Health inspection·September 29, 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.

F726 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. § 72311. Nursing Services (a)Nursing service shall include, but not be limited to, the following: (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. (E)Any untoward response or reaction by a patient to a medication or treatment. (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. § 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. The Department received a complaint on 7/6/2021 alleging a resident (Resident 1) was not receiving breathing treatments during the week of 6/7/2021 through 6/10/2021, and the resident’s Bi-level Positive Airway Pressure ([BiPAP] non-invasive ventilation machine that delivers oxygen to assist with breathing) machine was not working properly. Resident 1 complained to facility’s staff on numerous occasions of the ineffectiveness of the BiPAP machine and the error message being displayed on the BiPAP machine. The complainant alleged he called the facility numerous times during the week to have the BiPAP repaired or replaced with no response. On the morning of 6/10/2021, Resident 1 was transferred to a general acute care hospital (GACH) and passed away within two hours of arrival. On 7/7/2021, an unannounced complaint investigation was conducted at the facility. Based on interview and record review, the facility failed to do the following: 1. Ensure Registered Nurse 1 (RN 1) and Licensed Vocational Nurses 1, 2, and 3 (LVNs 1, 2, and 3), were competent and knowledgeable in the use of a Bi-level Positive Airway Pressure (BiPAP) and possessed skills for care and assessment during treatment. 2. Ensure Resident 1’s respiratory equipment, the use of a BiPAP machine, was in good condition and functioning properly as required by the care plan and policies and procedures. 3. Notify Resident 1’s physician of the resident’s refusal for respiratory care treatments, as required by the regulations and policy and procedures, when Resident 1 refused to use the BiPAP machine that was not working properly and experienced episodes of hyperventilation (rapid breathing). 4. Ensure Resident 1 was provided medication of oxygen, as ordered, through the BiPAP machine pursuant to the physician order. As a result, there was a delay in provision of care and an unexpected decline in Resident 1’s health. Resident 1, who had a diagnosis of chronic obstructive pulmonary disease ([COPD] inflammation of the lungs that causes obstructed airflow of the lungs) required continuous oxygen support. Resident 1 was found unresponsive on 6/10/2021 after not receiving prompt pulmonary (pertaining to the lungs) care after exhibiting hyperventilation and a COPD exacerbation, died at a general acute care hospital (GACH) within two (2) hours after being transferred. During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1, a 60 year-old female, was admitted to the facility on 6/4/2021, six days before her death. Resident 1's diagnoses included acute worsening of COPD, acute and chronic respiratory failure (syndrome in which the respiratory system fails in gas exchange functions) with hypoxia, acute and chronic respiratory failure with hypercapnia, dependence of supplemental oxygen, and pleural effusion (an abnormal collection of fluid between the thin layers of tissue [pleura] lining the lungs and the wall of the chest cavity) with dyspnea (difficulty breathing). During a review of Resident 1’s authorization referral for a BiPAP machine, dated 6/1/2021 and timed at 4:03 p.m., the authorization indicated an order for a respiratory assist device BiLevel with a facemask humidifier and tubing for Resident 1’s use at the skilled nursing facility (SNF). The referral indicated Resident 1 received the delivery of the BiPAP machine device on 6/3/2021.   During a review of a Compliance report from the BiPAP distributer, the report indicated graphs of Resident 1 receiving the BiPAP oxygen therapy on 6/4/2021 for 4 hours, on 6/5/2021 for 2.5 hours and on 6/6/2021 and 6/9/2021 less than half hour. The compliance report indicated Resident 1 did not receive oxygen therapy with the BiPAP machine on 6/7/2021 or 6/8/2021. According to the distributor’s compliance report, the average usage of the machine by Resident 1 was an hour and 26 minutes from 6/4/2021 to 6/9/2021. During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 6/10/2021, the MDS indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and understood others. The MDS indicated Resident 1 required extensive assistance of one-person staff assistance for dressing, toileting, personal hygiene, and bed mobility. During a review of Resident 1's electronic Medication Administration Record (eMAR), dated 6/4/2021, the eMAR indicated an order to be placed on the BiPAP machine at 9 p.m. and off at 6 a.m. everyday via nose pillow (cushions that seal at the base of the nostril and are help in place with a stretchy strap that goes around the back of the head) at bedtime. The eMAR indicated once at nighttime to check Resident 1’s heart rate (pulse), respirations, oxygen saturation, and remove per schedule. According to the EMAR, the nursing staff signed that Resident 1 was placed on the BiPAP machine daily, except for a single refusal on 6/9/2021 at 9 p.m. The EMAR indicated Resident 1's BiPAP machine was removed daily at 6 a.m. including the date of her death on 6/10/2021 [sic]. During a review of Resident 1's care plan titled, "COPD," dated 6/15/2021, the care plan goal was for Resident 1 to not experience signs or symptoms of poor oxygenation absorption. The staffs' interventions included to monitor for signs or symptoms of respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, administer oxygen by nasal cannula (thin plastic tubing inserted in the nose to deliver oxygen) at 3 liters/per minute, BiPAP machine on at 9 p.m. off at 6 a.m., wash tubing and headgear with whisper swivel if utilized, monitor for difficulty breathing on exertion, monitor and document oxygen saturation (percentage of oxygen absorbed in blood) every shift daily, monitor and document for anxiety, and give aerosol or bronchodilators (medication use to open the lungs and allow airflow) as ordered monitor and document any side effects or effectiveness. During a review of Resident 1's Nursing Progress Notes (NPN), dated 6/8/2021 and timed at 12:57 p.m., the NPN indicated Resident 1 and the resident's family member (FM 1) had verbalized something was wrong with the BiPAP machine (the machine had exhibited error messages). The NPN indicated for the staff to call the BiPAP distributer and speak with a representative and provide all information. The distributer will call resident to verify BiPAP machine concerns. The NPN note indicated a staff communicated the information with FM 1 and Resident 1. During a review of Resident 1's "Skilled Care Assessment (SCA)," dated 6/8/2021 and timed at 10:40 p.m., the SCA indicated Resident 1's vital signs were as follows: blood pressure (BP) of 128/68 (Normal Reference Range [NRR] 90/60-139/79), body temperature of 97.8 Fahrenheit ([F] NRR 97.9 to 99), and heart rate of 74 beats per minute ([bpm] NNR 60-100 bpm), respirations of 17 (NRR 12-20), oxygen saturation of 96% (NRR 95% to 100%) with oxygen via nasal cannula at 3 liters/minute. The assessment indicated Resident 1 was provided with return demonstration respiratory care (training) for the BiPAP machine. The assessment indicated Resident 1 refused BiPAP when offered, continuous oxygen at 3 liters/minute via nasal cannula for shortness of breath (SOB). Head of bed (HOB) slightly elevated, alert, and oriented verbalized needs and discomforts known. During a review of Resident 1's NPN, dated 6/8/2021, and timed at 10:46 p.m., created and written by Licensed Vocational Nurse [LVN 3] on 6/10/2021 at 10:49 p.m., the NPN indicated a call was received from the BiPAP machine distributer around 3:30 p.m. regarding the BiPAP machine having a leak. The BiPAP machine distributer assisted by phone on how to reset the BiPAP machine. The BiPAP machine distributer stated the BiPAP must be on Resident 1 before it was turned on. The NPN indicated Resident 1 was informed and understood. The BiPAP machine was placed on Resident 1 and was working properly with no leaks. During a review of Resident 1's SCA, dated 6/9/2021 and timed at 6:55 a.m., the SCA indicated Resident 1's vital signs were BP 124/72, body temperature of 97.8 F, heart rate of 74, with respirations of 18, and oxygen saturation of 96 % with oxygen via nasal cannula at 3 liters/minute. The SCA indicated Resident 1 was not provided with return demonstration regarding respiratory care and the BiPAP machine. The assessment indicated Resident 1 was alert and oriented able to make needs known. No acute distress noted, continuous oxygen at 3 liters/ minute via nasal cannula in place. Head of bed elevated, no shortness of breath or difficulty breathing noted, denied any pain or discomfort. Resident 1 was noncompliant with BiPAP at night. During a review of Resident 1's NPN, dated 6/9/2021, and timed at 9:20 p.m., the NPN indicated a text: devices BiPAP machine on at 9 p.m. and off at 6 a.m., with nose pillow at bedtime once during the night check heart rate, respiration, and oxygen saturation and remove per schedule. The NPN indicated Resident 1 keeps removing the BiPAP when applied, risks, and benefits explained but still refused. During a review of Resident 1's NPN, dated 6/9/2021, and timed at 11:01 p.m., the NPN indicated Resident 1 was refusing to be connected to the BiPAP machine because she could not tolerate the machine and it was causing her to have hyperventilation (breathe at an abnormally rapid rate). The NPN indicated Resident 1 preferred to be on nasal cannula and risks and benefits were explained but resident continued to refuse to use BiPAP machine. Resident 1’s oxygen saturation was 94 % on oxygen 3 liters/minute with nasal cannula. During a review of Resident 1's SCA, dated 6/10/2021 and timed at 7:05 a.m., the SCA indicated Resident 1's vital signs were BP of 120/70, body temperature of 98.0 F, heart rate of 95, with respirations of 22, and an oxygen saturation of 99 % via mask. The assessment indicated Resident 1 was not provided with return demonstration regarding respiratory care and the BiPAP machine. The SCA indicated Resident 1 was alert and oriented, able to make needs known with shortness of breath (SOB) and COPD exacerbation (a flare-up or worsening of symptoms). The HOB elevated with continuous oxygen 3 liters/ minute via mask. The oxygen saturation was at 98 %, Xanax ([Alprazolam] used to treat anxiety disorders and depresses respirations) given for hyperventilation. The SCA indicated Resident 1 was currently stable with stable vital signs, denies any pain or discomfort currently. The SCA indicated Resident 1 was noncompliant with the BiPAP machine at night. During a review of Resident 1’s Point Click Care ([PCC] an electronic documentation chart), dated 6/10/2021, the following was documented late, after the resident was transferred to the GACH and the facility’s staff were made aware Resident 1 had expired as follow: a. During a review of Resident 1's NPN, dated 6/10/2021 and timed at 7:25 a.m., (created and written by LVN 2 at 3:59 p.m. on 6/10/2021), the NPN indicated Resident 1 was received awake and alert with eyes open and responding to verbal and tactile (touch) stimuli. Resident 1 was noted on continuous supplemental oxygen at 3 liters/minute via nasal cannula and noted non-compliant with the use of the BiPAP machine, explanations of purpose of machine provided. b. During a review of Resident 1's Situation, Background, Assessment and Recommendation ([SBAR] an internal communication tool), dated 6/10/2021 and timed at 8:20 a.m. (created and written by LVN 3 on 6/10/2021 at 1:28 p.m.), the SBAR indicated upon making rounds at approximately 8:15 a.m. on 6/10/2021, Resident 1 was noted with shallow respirations, upon assessment noted oxygen levels at 70 % and nasal cannula placed at 3 liters/minute. Non-breathable mask was placed at 10 liters/minute full (100%) oxygen tank with oxygen level fluctuating from 92 to 94 %. Resident 1 was arousable, able to open eyes and nod, alert and verbally responsive to her name. HOB elevated, unable to grasp (siderail). Call placed to 911 (emergency services) continued monitoring while paramedics arrived. Resident 1’s BP was low at 80/40; heart rate elevated at 102, and respirations elevated at 32. The SBAR indicated Resident 1 had decreased consciousness (state of being awake and aware of one's surroundings), weakness, labored rapid shallow breathing, and low oxygen saturation. During a review of Resident 1's Fire Department Emergency Response record, dated 6/10/2021 and timed at 8:25 a.m., the report indicated Resident 1 was in moderate respiratory distress with altered level of consciousness (ALOC) and SOB. According to the Fire Department emergency response record, Resident 1 was found in bed with a loss of consciousness (LOC), respiratory distress. The report indicated staff members stated Resident 1 was not speaking or acting normal. The report indicated Resident 1's lung sounds were diminished on both sides. During a review of Resident 1's GACH Emergency Department (ED) records, dated 6/10/2021 and timed at 8:51 a.m., the ED note indicated Resident 1 arrived with altered mental status, difficulty breathing and SOB. On the initial evaluation, Reside