Health inspection·March 20, 2025

Code of Federal Regulations, Title 42, Section 483.21 Comprehensive person-centered care planning. (a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - Code of Federal Regulations, Title 42, Section 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... Code of Federal Regulations, Title 42, Section 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- (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) (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22, Section 72523(a) 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 On 1/27/2025, the California Department of Public Health (CDPH) received a complaint alleging that the facility failed to take timely action in response to Resident 1 having an elevated body temperature of 103.8 Fahrenheit (°F) and heart rate of 130 beats per minute (bpm) on 1/7/2025 at 11:43 p.m. On 1/28/2025, the CDPH conducted an unannounced visit at the facility to investigate the complaint allegations. During the investigation, CDPH determined the facility failed to inform Resident 1's physician and delayed Resident 1's transfer to a general acute care hospital (GACH) when Resident 1 had an elevated body temperature of 103.8 °F (normal body temperature 97°F to 99°F) and heart rate (HR) of 130 bpm (reference range is 60 to 100 bpm) on 1/7/2025 at 11:43 p.m. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 assessed and monitored Resident 1's condition, including vital signs, when the resident had a change in condition on 1/5/2025 at 10:12 p.m. due to body temperature of 99.8 °F, on 1/6/2025 at 10:57 a.m., due to having hematuria (blood in urine), and on 1/7/2025 at 11:43 p.m. due to an elevated body temperature of 103.8 °F and heart rate of 130 bpm. 2. Ensure licensed nurses notified Resident 1's physician when Resident 1 had a temperature greater than 99°F, heart rate greater than 90 bpm, and systolic blood pressure ([SBP]- pressure exerted when the heart beats and blood is ejected into the arteries [blood vessels that distribute oxygen-rich blood to your entire body]) less than 100 millimeters of mercury ([mmHg] a unit of measurement for pressure) as ordered by Resident 1's physician for sepsis (a life threatening condition in which the body's reaction to an infection) prevention dated on 11/5/2024. 3. Develop a care plan for Resident 1's diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder-impaired bladder control and difficulty emptying the bladder) with interventions to prevent the resident from developing a urinary tract infection ([UTI]- an infection in the bladder/ urinary tract) and sepsis. 4. Ensure licensed nurses transferred Resident 1 to GACH on 1/7/2025 at 11:53 p.m., without a delay of up to six hours, when Resident 1 had an elevated temperature of 103.8 °F and a heart rate of 130 bpm. As a result, on 1/8/2025 at 6 a.m. Resident 1 had a blood pressure of 72/40 mmHg with HR of 112 bpm and an altered level of consciousness ([ALOC]- change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings). Resident 1 was transferred to a GACH on 1/8/2025 via 911. Resident 1 was admitted to the GACH where he was diagnosed with septic shock (life threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and expired on 1/8/2025 at 8:11pm, approximately 13 hours after the resident was admitted to the GACH. A review of Resident 1's Admission Record indicated, Resident 1 was admitted to the facility on 5/11/2024 with diagnoses including acute respiratory failure (a serious condition that occurs when your lungs can't get enough oxygen into your blood or remove carbon dioxide), bronchopneumonia (an inflammation of the lungs that affects the small airways and the surrounding lung tissue), seizures (a sudden uncontrolled change in behavior or body movement caused by abnormal electrical activity in the brain), hemiplegia (paralysis on the same side of the body) and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe), and neuromuscular dysfunction of the bladder. A review of Resident 1's History and Physical (H&P), dated 5/13/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Physician Order Summary report dated 11/5/2024, indicated an order dated 11/5/2024 to notify Medical Doctor (MD) if Resident 1 had any of the following symptoms: 1. Temperature less than 96.8 °F or greater than 99 °F. 2. Heart rate greater than 90 beats per minute. 3. Respiratory (breathing) rate greater than 20 (reference range is 12 to 18 breaths per minute). 4. Acute change in mental status (sudden and significant change in a person's level of awareness, cognition, or consciousness). 5. Oxygen saturation ([O2 sat]- a measure of how much oxygen in the blood as a percentage) less than 90 percent ([%]) reference range is 95 to 100 %). 6. SBP (baseline less than 100 mmHg) more than 5 mmHg lower than the baseline, every shift for sepsis prevention. A review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 11/15/2024, indicated Resident 1 had severe impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 was dependent on staff with bed mobility, chair/ bed to chair transfer, and tub/ shower transfer. A review of Resident 1's Change Of Condition (COC) dated 1/6/2025 and timed at 6:19 a.m., indicated Resident 1 had moderate amount of hematuria in Resident 1's incontinent pad (diaper) and elevated temperature (not documented). The COC indicated on 1/6/2025 at 6:30 a.m. Resident 1's Medical Doctor (MD) 1 was notified, but there was no documentation of physician's recommendations or orders. A review of Resident 1's COC dated 1/8/2025 and timed at 7:10 a.m., indicated Resident 1 was unresponsive to verbal, tactile (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and deep stimuli (when a person does not respond to pain, touch, and voice). The COC indicated MD 1 was notified and facility staff called 911. A review of Resident 1's Paramedics Run Sheet (a detailed written record that paramedics fill out during each emergency medical call) dated 1/8/2025 timed at 6:33 a.m., indicated Resident 1 was observed with eyes open and unresponsive. The Paramedics Run Sheet indicated Resident 1 had fever (elevated body temperature above the normal range 98.6°F or higher) for three days and became hypotensive (low blood pressure) with an altered mental status. The Paramedics Run Sheet indicated on 1/8/2025 at 6:46 a.m., Resident 1's blood pressure was 70/40 mmHg, HR 110 bpm, and respiratory rate of 20 breaths per minute. A review of Resident 1's GACH Emergency Room (ER) Notes dated 1/8/2025, indicated Resident 1 was admitted on 1/8/2025 at 7:31 a.m., with diagnoses of UTI, acute kidney injury (a sudden loss of kidney function, that can range from minor to complete kidney failure) and septic shock. The GACH ER notes indicated on 1/8/2025 at 8:11 a.m. Resident 1's temperature was 98.7 °F, HR 111 bpm, and blood pressure 75/33 mmHg. The GACH ER notes indicated on 1/8/2025 at 6:12 p.m., the first code blue (a hospital emergency code that indicates a patient needs immediate medical attention, usually due to cardiac (heart) or respiratory arrest) for Resident 1 was called, and at 7:50 p.m., the second code blue was called. The GACH ER notes indicated on 1/8/2025, at 8:11 p.m., Resident 1 expired. During a concurrent interview and record review on 1/29/2025 at 3:14 p.m., Resident 1's Vital Sign Summary report was reviewed with LVN 2. LVN 2 stated she did not assess or monitor Resident 1's vital signs when the resident had temperature of 103.8 °F and HR 130 bpm on 1/7/2025 at 11:43 p.m. LVN 2 confirmed there was no documentation of Resident 1's temperature and HR after it was last taken on 11/7/2025 at 11:43 p.m. During a concurrent interview and record review on 1/29/2025, at 4:24 p.m., with Registered Nurse Supervisor (RNS 1), Resident 1's Weight and Vital Sign Summary dated 1/5/2025 through 1/7/2025, and Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is change of condition among the residents) and COC dated 1/6/2025 and 1/8/2025 were reviewed. The Weight and Vital Sign Summary indicated, Resident 1 had the body temperature and heart rate as followed: a. On 1/5/2025, at 10:12 p.m. Resident 1's body temperature was 99.8 °F. b. On 1/6/2025, at 11:25 a.m. Resident 1's HR was 96 bpm. c. On 1/6/2025, at 11:31 p.m. Resident 1's HR was 91 bpm. d. On 1/7/2025, at 2:31 p.m. Resident 1's body temperature was 99.1 °F and HR was 98 bpm. e. On 1/7/2025, at 10:32 p.m. Resident 1's body temperature was 99.8 °F. f. On 1/7/2025, at 11:43 p.m. Resident 1's body temperature was 103.8 °F, and HR was 130 bpm. During a concurrent interview and record review on 1/29/2025, at 4:24 p.m., Resident 1's Physician Order Summary was reviewed with RNS 1. RNS 1 stated Resident 1's physician order dated 11/5/2024 indicated to notify MD if Resident 1 had any of the following symptoms: a. Body temperature less than 96.8 °F or greater than 99 °F. b. Heart rate greater than 99 bpm. c. Respiratory rate greater than 20 breaths per minute. d. Acute change in mental status. e. O2 saturation less than 90 %. f. Systolic blood pressure more than 5 mmHg lower than the baseline (100 mmHg) every shift for sepsis prevention. RNS 1 stated the physician's orders should have been followed to notify Resident 1's physician of the resident's COC. RNS 1 stated there was no care plan for neuromuscular dysfunction of the bladder to ensure the licensed nurses had specific intervention related to this diagnosis. RNS 1 further stated that there was no re-assessment done by licensed nurses after Resident 1 was noticed to have COC (temperature of 103.8 °F and HR 130 bpm) on 1/7/2025 at 11:43 p.m. RNS 1 stated Resident 1's physician should have been notified of Resident 1's change in vital signs on 1/5/2025 and 1/7/2025, and hematuria on 1/6/2025 as ordered for sepsis prevention. RNS 1 stated the physician orders should have been followed so Resident 1's physician could have given orders to address Resident 1's COC. RNS 1 stated physician notification should be documented in Resident 1's medical record to ensure licensed nurses would know what treatment was ordered for Resident 1. During an interview on 1/29/2025, at 4:40 p.m., LVN 1 stated Resident 1's physician was not notified of Resident 1's temperature of 103.8 °F and HR 130 bpm on 1/7/2025 at 11:43 p.m. LVN 1 stated nonpharmacological ( healthcare strategies that do not involve the use of medications) interventions including cooling measures such as removing blankets, put a fan on, and placing cold towels on Resident 1's forehead and under the arms were initiated. LVN 1 stated Resident 1's physician was not informed when Resident 1 had a COC on 1/5/25 with a body temperature of 99.8 °F and hematuria. LVN 1 stated she failed to inform Resident 1's physician when the resident spiked a temperature of 103.8 F on 1/7/2025 at 11:43 p.m. LVN 1 stated she did not think it was an infection as Resident 1's temperature went down to 99 °F on 1/7/2025 at 2:31 p.m. LVN 1 stated she does not recall the exact time Resident 1's temperature was taken on 1/7/2025 and it was not documented. LVN 1 stated she did not notify the physician of Resident 1's HR of 130 bpm, as Resident 1's heart rate came down on 1/7/2025 due to cooling measures but failed to document. LVN