Health inspection·April 23, 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. § 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 an anonymous complaint on 1/28/2021 indicating the facility reported nine cumulative COVID-19 (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) positive deaths. On 1/28/2021, an unannounced complaint investigation was conducted. The facility failed to: 1. Immediately inform and consult with Resident 1’s physician when the resident (Resident 1) experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) and receiving additional oxygen, which requires a physician order, at 4:30 in the morning and continued to deteriorate. 2. Adhere to its policy and procedure (P/P) titled, "Significant Change in Condition, Monitoring," which stipulated if at any time a resident’s care needs change, the nurse supervisor should be made aware, and the physician and resident’s responsible party will be notified of the significant change. 3. Provide appropriate nursing care as required by the regulations and plan of care by failing to monitor Resident 1’s vital signs for further change in condition. Resident 1 experienced a drop in oxygen saturation ([SPO2] a measure of how much oxygen the blood is carrying with normal reference range (NRR) being 94-100 percent [%]) of 80-85 % and required an increase need for oxygen (O2) and the physician and/or family were not notified. As a result of not notifying the physician of Resident 1’s COC, there was a delay of evaluation, care, and treatment for Resident 1, who was recently admitted on 1/27/2021. Resident 1 was exhibiting a COC for over 8 hours before the physician was notified, which resulted in the resident's COC worsening. Resident 1 required an emergency transfer (911) to a general acute care hospital (GACH) in critical condition and required an immediate admission into the intensive care unit (higher level of care). During a review of Resident 1's Admission Record, the record indicated Resident 1, a 75 year-old female, was admitted to the facility on 1/27/2021. Resident 1's diagnoses included respiratory failure with hypoxia (not enough oxygen in the blood), COVID-19, pneumonia (infection that inflames the air sacs in one or both lungs), presence of a cardiac pacemaker (a device to control the heart beat) and sepsis (a life threatening complication of an infection). During a review of Resident 1's Minimum Data Set (MDS), an assessment and care-planning tool, dated 1/28/2021, the MDS indicated Resident 1 was moderately impaired with cognitive (thought process) skills for daily decision-making and required extensive assistance from staff for activities of daily living ([ADL] such as eating, toileting and grooming). During a review of Resident 1's COC form, the COC form indicated on 1/28/2021 at 9:32 a.m., Resident 1 had a low BP of 97/48 (NRR is 90/60-139/79) and a low SPO2 of 86 %, reported to resident's daughter and primary care clinician (PCC) on 1/28/2021 at 11:30 a.m. with recommendation from the PCC to transfer Resident 1 to the hospital. During an observation, on 1/28/2021 at 1:08 p.m., Resident 1 was lying in bed awake, appeared weak, pale, mild labored breathing (an abnormal respiration characterized by evidence of increased effort to breathe, including the use of accessory muscles of respiration, grunting, or nasal flaring), taking deep breaths at intervals, with the head of bed (HOB) elevated, and receiving oxygen 15 LPM (liters per minute) via a non-rebreather mask (mask which enables the delivery of high concentration of oxygen). During an observation on 1/28/2021 at 1:16 p.m., an overhead announcement was heard to clear the hallway for 911. Resident 1 was in her room laying in her bed with the HOB elevated, the resident was awake, appeared pale and was taking deep breaths and breathing fast while on a non-rebreather mask. On 1/28/2021 at 1:28 p.m., Resident 1 was transferred out of the facility to a GACH via 911 ambulance. During an interview on 1/28/2021 at 2:33 p.m., Certified Nurse Assistant (CNA 1) stated on 1/28/2021 at 7:15 a.m., during breakfast time, Resident 1 was receiving oxygen via nasal cannula [(NC] a lightweight tube with two prongs placed in the nose to deliver oxygen), no respiratory distress (difficulty breathing) noted and had no appetite, only eating 25% (percent) of her meal. CNA 1 stated during her rounds at approximately 10 a.m., Resident 1 was having a hard time breathing. CNA 1 stated the Physical Therapist ([PT 1] who helps injured or ill people to improve movement and manage pain; an important part of preventive care, rehabilitation, and treatment for residents with chronic conditions) called a Licensed Vocational Nurse (LVN 1) to assess Resident 1. LVN 1 and Registered Nurse (RN 1) came to assess Resident 1. During an interview on 1/28/2021 at 2:55 p.m., RN 1 stated he received a report from RN 2 regarding Resident 1 exhibiting desaturation (decreased oxygen level) on 1/28/2021 at 4:30 a.m. RN 1 stated he increased Resident 1's O2 to 10 LPM via NC. RN 1 stated during an assessment on 1/28/2021 at 9:30 a.m., Resident 1 was alert, verbal, talking with clear speech and showed no signs of physical distress, but the SPO2 level was low at 81-82 %. RN 1 stated the O2 was changed from 4 LPM to 15 LPM via a non-rebreather mask. RN 1 stated he elevated Resident 1's HOB to improve her breathing and he continued to monitor Resident 1. During a concurrent interview and record review on 1/28/2021 at 3 p.m., the Director of Staff development (DSD) stated, "A decrease in SPO2 was a COC and the physician and the resident's family should have been notified and the COC should have been documented." During a review of Resident 1's progress notes, the DSD was unable to locate any records that indicated Resident 1 had an episode of distress from 1/27/2021 to 1/28/2021. The DSD stated there was no documented vital signs for Resident 1 for the COC assessment and there were no notes that the physician and/or family were notified of the resident's COC. There were also no notes to reflect Resident 1's episodes of respiratory distress (difficulty breathing) or decrease of SPO2 on 1/27/2021 on the 11 p.m. to 7 a.m. night shift. During an interview on 1/28/2021 at 3:59 p.m., the Director of Rehabilitation ([DOR] directs the programs and staff of the rehabilitation services department) stated the Occupational Therapist ([OT 1] treat injured, ill, or disabled residents through the therapeutic use of everyday activities; help residents to develop, recover, improve, as well as maintain the skills needed for daily living and working) reported on 1/28/2021 at 9:30 a.m., she was not able to perform an OT assessment on Resident 1 because the resident did not look good and was unable to participate with the assessment. The DOR stated Resident 1's oxygen saturation was low at 80% and OT 1 reported Resident 1's condition to RN 1. During a telephone interview on 1/28/2021 at 5:17 p.m., PT 1 stated she was not able to perform a PT evaluation for Resident 1, due to labored breathing and asked LVN 1 to assess the resident on 1/28/2021 9:30 a.m. PT 1 stated LVN 1 and RN 1 checked the resident's SPO2 level, which was low at 80%. During a telephone interview on 1/29/2021 at 6:50 a.m., RN 2 stated he received a report from LVN 5 on 1/28/2021, Resident 1 was admitted on 1/27/2021 with diagnosis of COVID pneumonia (infection of the lungs) and had fluctuating SPO2 from the hospital. RN 2 stated on 1/28/2021 at 4:30 a.m., Resident 1's SPO2 was low at 80 to 85 % while receiving oxygen at 4 LPM via NC, so he increased the O2 to 5-10 LPM via NC which increased the SPO2 to 93 to 94. RN 2 stated he did not notify the resident's family and/or physician before increasing the O2 and of Resident 1’s COC. RN 2 stated he endorsed to RN 1 (charge nurse for next shift) to notify Resident 1's family and physician of the resident's COC. RN 2 stated he did not think he needed to notify the family and physician on his shift, because Resident 1's condition had improved. RN 2 stated he did not receive an order to change Resident 1's O2 level, and did not chart the COC or assess Resident 1's vital signs because he was the only charge nurse on the night shift for 37 residents on 1/27/2021-1/28/2021. During an interview on 1/29/2021 at 9:34 a.m., OT 1 stated she went to Resident 1's room on 1/28/2021 at approximately 9 a.m., to perform an OT assessment. OT 1 stated Resident 1 looked weak, tired, and had a low SPO2 level ranging from 86 to 87 % with O2 infusing via NC. OT 1 stated she asked the facility's Admission Coordinator (AC) to translate to ask Resident 1 how she felt. OT 1 stated the AC stated Resident 1 responded she felt better than she did the day prior. During an interview on 1/29/2021 at 11:11 a.m., RN 1 stated he notified Physician 1 on 1/28/2021 at 11:30 a.m., due to Resident 1 had a low SPO2 of 84-87% while receiving 15 LPM O2 via non-rebreather mask and Physician 1 ordered to transfer Resident 1 to hospital via 911. RN 1 stated he thought Resident 1 should not be in a skilled nursing facility with fluctuating SPO2 levels. RN 1 stated he should have called 911 at 11:30 a.m. and stated he did not know why he delayed Resident 1's transfer to the GACH. RN 1 stated a delay in transfer could have resulted in Resident 1 passing out and/or a respiratory arrest (stop breathing) and coded (stop breathing and heart stops) at the facility. RN 1 stated it was his mistake and he should have transferred the resident to the GACH right away. During an interview on 1/29/2021 at 12 p.m., the Director of Nurses (DON) stated she was made aware by DSD that Resident 1 was having a low SPO2 level at 85% at 10:30 a.m. on 1/28/2021 and told the DSD to notify the physician. The DON stated the nurse (RN 2) should have initiated a COC documentation and notified the physician and family of Resident 1's COC. The DON stated when a physician orders a transfer to a GACH via 911, the resident should be transferred to hospital as soon as possible. During a telephone interview on 1/29/2021 at 12:47 p.m., Physician 1 stated he received a text on 1/28/2021 at 11:30 a.m. regarding Resident 1's low SPO2 of 85% on 100 % non-rebreather mask and ordered Resident 1 to be transferred to hospital via 911. Physician 1 stated he was scheduled to go to facility on 1/28/2021 at 1 p.m., so when he arrived, he was surprised to see the resident was still there and did an assessment of Resident 1. Physician 1 stated upon assessment, Resident 1 had lots of crackles (sounds heard in a lung field that has fluid in the small airways), hypoxic on 100% non-rebreather mask, mild to moderate respiratory distress with the pneumonia worse. Physician 1 stated he ordered Resident 1 to be transferred to hospital via 911 so the resident can go to the hospital as fast as possible. During a review of Resident 1's Emergency Department (ED) physician notes, dated 1/28/2021 and timed at 2:26 p.m., the ED note indicated Resident 1 arrived in critical condition with acute decompensation (failure of an organ to function, especially the heart) and possible cardiopulmonary arrest (loss of heart function and breathing). The B/P was 192/87, heart rate at 84 bpm (beats per minute [NRR is 70-100]), respiratory rate at 39 (NRR is 12-20 per minute), SPO2 at 88%, and a temperature of 36.5 °F (Fahrenheit). The note indicated Resident 1 was tachypneic (abnormal rapid breathing), lungs with crackles diffusely (scattered), shows initial accessory muscle (refers to those that assist, but do not play a primary role, in breathing) use, no obvious retractions (a sign someone is working hard to breathe). The chest x-ray showed patchy interstitial and airspace opacities, of the mid to lower lungs (acute pneumonia). Resident 1 required a Bipap (bi-level positive airway used to maintain a consistent breathing pattern). The note indicated upon Resident 1's initial arrival, the physician spoke to Resident 1's family, and the family stated the resident does not want to have an endotracheal intubation (process of inserting a tube, an endotracheal tube (ET), through the mouth and then into the airway for ventilation [for oxygen exchange]). Resident 1's GACH final diagnoses included COVID-19 positive test with acute pneumonia and respiratory distress. Resident 1 was admitted to Intensive Care Unit ([ICU] higher level of care) in critical condition. During a review of the facility's undated P/P titled, "Significant Change in Condition, Monitoring," included the following: 1. If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the nurse supervisor should be made aware of and he/she will monitor. 2. Physician, resident, and responsible party will be notified of the significant change. The facility failed to: 1. Immediately inform and consult with Resident 1’s physician when the resident (Resident 1) experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) and receiving additional oxygen, which requires a physician order, at 4:30 in the morning and continued to deteriorate. 2. Adhere to its policy and procedure (P/P) titled, "Significant Change in Condition, Monitoring," which stipulated if at any time a resident’s care needs change, the nurse supervisor should be made aware, and the physician and resident’s responsible party will be notified of the significant change. 3. Provide appropriate nursing care as required by the regulations and plan of care by failing to monitor Resident 1’s vital signs for further change in condition. Resident 1 experienced a drop in oxygen saturation of 80-85% and required an increase need for O2 and the physician was not notified. As a result of not notifying the physician of Resident 1’s COC, there was a delay of evaluation, care, and treatment for Resident 1. Resident 1, who was exhibiting a change of condition for over 8 hours before the physician was notified resulted in the resident's COC worsening. Resident 1 required an emergency transfer (911) to a GACH in critical condition and required an immediate admission into the intensive care unit. These violations jointly, separately, or