Health inspection·August 8, 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, including but not limited to the following: 22 CCR §72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. 22 CCR §72523(a) Patient Care Policies and Procedure. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/24/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), was not transferred to a General Acute Care Hospital (GACH), per the family’s request, when Resident 1 had a Change of Condition (COC). On 6/25/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon completion of the investigation, CDPH determined that on 1/15/2024, Resident 1 was assessed with a decreased oxygen (O2) saturation rate ([O2 Sat] the level of oxygen carried by red blood cells through the arteries and delivered to internal organs. Reference range for O2 Sat is between 92-98%) and shortness of breath (SOB) and was transferred to a GACH on the same day. The facility failed to ensure: 1. The Respiratory Therapist ([RT] a medical professional who works with patients who have breathing problems or other lung conditions) obtained orders from Resident 1’s physician or nurse practitioner (NP) prior to changing Resident 1’s ventilator settings (used to control how much and how fast air is delivered to a patient’s lungs). 2. Registered Nurse Supervisor 1 (RNS 1) and RNS 2 followed the recommendations of Resident 1’s NP to transfer Resident 1 to a GACH when Resident 1’s respiratory rate (RR) was abnormal, at 40 breaths per minute and showed no signs of improvement. The RR reference range is 18-20 breaths per minute. 3. The nursing staff followed the facility’s undated policy and procedures (P&P) titled, “Mechanical Ventilation,” “Physician Orders and Telephone Orders,” and “Change of Condition,” that indicated ventilator changes are to be made only with a written physician’s order, physician’s orders shall be obtained prior to the initiation of any medication or treatment, the physician is responsible for making the decision for the resident to be transferred to the acute hospital for treatment. These deficient practices resulted in Resident 1’s respiratory ventilator setting changed without a physician’s or NP’s order, a delay in transferring Resident 1 to a GACH for evaluation and treatment, and placed Resident 1 at risk for further respiratory distress including respiratory arrest (when a person stops breathing or has ineffective breathing) A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, a 98 year-old female, was admitted to the facility on 12/10/2023 with diagnosis including acute (sudden onset) respiratory failure (a serious condition that makes it difficult to breathe on your own), tracheostomy (a hole that surgeons make though the front of the neck and into the trachea [windpipe] to insert a tube to provide an air passage to help a person breathe when the usual route for breathing is somehow blocked or reduced) status, and ventilator (a device that helps you breathe) dependence. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/17/2023, indicated Resident 1’s cognitive skills for daily decision making were severely impaired and she was not able to understand or be understood by others. The MDS indicated Resident 1 required mechanical ventilation, suctioning (removing mucous and other fluids from the windpipe and large airways), and O2 therapy. A review of Resident 1’s History and Physical (H&P) dated 12/14/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Order Summary Report (Physician’s Orders) dated 12/28/2023, indicated the following ventilator settings for Resident 1: 1. Assist Control of 18 ([AC] the number of breaths a patient is receiving from a breathing machine (ventilator) 2. Respiratory Rate ([RR] the number of breaths per minute a ventilator will deliver to a patient) of 18 breaths per minute. 3. Tidal Volume ([VT] the amount of air a person inhales during a normal breath) of 400. 4. Fraction of Inspired Oxygen ([FiO2] a ventilator setting that controls the percentage of O2 delivered to a patient) of 40% - 5 liters per minute (lpm) 5. Positive end-expiratory pressure ([PEEP] the maintenance of positive pressure at the airway opening at the end of expiration to keep the patient’s lungs from collapsing when they can’t breathe on their own) of +5. A review of Resident 1’s Situation, Background, Assessment and Recommendation form ([SBAR] a form of communication which provides a framework for communication between members of the health care team about a patient’s condition), dated 1/15/2024 and timed at 10:25 a.m., indicated RNS 1 notified Resident 1’s NP that Resident 1’s O2 Sat ranged from 88%-91%, and Resident 1 was experiencing shortness of breath (SOB). The SBAR indicated the NP ordered the following changes to the ventilator settings: 1. RR increased to 20 breaths per minute 2. VT increased to 450 3. Oxygen increased to eight lpm – approximately 52% FiO2. A review of Resident 1’s Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 3:30 p.m., indicated, RNS 1 notified Resident 1’s NP of Resident 1’s respiratory rate of 22 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated the NP ordered a chest X-ray (a diagnostic procedure that is used to diagnosed tumors bone injuries, and other diseases) and instructed RNS 1 to send Resident 1 to the GACH if Resident 1 needed more interventions, since Resident 1 was a full code. A review of Resident 1’s Continuous Ventilator Flowsheet dated 1/15/2024 and timed at 7 p.m., indicated Resident 1 had a respiratory rate of 40 breaths per minute. A review of Resident 1’s Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 7:30 p.m., indicated RNS 2 documented Resident 1’s O2 Sat was between 91-93% and Resident 1’s RR was 28 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated RNS 2 asked RT 1 to increase Resident 1’s PEEP ventilator setting from five to eight. The Licensed Personnel Weekly Progress Notes indicated Resident 1’s Family Member (FM 2) called and requested to transfer Resident 1 to a GACH. The Licensed Personnel Weekly Progress Notes indicated, RNS 2 documented Resident 1, “could not be transferred via a regular ambulance and would require a 911 transfer if he (RNS 2) decided that Resident 1 needed to be transferred to a GACH.” The Licensed Personnel Weekly Progress Notes indicated there was no documentation that RNS 2 obtained a physician’s order prior to asking RT 1 to change Resident 1’s ventilator settings or that Resident 1 was transferred to a GACH per FM 2’s request. A review of Resident 1’s Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8 p.m., indicated RNS 2 informed Resident 1’s NP of Resident 1’s RR of 40 breaths per minute and that he (RNS 2) changed Resident 1’s ventilator settings per the NP’s order on 1/15/2024 (this order was obtained from the NP after the ventilator settings had already been changed). The Licensed Personnel Weekly Progress Notes indicated Resident 1’s NP was concerned with Resident 1’s RR and requested that Resident 1 be transferred to a GACH. The Licensed Personnel Weekly Progress Notes indicated that RNS 2 would continue to monitor Resident 1 for improvement and if Resident 1 did not improve he (RNS 2) would transfer Resident 1 to a GACH. A review of Resident 1’s Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:30 p.m., indicated Resident 1’s RR was between 35-41 breaths per minute. The Licensed Personnel Weekly Progress Notes indicated Resident 1’s FM 1 and FM 2 requested that Resident 1 be transferred to a GACH. A review of Resident 1’s Licensed Personnel Weekly Progress Notes dated 1/15/2024 and timed at 8:40 p.m., indicated RNS 2 called 911 (about an hour and 40 minutes after Resident 1’s RR increased as evidenced by documentation on the Continuous Ventilator Flowsheet dated 1/15/2024 and timed 7 p.m.). During an interview on 6/24/2024 at 3:02 p.m., FM 2 stated on 1/15/2024 she requested several times that Resident 1 be transferred to a GACH via 911 but the licensed nurses refused to transfer Resident 1. During a telephone interview on 6/25/2024 at 9:44 p.m., RNS 2 stated he knew the ventilator settings were only to be changed with a physician’s or NP’s order, but he wanted to implement interventions that would hopefully stabilize Resident 1 because he (RNS 2) did not want to prematurely call 911 to transfer Resident 1 to a GACH. RNS 2 stated Resident 1 was still somewhat stable so he decided to have RT 1 change Resident 1’s ventilator settings and if Resident 1’s respiratory status did not improve he would call Resident 1’s NP for further orders. RNS 2 stated he did not think it was necessary to transfer Resident 1 to a GACH on 1/15/2024 at 8 p.m., after Resident 1’s NP’s recommendation to transfer Resident 1 to a GACH because Resident 1 was not showing signs of respiratory distress and he wanted to continue monitoring the interventions (change of ventilator settings) to see if Resident 1’s status improved. During an interview on 6/26/2024 at 2:17 p.m., RT 1 stated on 1/15/2024, he recommended to RNS 1 on several occasions throughout the shift (7 a.m. - 7 p.m.) that Resident 1 be transferred to a GACH for further evaluation and management because Resident 1’s RR was not improving, but RNS 1 did not agree with his recommendation. RT 1 stated because Resident 1 was not improving, he recommended to RNS 2 on 1/15/2024 at 7 p.m., that Resident 1 be transferred to a GACH, but RNS 2 did not agree with his recommendation. During a telephone interview on 6/26/2024 at 4:44 p.m., RNS 1 stated she did not feel the need to transfer Resident 1 to a GACH after the NP recommendation to transfer her because she (RNS 1) felt Resident 1 was stable. During an interview on 6/26/2024 at 5:44 p.m., the Director of Nursing (DON) stated based on Resident 1’s status and the recommendation made by the NP, Resident 1 should have been transferred to a GACH because Resident 1 was not improving. The DON stated licensed nurses, nor the RTs can change a ventilator setting without a physician’s or NP’s order because that was not within their scope of practice. The DON stated Resident 1 had the potential for cardiac arrest from increased carbon dioxide (colorless odorless gas that is a waste product of the body) in the blood due to an increased RR. A review of the facility’s undated policy and procedure (P&P) titled, “Mechanical Ventilation,” the P&P indicated ventilator changes are to be made only with a written physician’s order and by respiratory care provider. A review of the facility’s P&P titled, “Physician Orders and Telephone Orders,” dated 11/2017, the P&P indicated physician’s orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribe for and treat human illness. A review of the facility’s P&P titled, “Change of Condition,” revised 3/2021, the P&P indicated the physician is responsible for making the decision for the resident to be treated at the facility or be transferred to the acute hospital for treatment. The facility failed to ensure: 1. The Respiratory Therapist ([RT] a medical professional who works with patients who have breathing problems or other lung conditions) obtained orders from Resident 1’s physician or nurse practitioner (NP) prior to changing Resident 1’s ventilator settings (used to control how much and how fast air is delivered to a patient’s lungs) 2. Registered Nurse Supervisor 1 (RNS 1) and RNS 2 followed the recommendations of Resident 1’s NP to transfer Resident 1 to a GACH when Resident 1’s respiratory rate (RR) was abnormal, at 40 breaths per minute and showed no signs of improvement. The RR reference range is 18-20 breaths per minute. 3. The nursing staff followed the facility’s undated policy and procedures (P&P) titled, “Mechanical Ventilation,” “Physician Orders and Telephone Orders,” and “Change of Condition,” that indicated ventilator changes are to be made only with a written physician’s order, physician’s orders shall be obtained prior to the initiation of any medication or treatment, the physician is responsible for making the decision for the resident to be transferred to the acute hospital for treatment. These deficient practices resulted in Resident 1 receiving treatment that was not prescribed by Resident 1’s physician or NP and a delay in transferring Resident 1 to a GACH for evaluation and treatment and placed Resident 1 at risk for further respiratory deterioration. These violations jointly, separately, or in any combination, had the direct or immediate relationship to the health, safety, or security of Resident 1.