Health inspection·August 15, 2024

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 resident's choices, including but not limited to the following (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. 42 CFR §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— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (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) 22 CCR § 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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. (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. 22 CCR § 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/26/2024, the California Department of Public Health (CDPH) received a complaint regarding a resident death and delay in transporting the resident to a General Acute Care Hospital (GACH). On 6/27/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint. Upon investigation, CDPH determined that on 6/15/2024 the facility failed to ensure Resident 1, who experienced a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by low oxygen (O2) saturation (the amount of oxygen circulating in the blood) of 86 percent on room air (reference range for O2 saturation is 95% to 100%) was transferred to a GACH without a delay. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 2) monitored and assessed Resident 1’s vital signs (a measurement of the body's most basic functions including temperature, pulse rate, respiration rate and blood pressure) including O2 saturation rate when Resident 1 experienced a change of condition and as instructed by Registered Nurse Supervisor (RNS 1). 2. Ensure the licensed nurses informed Resident 1’s physician of Resident 1’s continuous oxygen desaturation (low blood oxygen concentration) ranging between 86% to 87% on continuous O2 via nasal cannula and Resident 1’s complaints of feeling weak, chest pain, and abdominal pain on 6/15/2024. 3 Ensure LVN 1 and LVN 2 notified the Nurse Practitioner of Resident 1’s complaints of chest pain, abdominal pain, and shortness of breath. 4. Follow its Policy and Procedure entitled “Change of Condition,” by failing to call 911 to transfer Resident 1 without delay to the GACH upon onset of the resident’s change in condition manifested by low O2 saturation of 86 %, chest pain, shortness of breath, and abdominal pain as ordered by Resident 1’s physician. These failures resulted in eight hours delay in transferring Resident 1 to the GACH from the onset of Resident 1’s change in condition on 6/15/2024 at 11:00 a.m. Resident 1 was not transferred to the GACH until 7:00 p.m., (eight hours after Resident 1 experienced oxygen desaturation to 86 %, shortness of breath, and complained of left chest pain and left abdominal pain rated 8 out of 10 on a pain scale from zero to 10. At the GACH, Resident 1 became bradycardic (a slow heart rate under 60 beats per minute), acutely altered, her heart rate slowed to the 20s and she stopped breathing. Resident 1 did not resume breathing and eventually had no cardiac activity. At the GACH, Cardiopulmonary Resuscitation [CPR] was started and continued from 8:36 p.m. to 9:04 p.m. without success. Resident 1 was pronounced dead on 6/15/2024 at 9:04 p.m. A review of Resident 1’s Admission Record indicated Resident 1, an 84 year-old female, was admitted to the facility on 5/30/2024 with diagnoses including closed fracture of the right tibia, chest pain, hyperlipidemia (abnormal high levels of fat in the blood), hypertensive urgency (a severe elevation in blood pressure), and anemia (a blood disorder in which the blood has a reduced ability to carry oxygen). A review of Resident 1’s History and Physical (H&P), dated 6/3/2024, indicated Resident 1 was alert and oriented to self, place and time. Resident 1 was able to make her own medical decisions. The H&P indicated “Staff, nursing, and family members/caregiver were to call 911 or go to the nearest emergency room if Resident 1 experienced chest pain, shortness of breath, loss of consciousness, change in vision, severe headache, or other alarming symptoms. “ A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/5/2024, indicated Resident 1 was dependent on nursing staff for changing positions from sitting to standing, and transferring from a bed to the chair. The MDS indicated Resident 1 needed maximum assistance (helper does more than half the effort) with toileting, showering, lower body dressing and putting on and off footwear. The MDS indicated Resident 1 needed moderate assistance (helper does less than half the effort) with personal hygiene, changing positions from sitting to lying down, and lying down to sitting position. During an interview on 6/27/2024 at 10:45 a.m., Certified Nursing Assistant (CNA 1) stated on 6/15/2024 between 10 a.m. and 11 a.m., he responded to Resident 1’s room call light. CNA 1 stated he responded to the call light and observed Resident 1 was having a hard time breathing and was holding her chest. Resident 1 complained of shortness of breath and verbalized she was not feeling well and needed help. CNA 1 stated he reported Resident 1’s condition to the Licensed Vocational Nurse (LVN 1) on 6/15/2024 at 11:00 a.m. CNA 1 stated LVN 1 went to Resident 1’s room to check Resident 1’s vital signs. During a concurrent interview and record review with LVN 2 on 6/27/2024 at 11:05 a.m., a text message communication between LVN 1, LVN 2 and the Nurse Practitioner dated 6/15/2024 at 3:12 p.m., was reviewed. On 6/15/2024 at 3:12 p.m. LVN 1 sent a text message to NP informing the NP Resident 1 was complaining of a throat ache. The text message indicated Resident 1’s O2 saturation rate was 86 % on room air (normal oxygen saturation was 95 %-100%), body temperature was 99 degrees Fahrenheit, blood pressure was 113/56 mmHg, respirations were 22 breaths per minute (Normal rate between 12 – 20 breaths per minute), and her pulse rate was 86 beats per minute. The text message indicated the NP was informed that Resident 1’s oxygen saturation went up to 94 percent after Registered Nurse Supervisor (RNS 1) administered oxygen at three liters per minute (L/min) via nasal cannula (a device that delivers oxygen through a tube and into the nose). LVN 2 stated she sent another text message right after LVN 1 indicated Resident 1’s oxygen saturation was 92% on 3.0 L/min of oxygen via nasal cannula. LVN 2 stated she also sent text to the NP (both LVN 1 and LVN 2's texts were on the same thread on 6/15/2024 at 3:12 p.m. text) informing the NP Resident 1’s blood pressure was 96/56 mmHg (blood pressure reference is 120/80 mmHg), pulse rate was 83 beats per minute and O2 saturation rate dropped to 87 % while receiving O2 at three liters per minute via nasal cannula. LVN 2 stated Resident 1 complained of pain in the right lower abdomen and shortness of breath at 3:00 p.m. LVN 2 stated she reported Resident 1’s COC to RNS 1 at 3:00 p.m. LVN 2 stated RNS 1 and LVN 1 told her to monitor Resident 1’s condition and if her condition worsened, Resident 1 should be sent to the GACH. LVN 2 stated at 4:00 p.m., she reported Resident 1’s COC to LVN 3 who was the LVN assigned to Resident 1 on the incoming 3:00 p.m. to 11:00 p.m. shift. LVN 2 stated 5:21 p.m. the NP responded back by text message at 5:21 p.m. and ordered a COVID-19 test and a chest x-ray. LVN 2 stated Resident 1 was weak and desaturating. LVN 2 stated any resident with an O2 saturation below 90 % on room air with a complaint of chest pain and shortness of breath should have been transferred to GACH for further evaluation and treatment. LVN 2 stated she does not know why Resident 1 was not sent to GACH when Resident 1 had a O2 saturation of 86 % on room air and 87 % on oxygen at 3.0 L /min via nasal cannula. LVN 2 stated the NP was not made aware of Resident 1’s complaint of abdominal pain or shortness of breath. LVN 2 stated on at 7:00 p.m. she spoke with LVN 3 because she noticed Resident 1’s oxygen saturation was not rising above 90 % on 5.0 L/min of oxygen via nasal cannula and her blood pressure was fluctuating. LVN 2 stated she called the Director of Nursing (DON) around 7:00 p.m. on 6/15/2024 and the DON instructed her to call 911 to facilitate transferring Resident 1 to the GACH. LVN 2 stated Resident 1 started to complain of chest pain while 911 was called. LVN 2 stated she should have called 911 immediately when Resident 1 O2 saturation was 87% while receiving oxygen at 3.0 L/min and complained of shortness of breath. A review of the text messages sent at 3:12 p.m. between LVN 1, LVN 2, and the NP, revealed the NP was informed Resident 1’s blood pressure was 96/56 and her O2 saturation was 87%. The text message did not report Resident 1’s complaint of chest pain or shortness of breath. A review of Resident 1’s medical records (including the vital sign record on 6/15/2024) indicated the nursing staff did not document the time Resident 1’s vital signs were taken on 6/15/2024. During a concurrent interview and record review on 6/27/2024 at 12:17 p.m., LVN 1 stated on 6/15/2024 between 11:00 a.m. and 12:00 p.m. Resident 1 complained of weakness. LVN 1 stated he did not have time to take Resident 1’s vital signs because he had other residents to take care of. LVN 1 stated at 1:24 p.m., he gave Resident 1 Tylenol Extra Strength 500 milligrams for generalized body pain. LVN 1 stated at 2:30 p.m., CNA 1 came to him (LVN 1) again and told him Resident 1 was not feeling well. LVN 1 stated the Tylenol was not working and Resident 1 looked weaker. LVN 1 stated he notified RNS 1 on 6/15/2024 of Resident 1’s condition. LVN 1 stated at 2:40 p.m., Resident 1’s vital signs were taken: temperature was 99.5 F, blood pressure was 113/56, respirations were 22, and O2 saturation was 86 % on room air. LVN 1 stated Resident 1 was placed on oxygen at 3.0 L/min via nasal cannula and the head of her bed was elevated to facilitate better breathing. LVN 1 stated at 3:12 p.m. a group text message (with LVN 1 and LVN 2) was sent to the NP, but NP did not respond. LVN 1 stated when Resident 1 had O2 saturation of 86%, the resident’s physician should have been notified by licensed staff and if the physician did not timely respond, she should have called the medical director (physician who provides guidance and leadership at the facility). During a record review of Resident 1’s H&P with LVN 1, the H&P indicated Resident 1’s physician ordered the facility staff to call 911 if Resident 1experienced chest pain, shortness of breath, loss of consciousness, change in vision, severe headache, or other alarming symptoms. LVN 1 stated Resident 1 should have been transferred to the GACH at the onset of Resident 1’s complaint of a chest pain and O2 saturation rate of 86 %. During an interview on 6/28/2024 at 3:24 p.m., LVN 3 stated LVN 1 informed her on 6/15/2024 (time unknown) of Resident 1’s O2 saturation of 86 % on room air. LVN 3 stated LVN 2 reported to her Resident 1 complained of chest pain at 4:00 p.m. LVN 3 stated she instructed LVN 2 to call 911. LVN 3 stated she did not call 911 herself because she did not want to overstep the boundaries with LVN 2, who was a charge nurse on the evening shift. LVN 3 stated she should have called 911 to facilitate Resident 1’s transfer to the GACH when Resident 1’s O2 saturation was 86 % while receiving O2 at 3.0 L/min via nasal cannula and complained of shortness of breath and chest pain. During an interview on 6/29/2024 at 12:03 p.m., RNS 1 stated on 6/15/2024 at 2:45 p.m., LVN 1 asked for assistance with Resident 1 because the resident’s O2 saturation was 86 % on room air. RNS 1 stated she was not informed of Resident 1’s low blood pressure of 96/56 mmHg or oxygen saturation of 87 % on oxygen 3.0 L/min via nasal cannula. RNS 1 stated she would have sent Resident 1 to the GACH if she had known the resident’s blood pressure was low and the O2 saturation was below normal range values. RNS 1 reviewed the physicians’ orders and stated Resident 1 was to be transferred to the hospital when she experienced oxygen desaturation and complained of chest pain. A review of Resident 2’s (Resident 1’s roommate) Minimum Data Set dated 6/3/2024 indicated Resident 2 had the ability to make herself understood. The MDS further indicated Resident 2 had the ability to understand others and had clear comprehension. During an interview on 6/30/2024 at 11:20 a.m., Resident 2 stated on 6/15/2024 Resident 1 complained of shortness of breath and was unable to move her leg in afternoon (Resident 2 could not remember the exact time). Resident 2 stated Resident 1 was having trouble breathing despite receiving oxygen. Resident 2 stated Resident 1 was having shortness of breath in the afternoon but was not transferred to a GACH until the evening of 6/15/2024. Resident 2 stated Resident 1 was also complaining of pain but did not know the exact location. During an interview on 7/1/2024 at 12:03 p.m., the DON, stated she received a call from LVN 2 on 6/15/2024 at 7:00 p.m. informing her that Resident 1 looked uncomfortable but was not in distress. The DON stated she told LVN 2 to call 911 and transfer Resident 1 to the GACH because Resident 1’s vital signs were not at her baseline, and she (the DON) considered Resident 1 as unstable. The DON stated if a resident complained of shortness of breath, chest pain and had oxygen desaturation of 86 %, licensed staff should not delay transfer to the GACH. The DON stated the vital signs are monitored every shift and as needed and must be documented at the time the vital signs were taken. The Department requested the facility’s policy and procedure for monitoring vital signs, but the facility failed to provide such policy and proc