Health inspection·October 25, 2024

§ 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 §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 9/9/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), was left alone to eat a meal unassisted, choked and was transferred to a General Acute Care Hospital (GACH). On 9/10/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. During the investigation CDPH determined that Resident 1 choked while eating a meal at dinner time and there was a fourteen minute delay in calling 911. The facility failed to: 1. Ensure facility staff called 911 immediately to activate Emergency Medical Services ([EMS] a system that responds to emergencies in need of highly skilled pre-hospital clinicians). 2. Delegate staff to retrieve the facility's crash cart (a mobile cabinet that contains equipment and medications used to treat patients in a medical emergency) and obtain a non-rebreather mask ([NRM] a device that delivers a large amount of O2, between 10 to 15 liters per minute [LPM]) to deliver an effective amount of oxygen (O2). 3. Ensure staff followed the facility's Policy and Procedure (P/P), titled "Emergency Procedure Choking," that indicated if unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest general acute care hospital (GACH), and titled "Crash Cart Policy," that indicated the emergency crash cart is to be used for residents' requiring immediate interventions such as cardio-pulmonary resuscitation (CPR), suctioning, oxygen, etc." These failures resulted in: 1. Fourteen-minutes delay in calling 911 after Resident 1 was found choking, when Registered Nurse (RN 1) and Licensed Vocational Nurse (LVN 1) went to check Resident 1's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) while at the same time calling the Director of Staff Development (DSD) to inquire if they should call 911. 2. Resident 1, whose oxygen saturation rate ([O2sat] the percentage of oxygen [O2] in person's blood: normal level is 95% to 100% without the use of supplemental [extra] oxygen]), during the choking episode, fluctuated between 52% and 82% was not administered O2 at a higher rate via a NRM to provide effective respiratory ventilation (air exchange in and out of the lungs) and instead was provided O2 at five liters per minute (LPM) via a nasal cannula ([NC] a medical device that delivers low amounts of O2, usually between one to six LPM until EMS arrival. This deficient practice had the potential to result in Resident 1's death. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 67-year-old male, was admitted to the facility on 3/13/2024 with diagnoses including dysphagia (difficulty swallowing), and encephalopathy (a disease affecting brain and its function). A review of Resident 1's History and Physical (H&P), dated 3/22/2024, 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 6/18/2024, indicated Resident 1 had severely impaired cognitive skills (ability to learn, understand, and make decisions) for daily decision making and was dependent on staff for eating. The MDS indicated Resident 1 had difficulty or pain with swallowing and was prescribed a mechanically altered diet. A review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team) dated 9/8/2024 and timed at 5:55 p.m., indicated Resident 1 had decreased consciousness (state of being aware and responsive to one's surroundings), shortness of breath (SOB) and a low O2sat while eating (in bed). The SBAR indicated LVN 1 notified RN 1, who after assessing Resident 1, called 911. The SBAR indicated Resident 1 was transferred to a GACH for further evaluation and treatment. A review of Resident 1's Nurses Progress Note dated 9/8/2024 and timed at 5:56 p.m., indicated at 5:15 p.m., Resident 1 was slumped over in bed choking, RN 2 performed a mouth sweep (when a finger is placed in a person's mouth to remove any objects) and noticed Resident 1's lips were blue (a life-threatening sign indicating a lack of oxygen in body). The Nurses Progress Note indicated RN 1 administered two LPM of O2 to Resident 1 via a NC. The Nurses Progress Note indicated Resident 1's O2sat was 82%. The Nurses Progress Note indicated RN 1 increased the administration of O2 to Resident 1 to 5 LPM and requested a NRM. The Nurses Progress Note indicated Resident 1's lips were no longer blue but Resident 1 was observed with agonal breathing (irregular or gasping breaths, a sign of a severe medical emergency that occurs when the brain is not getting enough O2, and a person is near death). The Nurses Progress Notes indicated the Director of Staff Development (DSD) and 911 were called, and when the paramedics arrived, Resident 1's O2sat was 52% while on O2 at five LPM via a NC. On 9/13/2024, at 1:30 p.m., the facility's video surveillance was viewed with the DSD present. The video surveillance reflected the following events were observed to occur on 9/8/2024: 5:28 p.m. - LVN 1 entered Resident 1's room. 5:30 p.m. - RN 1 entered Resident 1's room. 5:33 p.m. - RN 2 entered Resident 1's room. 5:35 p.m. - RN 1 and LVN 1 exited Resident 1's room, walked to the nurse's station, that was located near Resident 1's room, sat in front of a computer and engaged in a discussion about what was viewed on the computer.(RN 1 and LVN 1 were observed pointing at the computer screen). 5:38 p.m. - RN 1, who was still at the nursing station, picked up a telephone and made a call. 5:41 p.m. - CNA 1 brought an O2 tank into Resident 1's room, then she was observed exiting Resident 1's room. 5:42 p.m. - CNA 1 brought a physiological monitor (a device that measures and displays a person's vital signs [v/s]) into Resident 1's room. At the same time RN 1 was observed making a telephone call. 5:48 p.m. - Paramedics arrived at Resident's 1 room. 5:55 p.m. - Resident 1 was transferred from his room on a gurney while being ventilated by a paramedic using a bag-valve mask ([BVM] a handheld device used to provide O2 and ventilation to people who are in respiratory distress or not breathing adequately). A review of Resident 1's Rescue and Emergency Medical Service Incident report dated 9/8/2024, indicated EMS was dispatched to the facility on 9/8/2024 at 5:42 p.m., and arrived at the facility at 5:47 p.m. The Rescue and Emergency Medical Service Incident report indicated Resident 1 was found seated in bed, his Glasgow Coma Scale ([GCS] a tool medical professional's use to objectively evaluate the degree to which a person is conscious or comatose. It operates on a scale of 3 to 15. A score of 15 means you are fully awake, responsive and have no problems with thinking ability or memory. A score of eight or fewer generally means you are in a coma. The lower the score the deeper the coma) was 6.0. The Rescue and Emergency Medical Service Incident report indicated Resident 1 had an altered level of consciousness ([ALOC] a change in a person's state of awareness and alertness) that occurred after eating. The Rescue and Emergency Medical Service Incident report indicated Resident 1 presented with diminished lung sounds, labored breathing, pale skin, and was immediately transported to the GACH for an uncontrolled airway. The Rescue and Emergency Medical Service Incident report indicated Resident 1 was ventilated via a BVM and small portions of a foreign body were removed from Resident 1's throat using McGill forceps (a medical instrument used for procedures in the throat and mouth such as foreign object removal) while enroute to the GACH. A review of the GACH's Face Sheet, indicated Resident 1 was admitted to the GACH on 9/8/2024. A review of the GACH's Emergency Room (ER) Consultation report dated 9/10/2024, indicated Resident 1 was admitted to the GACH after choking on spaghetti noodles requiring intubation (a medical procedure where a tube is inserted into a person's airway to help with breathing through a machine) on arrival to the GACH. The ER Consultation report indicated during intubation, the ER physician noted large amounts of spaghetti was present before and after Resident 1's vocal cords. A review of the GACH's Operative and Procedure report, dated 9/8/2024, indicated Resident 1 underwent a bronchoscopy (a procedure that examines the inside of the lungs and airways using a thin, flexible tube called a bronchoscope) to remove food material that was consistent with spaghetti. During an interview on 9/10/2024 at 1:40 p.m., CNA 1 stated on 9/8/2024 she was feeding Resident 1 dinner which consisted of noodles when she observed Resident 1 coughing nonstop. CNA 1 stated she stayed with Resident 1 and called CNA 2, who was in the hallway, to get help. CNA 1 stated LVN 1 and RN 1 came to Resident 1's room and LVN 1 performed the Heimlich Maneuver (first aid technique to help someone who is choking) on Resident 1, that was when she (CNA 1) left Resident 1's room to attend to her other assigned residents. CNA 1 stated she was not instructed by LVN 1 or RN 1 to call 911 or to get the crash cart. During an interview on 9/10/2024 at 3:30 p.m., CNA 2 stated she was passing out dinner trays in the hallway when she heard CNA 1 call for help, she (CNA 2) went to Resident 1's room and observed Resident 1 sitting up in bed, making gurgling noises and having a hard time breathing. CNA 2 stated, CNA 1 asked her to get assistance and she (CNA 2) called LVN 1 to the room. CNA 2 stated she was not instructed by the licensed nurses to call 911 or to get the crash cart. During an interview on 9/10/2024 at 3:45 p.m., LVN 1 stated CNA 2 called him to go to Resident 1's room, and when he arrived in Resident 1's room, CNA 1 told him that Resident 1 began to choke while she was feeding him spaghetti noodles for dinner. LVN 1 stated he observed Resident 1 drooling and he (Resident 1) appeared to be choking. LVN 1 stated he performed the Heimlich maneuver on Resident 1 and saw food particles expel from Resident 1's mouth. LVN 1 stated when RN 1 and RN 2 entered Resident 1's room, he left the room to validate Resident 1's code status to determine if 911 should be called. LVN 1 stated he did not inform RN 1 that he had performed the Heimlich maneuver on Resident 1, and he did not remember giving a report to the RNs before he left Resident 1's room. LVN 1 stated he did not return to the room, and he did not call 911 right away because he was looking for Resident 1's code status. During an interview on 9/10/2024 at 4:20 p.m., RN 2 stated CNA 2 called her to Resident 1's room, and when she arrived, she observed Resident 1 with what appeared to be noodles in his mouth. RN 2 stated she was able to sweep the food from Resident 1's mouth but his lips were blue. RN 2 stated she asked staff members for a suction device, oxygen and a nonrebreather mask, and CNA 1 brought her an O2 tank and a NC. RN 2 stated she applied the NC and administered O2 to the Resident 1 before asking staff to bring her a v/s machine. RN 2 stated Resident 1's O2sat was 82% on 5 LPM of O2 via a NC. RN 2 stated she then asked staff for a non-rebreather mask, but no one brought her the supplies she asked for. RN 2 stated staff should have brought the crash cart to Resident 1's room once the emergency was identified and 911 should have been called immediately to ensure Resident 1 did not have a delay in care. During an interview on 9/11/2024 at 12:25 p.m., RN 1 stated CNA 2 called her to Resident 1's room, and when she arrived, she observed CNA 1, CNA 2 and LVN 1 at Resident 1's bedside, LVN 1 was performing the Heimlich maneuver on Resident 1 which resulted in some food particles (noodles) being expelled from Resident 1's mouth. RN 1 stated Resident 1's mouth was blue, and RN 2 gave Resident 1 O2 via a NC, checked Resident 1's O2sat, which was 82%. RN 1 stated she left the room to assist LVN 1 to look for Resident 1's code status to determine if 911 needed to be called. RN 1 stated she called the DSD who instructed her to call 911 immediately. RN 1 stated she should have called or instructed staff to call 911 immediately instead of searching the chart for Resident 1's code status. RN 1 stated the delay in calling 911 put Resident 1 at risk of further injury and death. During an interview on 9/12/2024 at 1:20 p.m., the DSD stated on 9/8/2024 at approximately 5:30 p.m., RN 1 called her at home. The DSD stated RN 1 informed her that Resident 1 choked while he was eating and asked her about calling 911 and locating Resident 1's code status. The DSD instructed RN 1 to call 911 right away and to retrieve Resident 1's code status after calling 911. The DSD stated the facility staff should have called 911 once the Resident 1 was observed choking because time was critical. The DSD stated the facility delayed care to Resident 1 by not calling 911 immediately and stated the licensed nurses should have remained with Resident 1 and instructed the non-licensed staff to call 911 and retrieve the crash cart and any other needed supplies. During an interview on 9/12/2024 at 4:30 p.m., the DON stated 911 must be initiated once an emergency such as choking has been identified. The DON stated, while the licensed nurses provided care to Resident 1, other staff should have been instructed to call 911 and bring the crash cart to Resident 1's room. The DON stated Resident 1 experienced a delay in care that could have led to serious injury and death. During an interview on 9/13/2024, at 1:30 p.m., after viewing the facility's video surveillance, the DSD stated it appeared as if RN 1 made a call to her at 5:38 p.m., (10 minutes after LVN 1 was observed entering resident 1's room) and called 911 at 5:42 p.m., (14 minutes after LVN 1 was observed entering Resident 1's room). The DSD stated there was a delay in Resident 1's care when 911 was not called immediately after Resident 1 was identified as choking and by not bringing the emergency cart to Resident 1's room. A review of the facility's policies and Procedures (P&P), titled "Crash Cart Policy," revised 1/20/2024, indicated the emergency crash cart is to be used for residents' requiring immediate interventions such as CPR, suctioning, oxygen, etc. A review of the facility's P&P, titled "Emergency Procedure Choking," revised 8/2018, the P&P indicated trained staff will assist a resident who is choking by attempting to expel foreign body from the airway, if unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest GACH. A review of an online article titled, "Adult Basic Life Support," indicated, the actions taken during the first few minutes of an emergency are critical to the victim's survival. Basic Life Support ([BLS] set of life saving procedures performed in the early stages of an emergency) includes recognition of foreign body airway obstruction ([FBAO] a medical emergency that occurs when a foreign object such as food blocks the airway and prevents breathing). Early access requires prompt recognition of emergencies that require time critical BLS interventions, such as heart attack, stroke, FBAO, respiratory and cardiac arrest. Early access of the EMS system quickly alerts EMS providers who can respond with a defibrillator. Foreign bodies may cause either partial or complete airway obstruction, with partial airway obstruction the victim may be capable of either good air exchange or poor air exchange. If partial airway obstruction pers