Other·September 12, 2023

§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. On 7/31/23 at 11:21 a.m. the California Department of Public Health (CDPH) received a complaint regarding infection control. On 8/2/23 CDPH conducted an announced visit at the facility to investigate the complaint allegation. During the investigation CDPH identified deficiencies unrelated to infection control. The facility failed to: 1. Ensure staff did not delay administration of cardiopulmonary resuscitation [(CPR) cardo pulmonary recitation, an emergency procedure that can help save a person's life if their breathing or heart stops] on Resident 1 for approximately 21 minutes, when Resident 1 was found, unresponsive, not breathing, and without a pulse (no heartbeat). 2. Have a system in place for staff to be able to immediately (without any intervening time) identify residents' code status during an emergency that warrants initiation of CPR without loss of valuable time to implement life saving measures. These deficient practices resulted in delayed provision of emergency resuscitation for Resident 1 and placed 51 current residents, who had a Full Code (residents’ choice that when the resident’s heart stopped beating or the resident stopped breathing, all interventions are carried out to keep the resident alive, including CPR) status at risk of not receiving life saving measures immediately without loss of valuable time for being successfully revived. A review of Resident 1’s Admission Record (AR) indicated Resident 1, a 73-year-old male, was admitted on 5/29/22 with diagnoses including hemiplegia (weakness of one side of the body), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes mellitus (the body’s inability to efficiently process sugar for energy). A review of Resident 1’s Minimum Data Set ([MDS]- a standardized assessment and care planning tool) dated 5/3/23 indicated Resident 1 was severely cognitively (thinking and reasoning) impaired and required extensive assistance with activities of daily living (ADLs – eating, personal hygiene, getting dressed and toileting). During an interview on 8/3/23 at 11:41 a.m. with CNA 4, CNA 4 stated on 8/2/23 at around 7:50 a.m. when she brought Resident 1’s breakfast tray to Resident 1’s room, the resident did not respond to verbal stimulus (an action that results in a response in a healthy person). CNA 4 stated she called Licensed Vocational Nurse (LVN 1) to evaluate Resident 1. CNA 4 stated LVN 1, the Registered Nurse (RN 1) and the Director of Nursing (DON) came to the room. CNA 4 stated she did not start CPR because she did not know Resident 1’s code status. CNA 4 stated the code status of residents’ is available in the residents’ electronic health record (EHR) located at the nursing station. During an interview on 8/2/23 at 1:01 p.m., with LVN 1, LVN 1 stated on 8/2/2023 at 7:50 a.m. she was called by CNA 4 to Resident 1’s room where she (LVN 1) found Resident 1 unresponsive and was unable to obtain Resident 1’s vital signs (measurements of the body’s’ basic functions breath, heart rate and temperature). LVN 1 stated Resident 1’s code status had to be verified prior to initiating CPR. LVN 1 stated she would need to go to the nursing station, log into the computer to find a resident’s code status documented on the Physicians Orders for Life Sustaining Treatment (POLST) in the EHR before knowing if it was right to initiate or not initiate CPR. After verification of Resident 1’s code status in EHR it was determined that the resident had a POLST dated 5/30/22, indicating if the resident had no pulse and was not breathing “do not attempt to resuscitate (DNR).” However, staff did not know Resident 1’s code status until 21 minutes after the resident was found unresponsive. If Resident 1’s code status was different from DNR, the staff would not have been able to revive the resident by performing CPR due to loss of essential time to implement life saving measures. During an interview on 8/2/23 at 1:34 p.m., with RN 1, RN 1 stated she responded to the emergency call to Resident 1’s room. RN 1 stated Resident 1 was not responsive and without a pulse. RN 1 stated she would need to know a resident’s code status prior to initiating CPR which can be found in the resident’s EHR, therefore, she did not initiate Resident 1’s CPR right when the resident was found unresponsive and pulseless. During an interview and concurrent record review of Residents 1’s code status on 8/2/23 at 3:33 p.m., with CNA 5, CNA 5 stated a resident’s code status can be found in a resident’s EHR but was unable to find it right then. CNA 5 was observed demonstrating how to find a resident’s code status in the EHR dashboard (a screen with the resident’s vital medical information for healthcare workers to refer to, especially during time sensitive situations). CNA 5 had to look through two other residents’ EHR’s before she could find a random resident whose code status was indicated in the dashboard of the EHR. CNA 5 stated EHR dashboard did not indicate the code status for all residents, including Resident 1. During an interview on 8/2/23 at 3:40 p.m. with the Health Information Manager (HIM- the staff member that organizes, oversees, and protects patient health information), the HIM stated a resident’s code status is entered on the EHR dashboard when the licensed nurse enters the order for a resident’s code status. The HIM stated that unless the code status is entered by the licensed nurse, the code status will not be in the resident’s record. During an interview on 8/2/23 at 4:14 p.m., with LVN 4, LVN 4 stated a resident’s code status can be found in the EHR. Concurrently, LVN 4 was observed demonstrating how to find the code status on the EHR dashboard. During the demonstration, Resident 1’s code status was missing on the EHR dashboard. LVN 4 was observed searching under the Documents Section (completed and digitally added health information forms) of the EHR scrolling through numerous documents to find Resident 1’s POLST with the code status. During an interview on 8/3/23 at 9:51 a.m., with DON, the DON stated during a code blue (a notification system to indicate a patient/resident requires resuscitation or other immediate medical attention), one licensed nurse checks for the code status order in the EHR. The DON stated a resident’s code status can be found on the EHR dashboard or in the documents section, on the POLST document. In a subsequent interview at 12:10 p.m., the DON demonstrated how to find the code status of Resident 1. During the demonstration, the DON could not find Resident 1’s code status on the EHR dashboard and had to check for Resident 1’s POLST under the Documents Section. The DON stated if there is no code status on the dashboard and there is no POLST under the Documents Section as to whether the resident wishes for resuscitation measures, or no resuscitation measures, then the resident is considered a full code (requiring CPR). During an interview on 8/4/23 at 9:03 a.m., with the Director of Staff Development (DSD), the DSD stated when he responded to the emergency in Resident 1’s room, RN 1 and CNA 4 were unaware of the Resident 1’s code status and needed to verify Resident 1’s code status before determining whether to initiate CPR. The DSD stated when the DON verified Resident 1’s code status and informed the responding staff that Resident 1 was a DNR, and not initiation CPR. During an interview on 8/4/23 at 11:19 a.m., with the Medical Director (MD), the MD stated he is unsure if the facility had a way to immediately identify the code status of the residents. The MD acknowledged the facility should have a method to immediately identify the resident’s code status. The MD stated that CPR should be initiated immediately (for full code residents). During an observation on 8/4/2023 at 12:25 p.m., outside of Resident 1’s room, the distance between the nurses’ station and Resident 1’s room was measured and was approximately 16 feet away or a one-minute walk. A review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular (relating to the heart and blood vessels) Care Committee (ECC) Guidelines, the article indicated if there was no breathing, or only gasping (strain to take a breath), and pulse not felt, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines According to the Centers for Disease Control ([CDC] the nation’s science-based, data-driven, service organization that protects the public’s health) in nine out of ten people whose hearts have stopped beating, or they are not breathing, CPR can improve the odds of survival if it is done within the first few minutes, CPR can double or triple a person’s chance of survival. https://www.cdc.gov/heartdisease/cpr.htm A review of the facility’s policy and procedure, titled “Emergency Care, General Guidelines” dated 2006, indicated to initiate CPR unless resident’s advance directive indicates refusal of CPR. The facility failed to: 1. Ensure staff did not delay administration of CPR to Resident 1 for approximately 21 minutes, when Resident 1 was found, unresponsive, not breathing, and without a pulse (no heartbeat). 2. Have a system in place for staff to be able immediately (without any intervening time) identify residents' code status during an emergency that warrants initiation of CPR without loss of valuable time to implement life saving measures. These deficient practices resulted in delayed provision of emergency resuscitation for Resident 1 and placed 51 current residents, who had a Full Code status, at risk of not receiving life saving measures, CPR, immediately without a loss of essential time for being successfully revived. This violation presents a direct or immediate relationship to the health, safety, security, or welfare of the 51 residents who had a full code status.