Health inspection·January 30, 2025

Quality of Care 42 CFR § 483.25 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. Notification of Changes 42 CFR §483.10 (g)(14)(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- 42 CFR §483.10 (g)(14)(i) (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); 42 CFR §483.10 (g)(14)(i)(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 Cal. Code Reg. § 72311 Nursing Service- General (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. 22 Cal. Code Reg. § 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. 22 Cal. Code Reg. § 72517 Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. (2) Prevention and control of infections. On 12/30/2024, the California Department of Public Health (CDPH) received a complaint against the facility, a Skilled Nursing Facility (SNF), alleging on 12/29/2024, a resident (Resident 2) was transferred from the facility to a general acute care hospital (GACH) for worsening leg infection, improper wound care management, and signs of neglect. On 12/31/2024, the CDPH conducted an unannounced complaint investigation at the facility. The facility failed to: 1. Timely notify a resident's physician of a significant change in the resident's condition, causing a delay in providing the correct treatment for hypoxia (absence of oxygen in the tissues to sustain bodily functions) and swelling of his right first toe. 2. Implement its policy and procedure (P&P) titled, "Change in a Resident's Condition," which indicated the facility will notify a resident's physician when there was a significant change in the resident's condition. Failure to notify Resident 2's physician when Resident 2 was observed experiencing a change of condition (COC) and becoming hypoxic with discoloration and swelling on his right first toe delayed medical treatment. Consequently, there was a one-hour delay in transferring Resident 2 to a GACH where the resident was diagnosed with septic shock (a life-threatening condition that occurs when a severe infection causes dangerously low blood pressure), acute renal failure (sudden loss of kidney function), and cellulitis (a skin infection that causes swelling and redness). Resident 2 expired approximately 31 hours later. Resident 2 was a 73 year-old male admitted to the facility, on 11/24/2024 with diagnoses including cellulitis of the right and left lower limb (leg), acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the left calf muscular vein (part of the deep vein system that drains blood from the calf muscles back to the heart), and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs). A review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 11/27/2024, indicated Resident 2's cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) to the left and right foot and an infection of the left and right foot. A review of Resident 2's Change in Condition (COC), dated 12/29/2024, indicated on 12/29/2024 at 3:08 a.m., Resident 2 was observed with discoloration and swelling of his right first toe and bleeding from the right, lower extremity (leg). The COC indicated Resident 2 had abnormal vital signs (measurements of the body's most basic functions) and altered mental status (a change in how well your brain is working). The COC indicated 9-1-1 was called at 4:09 a.m., and Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition was observed. A review of Resident 2's Progress Notes, dated 12/29/2024, indicated on 12/29/2024 at 3:08 a.m., Licensed Vocational Nurse (LVN) 1 assessed Resident 2's discoloration and swelling on his right first toe. The Progress Notes indicated Resident 2 appeared confused. The Progress Notes indicated the following vital signs and assessments: a. At 3:10 a.m., Resident 2's vital signs were the following: Blood pressure (BP, force of blood used to get through the vessels of the body) was 106/64 (normal range of 120-129 [top number] and 80-84 [bottom number) millimeters of mercury ([mm Hg], unit of measurement), respiratory rate (RR, breathing) of 21 breaths per minute (normal RR 12 to 20 bpm), heart rate (HR) was 66 beats per minute ([BPM], normal range 60 to 100 BPM), temperature of 98.8 degrees Fahrenheit ([F], a unit of measurement, normal temperature range 97 to 99 F), and oxygen saturation of 84% (normal range 93 - 100%) on room air. The Progress Note indicated supplemental oxygen was initiated at 5 liters per minute (L, unit of liquid volume) via an oxygen mask. b. At 3:40 a.m., the Progress Note indicated Resident 2 had no changes from the assessment done at 3:10 a.m. The Progress Note indicated Resident 2 was "making noises." Resident 2's vital signs were the following: BP was 94/84 mmHg, RR was 21 bmp, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 87% while receiving 10 LPM of oxygen via an oxygen mask. c. At 3:55 a.m., Resident 2's vital signs were the following: BP was 104/48 mmHg, RR was 22 bpm, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 84% while receiving 15 LPM of oxygen via an oxygen mask (a mask placed over the nose and mouth and connected to a supply of oxygen). d. At 4:07 a.m., Resident 2 was observed with his eyes closed, with labored breathing, and with his (unspecified) upper extremity cold to the touch. Resident 2 was unable to respond verbally but would awake to tactile stimuli (any form or touch or physical contact perceived by the skin). Resident 2's vital signs were the following: BP was 104/52 mmHg, RR was 22 bpm, HR was 116 BPM, temperature was 99.1 F, and oxygen saturation was 87% while receiving 15 LPM of oxygen via a non-rebreather mask (oxygen mask that delivers high concentrations of oxygen). The Progress Notes dated 12/29/2024, indicated 9-1-1 was called at 4:09 a.m. and the emergency medical services (EMS) arrived at the facility at 4:13 a.m. The Progress Notes indicated on 12/29/2024, Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition. A review of Resident 2's GACH Emergency Department (ED) Note, dated 12/29/2024 at 5:10 a.m., indicated upon arrival to the ED, Resident 2's vital signs were the following: BP was 64/43 mmHg, RR was 22 bpm, HR was 98 BPM, temperature was 104.9 F, and oxygen saturation was 87% on 15 LMP of oxygen via an oxygen mask. The GACH ED Note indicated Resident 2 was brought to the GACH via ambulance for worsening cellulitis to the bilateral (affecting both sides) lower extremities. The GACH ED Note indicated Resident 2's legs were initially wrapped in gauze and plastic bags and when removed the legs were noted to be "extremely pungent malodorous (a strong, sharp, unpleasant odor)". The GACH ED Note indicated Resident 2's lactic acid level (a blood test used to help diagnose sepsis [a life-threatening blood infection]) was elevated at 3.46 millimoles per liter ([mmol/L, unit of measurement], normal value of 0.7 to 1.9 mmol/L). The GACH ED Note indicated Resident 2's white blood cell count ([WBC], a blood test that indicate the presence of inflammation or infection) was elevated at 16 microliters ([X10^3/Ul]- a unit of measurement, normal WBC count 4.5 to 11). The GACH ED Note indicated Resident 2 was diagnosed with septic shock (a life-threatening condition that occurs when an infection causes a dangerously low blood pressure and organ failure), acute renal failure (condition where kidneys suddenly lose their function), and cellulitis. A review of Resident 2's GACH History and Physical (H&P), dated 12/29/2024 at 7:57 a.m., indicated Resident 2 had worsening right, lower extremity cellulitis. The GACH H&P indicated Resident 2 remained hypotensive (low blood pressure) despite fluid resuscitation (a medical procedure that involves replacing fluids lost by the body) and received norepinephrine (a vasopressor [drug used to make blood vessels constrict or become narrow to raise blood pressure]), vasopressin (a vasopressor), and phenylephrine (vasopressor). The H&P indicated the general surgeon was consulted and a decision was made for Resident 2 to have an emergent right, below the knee amputation. A review of Resident 2's GACH Clinical Notes, dated 12/29/2024 at 6:21 p.m., indicated Resident 2 continued to receive Levophed (used to treat life-threatening low blood pressure) and phenylephrine despite the right, lower extremity amputation and continued fluid resuscitation. The Clinical Note indicated Resident 2's left lower extremity appeared worse than at admission (12/29/2024), with new ischemic changes (when the part of the body does not get enough blood or oxygen) to the soft tissue (the body's supporting tissues such as fat, skin, and muscle). The Clinical Note indicated the care team will proceed with an emergent left below the knee amputation. A review of Resident 2's GACH Nursing Progress Notes, dated 12/29/2024 at 10 a.m., indicated Resident 2 arrived in the Intensive Care Unit (ICU, a hospital ward that provides specialized care for patients who are very ill or injured) at 9:00 a.m. and was intubated (a procedure that involves the insertion of a tube to facilitate breathing) at 10:30 a.m. The notes indicated Resident 2 underwent right and left below the knee amputations (removal of a limb) and was required to be placed on "maximum continuous doses" of norepinephrine (a vasopressor), vasopressin, and phenylephrine. A review of Resident 2's GACH Amputation Below Knee Procedure Notes, dated 12/29/2024, indicated Resident 2 underwent bilateral below the knee amputations. A review of Resident 2's GACH Rapid Response Note, dated 12/30/2024 and timed at 11:54 a.m., indicated Resident 2 became pulseless (no heartbeat), required chest compressions, and expired at 11:57 a.m. from cardiac arrest (occurs when the heart suddenly stops beating). During an interview on 1/2/2025 at 12:52 p.m., LVN 1 stated on 12/29/2024, at approximately 3 a.m., he noticed Resident 2 "looked off". LVN 1 stated Resident 2 had blood on his right lower extremity and his right toe had a dark purple discoloration. LVN 1 stated at the beginning of the shift at 11 p.m., Resident 2 did not have any bleeding or dark purple discoloration on his right toe. LVN 1 stated he began to check Resident 2's vital signs and observed the resident's oxygen saturation was low, at 84%. LVN 1 stated he initiated supplemental oxygen and had to increase the amount of oxygen to Resident 2, however, Resident 2's oxygen saturation did not improve and fluctuated between 84 to 87%. LVN 1 stated due to Resident 2's condition, wound care was not provided to Resident 2's legs and instead was wrapped with additional gauze and a plastic bag. LVN 1 stated he attempted to notify Resident 2's physician towards the end of his shift at approximately 7 a.m., (four hours after Resident 2's initial change of condition). LVN 1 stated Resident 2's physician was not notified when Resident 2's initial change of condition was noted at 3:10 a.m. LVN 1 stated he "went with his nursing judgement" and acted to treat Resident 2's desaturation (decrease in oxygen saturation) instead of calling Resident 2's physician and waiting for orders. LVN 1 stated he should have notified Resident 2's physician of the resident's status and initial desaturation of 84% for guidance on how to proceed with Resident 2's care. LVN 1 stated if he notified Resident 2's physician sooner, he may have been directed to call 9-1-1 sooner. During an interview on 1/2/2025 at 2:20 p.m., Registered Nurse (RN) 1 stated Resident 2 did not have any respiratory issues and never required supplemental oxygen. RN 1 stated if a resident required 10 LPM of oxygen, regardless of improvement, he would have to immediately call 9-1-1. RN 1 stated Resident 2 requiring supplemental oxygen was a change of condition and his physician should have been notified immediately. RN 1 stated notifying the physician would provide a line of communication where the physician may give orders on how to proceed with treatment. RN 1 stated the physician may request to call 9-1-1 due to the need of a higher level of care for prompt assessment and treatment. RN 1 stated Resident 2 was hypoxic (having too little oxygen) for over an hour and could have been hypoxic long before LVN 1 assessed him. RN 1 stated the lack of physician notification resulted in a delay in care. During an interview on 1/2/2025 at 3:56 p.m., the Director of Nursing (DON) stated Resident 2 should have been sent to the GACH sooner. The DON stated Resident 2 had a change in oxygenation and mental status. The DON stated Resident 2's physician should have been notified of Resident 2's initial change of condition. The DON stated Resident 2 should not have been allowed to decline to the degree of being responsive only to tactile stimuli. The DON stated Resident 2 was hypoxic for over an hour, which meant he was not getting oxygen to his vital organs. The DON stated Resident 2 suffered a delay in care. A review of the facility's P&P titled, "Change in a Resident's Condition or Status", revised 2/2021, indicated the nurse would notify the resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition. The facility failed to: 1. Timely notify a resident's physician of a significant change in the resident's condition, causing a delay in providing the correct treatment for hypoxia and swelling on his right toe. 2. Implement its policy and procedure (P&P) titled, "Change in a Resident's Condition," which indicated the facility will notify a resident's physician when there was a significant change in the resident's condition. Failure to notify Resident 2's physician when Resident 2 was observed experiencing a COC and becoming hypoxic with discoloration and swelling on his right first toe delayed medical treatment. Consequently, there was a one-hour delay in transferring Resident 2 to a GACH where the resident was diagnosed with septic shock, acute renal failure, and cellulitis. Resident 2 expired approximately 31 hours later. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a substantial factor in the death of a resident.