Health inspection·June 23, 2023

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 5/5/2023 the California Department of Public Health (CDPH) received a complaint indicating Resident A had a change of condition (COC) and was later transferred to a general acute care hospital (GACH) where he passed away five days later. On 5/5/2023, at 12:59 p.m., CDPH made an unannounced visit to the facility to investigate the allegation. Upon investigation it was determined that following Resident 1’s sudden COC, the facility did not monitor or assess Resident 1 for over seven hours. Resident 1 was transferred to a GACH, admitted to its Intensive Care Unit ([ICU] a unit in the hospital that provides the critical care and life support for acutely ill and injured patients), where he was intubated (insertion of tube either through the mouth or nose into the airway to aid with breathing, deliver anesthesia or medic ions) for eight days. Resident 1 was diagnosed with an acute cerebral vascular accident ([CVA] a disruption of blood to the cells in the brain [stroke]) and deemed outside of the treatment window (within three hours of having a stroke, or for some eligible patients, up to 4.5 hours after the onset of a stroke) for treatment using tissue plasminogen activator ([tPA] a drug often used to treat CVA, when given in a timely manner can reduce damage to the brain by restoring blood flow to brain regions affected by a stroke). Resident 1 expired on 2/11/2023 at 1 a.m. The facility failed to: 1. Continuously assess and monitor Resident 1’s status after he exhibited a significant COC as ordered by the physician on 2/3/2023. 2. Assess and recognize an emergent situation sooner than seven hours after Resident 1’s COC that the intervention of providing IV fluids to Resident 1 was not effective, preventing a timely transfer of Resident 1 to the GACH during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective. 3. Follow the facility’s Policy and Procedure (P&P) titled “Change of Condition, Resident,” which stipulated, to intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. This failure resulted in Resident 1 being unmonitored and unassessed for over seven hours leading to a delay in Resident 1’s evaluation and the GACH’s inability to render appropriate treatment in a timely manner. A review of Resident 1’s Admission Record, (Face Sheet) indicated the facility admitted Resident 1 on 1/29/2023 with diagnoses including encephalopathy (altered brain function) and chronic kidney disease ([CKD] when the kidneys are damaged and cannot filter blood). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 1/29/2023 indicated Resident 1’s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 had clear speech, was usually understood, and had the ability to understand others. A review of Resident 1’s Change of Condition (COC) note, dated 2/3/2023 and timed at 12:30 p.m., indicated Resident 1 was usually more alert and talkative but became less responsive to staff and to stimuli (anything that triggers a physical or behavioral change). The COC indicated Resident 1 had a sudden altered level of consciousness ([ALOC] when a patient is not as awake, alert, or able to understand or react as normal). The COC indicated staff notified Resident 1’s physician and the physician put in an order for intravenous ([IV] a method of putting drugs or other substance through a needle or tube inserted into a vein) fluids. A review of Resident 1’s Progress Notes (PN), dated 2/3/2023 and timed at 12:30 p.m., indicated staff notified Resident 1’s physician that Resident 1 was less responsive to staff and to stimuli, would not open her eyes, her mucous membranes appeared dry, there was visible skin tenting (when the skin is pinched and it stays up in a tent shape once you let it go, people who are dehydrated may experience this) and Resident 1 had only urinated twice since midnight (2/3/2023). The PN indicated Resident 1’s vital signs ([v/s] measurements of the body’s most basic functions, the main ones being temperature, pulse rate, breathing rate and blood pressure) were as follows: 1. Blood pressure was elevated at 176/92 millimeters of mercury ([mm Hg] a unit of measurement, normal range less than 130/80 for a male over 65). 2. Heart rate 73 beats per minute ([bpm] normal range 60- 100 bpm). 3. Respirations 18 breaths per minute ([bpm] normal range 12-18 bpm). 4. Temperature was 97.7 degrees Fahrenheit ([F] scale for measuring temperature, normal range 97.8 F-99.1 F). 5. Blood sugar was 126 milligrams per deciliter ([mg/dl] a unit of measurement; amount of glucose (sugar) in the blood]) normal range 90-130 mg/dl). A review of PN dated 2/3/2023 and timed at 12:30 p.m., indicated Resident 1’s physician ordered Resident 1 to receive 2000 milliliters [(ml) unit of liquid measurement) of Normal Saline ([NS] a mixture of sodium [salt]) chloride and water) 0.9% at the rate of 100 ml/per hour and to continue monitoring. At 2 p.m., (one hour and thirty minutes after Resident 1’s initial COC assessment) the PN indicated Resident 1’s IV was removed due to Resident 1’s activity. The PN indicated Resident 1 responded to physical stimuli and was able to open both eyes with a focused stare. A review of Resident 1’s Electronic Medication Administration Record (eMAR) note, dated 2/3/2023 and timed at 3:16 p.m., indicated to monitor and document every shift, and report to the physician (MD) Resident 1’s signs and symptoms (s/s) of dehydration including tenting skin, new onset of confusion, dizziness on sitting and standing, increased pulse, headache, fatigue, weakness, and dizziness. The eMAR note indicated an endorsement was made to the incoming evening shift nurse to indicate Resident 1 was extremely fatigued (tired), responsive but could not keep his eyes open and Resident 1’s physician ordered IV hydration. A review of Resident 1’s PNs dated 2/3/2023, indicated there were no additional assessments of Resident 1’s v/s, urinary status, skin, lips, mucous membranes, or the resident’s cognitive status. A review of Resident 1’s eMAR, dated 2/3/2023 and timed at 7:54 p.m., (seven hours and 25 minutes after Resident 1’s initial COC assessment) indicated Resident 1 was not verbally responsive at this time. Resident 1’s eMAR notes and PNs indicated there was no documentation of another assessment or continued monitoring after Resident 1’s initial COC at 12:30 p.m. A review of Resident 1’s Health Status Note (HSN), dated 2/3/2023 and timed at 8:45 p.m., (eight hours and 15 minutes after Resident 1’s initial COC assessment), indicated Resident 1 remained in a sleeping state and was not easy to arouse. The HSN indicated due to Resident 1’s continued altered status, Resident 1’s physician instructed staff to transfer Resident 1 to a GACH for further evaluation. A review of Resident 1’s Physician’s Orders (PO), dated 2/3/2023, indicated to transfer Resident 1 via 911 for further evaluation. A review of the GACH’s Emergency Department (ED) notes, dated 2/3/2023, indicated Resident 1 arrived at the ED at 9:05 p.m., and was intubated upon arrival to protect his airway. A review of the ED’s Physical Exam (PE), indicated Resident 1’s Glasgow Coma Scale ([GCS] a clinical scale used to reliably measure a person’s level of consciousness after a brain injury, severe=8 or less, moderate=9-12, mild=13-15) was a 6, his pupils were pinpoint (indicates a problem with your health), he was only moving his left upper extremity, bilateral lower extremities and he had a right sided facial droop. A review of GACH’s History of Present Illness (HPI), indicated Resident 1 was not a candidate for tPA as he was outside the window for treatment, as confirmed during a neurology consult and by a neuro-interventionalist (a doctor who specializes in treatments of the brain, neck, and spine). A review of the GACH’s Computed Tomography ([CT] a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) report dated 2/3/2023 and timed at 9:22 p.m., indicated Resident 1 suffered a left middle carotid artery ([MCA] a major artery that supplies blood to the brain) occlusion (complete or partial blockage of a blood vessel). A review of Resident 1’s GACH Discharge Summary (DS) dated 2/11/2023 and timed at 5:37 p.m., indicated intervention was not deemed appropriate for Resident 1 as it would not provide any meaningful benefit to quality of life, as his prognosis was already grim given the large size of the infarct (blockage in blood supply). The DS indicated Resident 1’s family was made aware and came to the decision to initiate comfort care (care to control pain and other symptoms so the patient can be as comfortable as possible). The DS indicated Resident 1 passed away on 2/11/2023. During a telephone interview with Resident 1’s Responsible Party (RP) on 5/5/2023 at 2:38 p.m., the RP stated she was present when Resident 1 had a COC (2/3/2023). The RP stated, at approximately 11:30 a.m., she was talking to Resident 1 when the resident suddenly stopped talking. The RP stated she left Resident 1 and found a nurse and reported what happened, and that nurse grabbed another nurse to check on Resident 1. The RP stated the nurse told her Resident 1 looked dehydrated, they called Resident 1’s physician and obtained an order to start Resident 1 on IV fluids. The RP stated she left the facility and returned at approximately 7:30 p.m., the same day, and when she went to see Resident 1 she found the resident in the same condition as the resident was previously at 11:30 a.m. The RP stated she went to get a nurse and asked why Resident 1 was still in the same condition, the nurse checked Resident 1 and stated Resident 1 needed to be transferred out immediately. The RP stated the GACH told her Resident 1 had suffered a major stroke. During an interview with Registered Nurse 1 (RN 1) on 5/5/2023 at 4:01 p.m., RN 1 stated when a resident has a sudden change of consciousness it is important to call 911 as soon as possible. If it is a possible stroke, time becomes an important factor when treating the stroke. During an interview with the Director of Nursing (DON) on 5/8/2023 at 2:06 p.m., the DON stated if a resident has a COC, staff call the MD to report the resident’s status and obtain orders as needed. The DON stated staff continue to monitor the resident to see if the interventions that were implemented worked. The DON stated the resident’s COC is reported to the oncoming nurses during their huddle, so incoming nurses will continue to monitor the resident. The DON stated if a resident is known to be verbal, suddenly stops talking and only responds to painful stimuli, staff need to escalate the situation and call 911 immediately. The DON stated she was unaware of Resident 1’s COC until later that evening. The DON stated when she assessed Resident 1, Resident 1 was not responding verbally but was able to move, he was able to squeeze the DON’s hands but was very weak. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/9/2023 at 3:43 p.m., LVN 1 stated at the beginning of shift, a report is given about all residents who have COCs during the outgoing shift, so the incoming shift knows to monitor and document any changes and/or if the interventions are working for the resident. LVN 1 stated any residents with COCs need to be monitored closely. During an interview with LVN 5 on 5/10/2023 at 11:20 a.m., LVN 5 stated it was important to continue monitoring residents with any COC and to document any findings whether there is a change or not. During a phone interview with RN 2 on 5/10/2023 at 2:52 p.m., RN 2 stated she reported her findings to Resident 1’s physician after assessing Resident 1. RN 2 stated when she assessed Resident 1 there was nothing indicating a stroke, so she thought he had an infection or was dehydrated. RN 2 stated, Resident 1 was moving around a lot and was very active. RN 2 stated she did not remember if she reported to Resident 1’s physician that he (Resident 1) could not speak or if she endorsed Resident 1’s status to the incoming shift. A review of the facility’s LVN Job Description (JD), dated 8/2011, indicated qualifications included being knowledgeable of nursing/medical practices and procedures. Safety concerns are identified, and appropriate actions are taken to maintain a safe environment including recognizing emergency situations and appropriate action is instituted in a timely matter. A review of the facility’s RN Supervisor JD, dated 8/2011, indicated the RN’s responsibilities included performing assessments and identifying changes in resident’s physical or psychological condition. A review of the facility’s P&P, titled “Change of Condition, Resident,” revised 11/2017, indicated it is the policy of the facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective matter. In the event of a life-threating situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and possible transport to an acute hospital. The staff will continue to monitor and document resident’s condition at a minimum of every shift for 72 hours and as needed, until the acute episode has subsided, and the resident is stable. 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 tPA, 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. The facility failed to: 1. Continuously assess and monitor Resident 1’s status after he exhibited a significant COC as ordered by the physician on 2/3/2023. 2. Assess and recognize an emergent situation sooner than seven hours after Resident 1’s COC that the intervention of providing IV fluids to Resident 1 was not effective, preventing a timely transfer of Resident 1 to the GACH during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective. 3. Follow the facility’s P/P titled “Change of Condition, Resident,” which stipulated, to intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. This failure resulted in Resident 1 being unmonitored and unassessed for over seven hours leading to a delay in Resident 1’s evaluation and the GACH’s inability to render appropriate treatment in a timely manner. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.