Health inspection·August 29, 2024

42 CFR §483.24 Quality of Life (a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (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. 22 CCR § 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. (9) Signs and symptoms of cardiopulmonary distress. 22 CCR §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. On 7/8/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident choked on a meal. On 7/10/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the nursing staff did not immediately initiate basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) measures such as Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) and did not immediately call 911 when Resident 1 became unresponsive, breathless, and pulseless on 7/6/2024 during meal time while in the dining room. The facility failed to: 1. To provide emergency care or initiate life-saving measures including CPR to Resident 1 in a timely manner when the resident was found unresponsive and without breath or pulse by facility staff. 2. To provide adequate training and supervision to employees to ensure appropriate emergency care or initiate life-saving measures are immediately taken, resulting in facility staff's failure to provide emergency care or initiate life-saving measures including CPR to Resident 1 when the resident was discovered to be unresponsive and without breath or pulse. 3. Ensure staff called 911 as soon as Resident 1 was found unresponsive, breathless, and pulseless in accordance with the facility's policy and procedure titled, "Cardiopulmonary Resuscitation." As a result, there was an eight-minute delay in starting Resident 1's CPR. Resident 1 was pronounced dead at the facility on 7/6/2024, at 6:03 p.m. These deficient practices placed other 58 residents, who had a Full Code (a medical code status that indicates that a patient's medical team should perform all procedures necessary to save their life in the event of a medical emergency, including CPR) status at risk not to receive life saving measures timely, including CPR, thereby increasing the risk of further injury and death. A review of Resident 1's Admission Record indicated Resident 1, a 72-year-old male, was admitted to the facility on 09/19/2008 and re-admitted on 06/14/2020, with diagnoses including blindness, essential hypertension (high blood pressure), seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), and dementia (the loss of cognitive functioning -thinking, remembering, and reasoning) with psychosis (mental disorder characterized by a disconnection from reality). A review of Resident 1's History and Physical (H&P), dated 9/09/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Sheet ([MDS]- a standardized assessment and care screening tool) dated 05/31/2024 indicated Resident 1 had severely impaired cognitive skills (ability to learn, understand, and make decisions) for daily decision making and required supervision or touching assistance for eating, upper body dressing, partial or moderate assistance for oral hygiene, toileting, putting on and taking off footwear, maximal assistance for shower and lower body dressing. The MDS indicated Resident 1 had severely impaired vision. The MDS indicated Resident 1 did not have Physician's Order for Life Sustaining treatment ([POLST] a written medical order from a physician that specify the types of medical treatment resident want to receive during serious illness). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 07/06/2024, SBAR indicated Resident 1 status was a Full Code. During a concurrent interview and record review on 7/9/2024 at 3:37 p.m., with Registered Nurse (RN 2), Resident 1's Nursing Progress Notes dated 07/06/2024 were reviewed. The Nursing Progress Notes indicated on 07/06/2024 at 5:27 p.m. Resident 1 died of cardiac arrest (heart stops beating suddenly) while he was having dinner in the dining room when suddenly became unresponsive, not breathing, and pulseless (without pulse). The Nursing Progress Notes indicated, and RN 2 confirmed, CPR was not initiated until Resident 1 was wheeled out from the dining room back to Resident 1's room. On 7/10/2024, at 9:35 a.m., during viewing of the facility's recorded video footage for 7/6/2024, and concurrent interview with the ADM, the video recording indicated that on 7/6/2024 at 5:00 p.m., Resident 1 was sitting in a wheelchair in the dining room waiting for his dinner to be served. The recorded video demonstrated that at 5:27 p.m., while Resident 1 was having dinner, CNA 5 was running toward Resident 1's direction. The recorded video demonstrated Resident 1, while in the wheelchair, slumped forward and was not moving. The video demonstrated CNA 5 picked Resident 1 up and performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person). Resident 1 remained unresponsive. CNA 5 placed the resident back on a wheelchair and wheeled Resident 1 out of the dining room back to his room. At 5:35 p.m., a crash cart was brought by the LVN (unknown) in Resident 1's room and CNA 5 began administering CPR on Resident 1. At 5:43 p.m., paramedics arrived. The video recording indicated there was an eight-minutes delay from the time Resident 1 slumped forward and became unresponsive until staff initiated Resident 1's CPR. During an interview with RN 2 on 07/10/2024 at 4:30 p.m., RN 2 stated he was not present in the dining room when Resident 1 became unresponsive, but staff informed him, and he went to the dining room to help. RN 2 stated he did not arrive until after Resident 1 was wheeled out from the dining room. RN 2 stated if Resident 1 was a Full code the licensed nurses should have immediately start CPR as soon as Resident 1 become unresponsive and was not breathing. RN 2 stated it was important to initiate CPR right away when Resident 1 became unresponsive, not breathing, and pulseless, because every second counts and time was a factor to save Resident 1's life. During an interview with CNA 5 on 7/11/2024 at 9:07 a.m., CNA 5 stated he was responsible for taking care of Resident 1 while in the dining room on 7/6/2024. CNA 5 stated he thought Resident 1 was choking when Resident 1 became unresponsive during dinner. CNA 5 stated he performed a Heimlich maneuver but Resident 1 continue to be unresponsive. CNA 5 stated LVN 3 came and assessed Resident 1's airway. CNA 5 stated LVN 3 said she cannot see any food blockage in Resident 1's mouth. CNA 5 stated Resident 1 continued to be unresponsive. CNA 5 stated she asked LVN 3 to perform CPR but was told "not yet." CNA 5 stated CPR was not provided to Resident 1 when Resident 1 remained unresponsive and LVN 3 confirmed the resident had no pulse. CNA 5 stated if Resident 1's CPR was started right away "we could have saved his life." CNA 5 stated that LVN 3 did not call 911 and did not ask anyone to call 911 at the time when Resident 1 became unresponsive and not breathing. CNA 5 stated LVN 3 instructed him to wheel Resident 1 out from the dining room back to Resident 1's room so that CPR can be provided. CNA 5 stated his belief that LVN 3 was concerned for Resident 1's privacy and concerned with not making other residents in the dining room panic. During an interview with LVN 2 on 7/11/2024 at 12:18 p.m. LVN 2 stated LVN 3 came to help when Resident 1 was observed unresponsive. LVN 2 stated Resident 1 was grabbing his chest and then became unresponsive, so staff thought Resident 1 was choking. LVN 2 stated CNA 5 provided Heimlich maneuver while LVN 3 assessed the airway. LVN 2 stated CPR was not started in the dining room right away when Resident 1 became unresponsive and had no signs of pulse. LVN 2 stated that there was a delay in initiating CPR, and no one called 911 for emergency services. LVN 2 stated CPR was initiated when Resident 1 was brought back to his room and transferred to bed. LVN 2 stated that CPR was not done on the floor in the dining room out of concern for the resident's privacy and to prevent other residents in the dining room from panic. During an interview with LVN 2 on 7/12/2024 at 11:50 a.m., LVN 2 stated that on 7/6/2024 at approximately 5:27 p.m., Resident 1 was sitting in his wheelchair in the dining room. LVN 2 stated Resident 1 lost consciousness when CNA 5 was doing the Heimlich maneuver. LVN 2 stated CNA 5 sat Resident 1 on his wheelchair, wheeled Resident 1 back to his room and carried Resident 1 to his bed. LVN 2 stated CPR was not initiated right away on the scene (dining room). LVN 2 stated that every second mattered to save Resident 1's live. LVN 2 stated if CPR was started right away when Resident 1 became unresponsive there could be a chance for Resident 1's survival. During an interview with the Director of Nursing (DON) on 7/12/2024 at 12:05 p.m., the DON stated CPR should not be delayed once resident became unresponsive, not breathing, and pulseless, staff should respond quick in an emergency situation and initiate CPR. During an interview with CNA 5 on 7/12/2024 at 12:10 p.m. CNA 5 stated LVN 5 and LVN 3, who responded when Resident 1 became unresponsive, did not initiate CPR right away and did not call 911. During an interview on 7/12/2024 at 3:40 p.m., RN 1 stated that CPR should have been initiated right away when staff identified Resident 1 was unresponsive and not breathing. RN 1 stated CNA 5 and LVN 3 should not have taken Resident 1 to his room and placed Resident 1 on bed before starting CPR, because time was very critical and important. The DON stated CNA 5 and LVN 3 should have initiated CPR as soon as Resident 1 was found unresponsive and possibly could have saved Resident 1's life. A review of Resident 1's Nursing Progress Notes dated 7/6/2024 timed at 5:32 p.m. indicated "911 was immediately called. At 5:42 p.m. paramedics arrived and continue CPR and cardiac (heart) medications were initiated. At 6:03 p.m., CPR failed, and the resident pronounced expired." A review of an online article titled, "American Heart Association 2020 CPR and Emergency Cardiovascular ( involving the heart) Care Committee Guidelines," the article indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers indicated to verify for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions (the act of applying pressure to someone's chest to help blood flow) and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines A review of the facility's P&P titled "Cardiopulmonary Resuscitation," (undated) the P&P indicated "Establish the need for CPR, send another person to call for emergency services, remain with the resident and call for help...If the pulse is absent...compress the sternum straight down one and a half to two inches at a rate of 100 compression each minute..." The facility failed to: 1. To provide emergency care or initiate life-saving measures including CPR to Resident 1 in a timely manner when the resident was found unresponsive and without breath or pulse by facility staff. 2. To provide adequate training and supervision to employees to ensure appropriate emergency care or initiate life-saving measures are immediately taken, resulting in facility staff's failure to provide emergency care or initiate life-saving measures including CPR to Resident 1 when the resident was discovered to be unresponsive and without breath or pulse. 3. Ensure staff called 911 as soon as Resident 1 was found unresponsive, breathless, and pulseless in accordance with the facility's policy and procedure titled, "Cardiopulmonary Resuscitation." As a result, there was an eight-minute delay in starting Resident 1's CPR. Resident 1 was pronounced dead at the facility on 7/6/2024, at 6:03 p.m. These deficient practices placed other 58 residents, who had a Full Code status at risk not to receive life saving measures timely, including CPR, thereby increasing the risk of further injury and death. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.