Health inspection·February 23, 2024

§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); available and provided upon request to the physician. §483.21(b) Comprehensive Care Plans §483.21(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 - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. §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. §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. (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. (E) Any untoward response or reaction by a patient to a medication or treatment. (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. §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 1/8/2024, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. During the visit, CDPH discovered a resident suffered a change of condition that occurred over a 24-hour period and passed away. Based on interview, and record review, the facility failed to: 1. Notify the physician when Resident 95 had a change of condition. The resident experienced difficulty breathing from congestion, gurgling, and wheezing in the lungs, with an episode of emesis (vomiting). As a result of the change of condition, Resident 95 experienced respiratory distress with vomiting on 11/9/2023. A 911 call was placed to emergency services one and a half hours after the resident had a change of condition (COC) and the paramedics pronounced the resident deceased in the facility. A review of Resident 95’s Admission Record indicated Resident 95, was an 83 year-old male, originally admitted to the facility on 9/20/2011 and readmitted on 11/7/2023, two days before the resident was pronounced deceased. Resident 95’s diagnoses included anemia (low level of red blood cells), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Parkinson’s disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), gastrointestinal (stomach) bleed, status post percutaneous endoscopic gastrostomy ([PEG] - medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) replacement, and diabetes mellitus (abnormal blood sugar). A review of Resident 95’s Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 10/6/2023, indicated Resident 95’s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 95 was completely dependent on staff for eating, oral hygiene, personal hygiene, toileting hygiene, bathing, and dressing. The MDS indicated Resident 95 had a feeding tube. A review of Resident 95’s Care Plan titled, “Risk for Aspiration (choking),” revised on 7/3/2023, indicated Resident 95 was at risk for aspiration of food and liquids secondary to advanced dementia, Parkinson’s disease, and gastrostomy (PEG). The care plan interventions indicated staff will notify the physician of changes of condition. A review of Resident 95’s COC note, dated 11/3/2023 at 12:21 a.m., indicated on 11/2/2023 at 11:45 p.m., Resident 95 exhibited congestion, wheezing and a gurgling sound. The COC indicated Resident 95 was transferred to the general acute care hospital (GACH). A review of Resident 95’s GACH records titled, “Procedure Notes,” dated 11/4/2023, indicated Resident 95 had an esophagogastroduodenoscopy ([EGD]- a test to examine the lining of the gastrointestinal [GI -relating to the stomach and intestines] tract) with a gastrostomy tube replacement. The procedure notes indicated there was evidence of gastric ulcers (open sores that develop on the lining of the stomach) with evidence of recent bleeding. Resident 95 had a hemoglobin (Hgb, a protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon dioxide back to the lungs) of 5.8 grams per deciliter (g/dl, unit of measurement) (Normal Reference Range for men 14.0 g/dl and 18 g/dl) and was treated with a blood transfusion. A review of Resident 95’s undated GACH Interfacility Transfer and Order Form, indicated Resident 95 had a diagnosis of GI bleed. A review of Resident 95’s “Re-Admission Patient -Alert” Sheet, dated 11/7/2023, indicated Resident 95 was re-admitted to the facility from the GACH on 11/7/2023 at 7 p.m. A review of Resident 95’s COC, dated 11/9/2023 at 7:17 a.m., indicated on 11/9/2023 at 5 a.m., Licensed Vocational Nurse (LVN) 6 noticed Resident 95 had congestion, gurgling, and wheezing. The COC indicated at 5:15 a.m., LVN 6 administered a breathing treatment to the resident, and at 6 a.m., Resident 95 was suctioned due to vomiting a “whitish amount of emesis.” The COC indicated at 6:15 a.m., Resident 95 did not respond to tactile (touch) and painful stimuli, appeared pale in color with an oxygen saturation (amount of oxygen in the blood) of 88% (normal range is 92 to 100%), and oxygen was administered. The COC indicated chest compressions were started at 6:30 a.m., and 911 was called. The COC indicated paramedics arrived at the facility at 6:40 a.m., chest compressions were resumed, and Resident 95 was pronounced deceased “around 7:20 a.m.” A review of Resident 95’s Medication Administration Record (MAR), for the month of November 2023, indicated on 11/9/2023 at 5:56 a.m., LVN 6 administered Ipratropium -Albuterol Inhalation Solution (a breathing treatment medication) 0.5-2.5 (3) 3mg per 3 millimeters. During an interview on 1/10/2024, at 12:41 p.m., LVN 6 stated she noticed Resident 95’s change in respiratory status around 2 a.m. on 11/9/2023. LVN 6 stated Resident 95 had labored breathing, was coughing, gurgling, and wheezing. LVN 6 stated she suctioned Resident 95 and administered a breathing treatment. LVN 6 stated she administered supplemental oxygen after one hour but Resident 95 was not getting better, so she suctioned the resident a second time. LVN 6 stated, “At 4:00 a.m., I gave another breathing treatment and continued with my medication pass for the other residents. When I came back, he (Resident 95) was already dying around 5 a.m.” LVN 6 stated, “I was so busy at that time I was passing medications for 50 plus residents, and we caused a delay in care.” LVN 6 stated there may have been a possibility that Resident 95 could have survived if the physician and 911 were notified or called earlier during the shift. LVN 6 stated, “We called 911 late already. It should have been right away when I first noticed he was having labored breathing.” During a concurrent interview and record review, on 1/10/2023, at 3:03 p.m., with LVN 7, Resident 95’s COC report, dated 11/9/2023 at 7:17 a.m. was reviewed. LVN 7 stated the COC report indicated on 11/9/2023 Resident 95’s COC of congestion, gurgling, and wheezing, and emesis was identified at 5 a.m. by LVN 6, and the physician was not notified until Resident 95 had already expired. LVN 7 stated she would have checked Resident 95’s vital signs immediately (at 5 a.m.), administered supplemental oxygen, and notified the physician right away. LVN 7 stated Resident 95’s death could have been avoided had the physician been made aware of Resident 95’s symptoms of respiratory distress (on 11/9/2023). During an interview, on 1/11/2024, at 10:30 a.m., with the Medical Director (Physician 1), Physician 1 stated there should be no delay in physician notification, especially if a resident exhibited adverse changes in respiratory status such as wheezing, gurgling, congestion, or cough because it could lead to resident’s harm. Physician 1 stated he expected the nurses to notify the attending physician of any COC for all residents. During a concurrent interview and record review with the Director of Nursing (DON), on 1/11/2023, at 1:47 p.m., Resident 95’s “COC” dated 11/9/2023 at 7:17 a.m., was reviewed. The DON stated the COC indicated on 11/9/2023 at 5 a.m., LVN 6 identified Resident 95’s change of condition but the physician had not been notified of any changes until after Resident 95 expired. The DON stated she expected LVN 6 to notify the physician, and call 911, especially if Resident 95’s COC was initially noticed by LVN 6 at 2 a.m., and if Resident 95 had not been responding to treatment. The DON stated the delay in physician notification of both Resident 95’s elevated blood sugar levels and Resident 95’s initial episode of respiratory distress could have contributed to Resident 95’s demise. The DON stated, “If 911 was called sooner, it could have led to a better outcome for the resident.” The DON stated it was the expectation of all licensed nurses to notify the physician of COC and to call 911 right away, especially if the care of a resident could not be managed at the facility. A review of the facility’s policy and procedure (P&P), titled, “Change of Condition”, dated 1/24/2017, indicated “chest congestion or shortness of breath” was considered a change of condition, and all changes of condition should be handled promptly, the physician shall be called promptly, and 911 should be called in cases of emergency. The facility failed to: 1. Notify the physician when Resident 95 had a change of condition. The resident experienced difficulty breathing from congestion, gurgling, and wheezing in the lungs, with an episode of emesis on 11/9/2023. As a result, Resident 95 experienced respiratory distress with vomiting on 11/9/2023. A 911 call was placed to emergency services one and a half hours after the resident had a COC and the paramedics pronounced the resident deceased in the facility. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.