90% on 11/18/2023. Resident 1’s physician further stated he was not informed of Resident 1 oxygen saturation levels as follows: 87 % on 11/17/23, 82% on 11/18/23, 81% on 11/22/23 and 85% on 12/8/23. Resident 1’s physician stated he was not informed Resident 1 was not placed on the CPAP machine from 11/17/2023 to 11/19/2023, from 11/21/2023 to 11/22/2023 and on 12/7/2023. During a telephone interview on 12/26/2023 at 2:40 p.m., LVN 8 stated when Resident 1 was placed on the non-rebreather mask on 11/21/2023, a higher dosage of oxygen up to 15 L/min should have been applied and not 5 L/min. LVN 8 stated the licensed nurses must obtain an order from Resident 1’s physician and document in Resident 1’s Licensed Nurses Progress Notes. LVN 8 stated if it was not documented it was not done. During an interview on 12/26/2023 at 4:10 p.m., the DON stated when Resident 1’s oxygen saturation fell below 92% and the CPAP was not administered on 11/17/2023 to 11/19/2023, 11/21/2023 to 11/22/2023, and 12/7/2023, the licensed nurses should have notified Resident 1’s physician, monitored Resident 1’s oxygen saturation and respiratory status including rate of respiration, breathing pattern, and use of accessory muscles continuously. During a telephone interview on 12/26/2023 at 4:15 p.m., LVN 3 stated on 11/17/2023 at 11:32 p.m. she removed Resident 1’s CPAP machine and administered 4.0 L/min of oxygen via NC. LVN 3 confirmed she did not notify Resident 1’s physician. LVN 3 stated she checked the CPAP mask seal and setting, monitored Resident 1’s oxygen saturation but did not document these treatments were performed. LVN 3 stated she should have left Resident 1 on the CPAP machine per his physician’s order. During a telephone interview on 12/27/2023 at 8:55 a.m., Resident 1, while at another skilled nursing facility, stated