Health inspection·February 25, 2025

§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... §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); §72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, 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. (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). §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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 1/16/2025, 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 slurred speech and Family Member (FM) 1 expressing concerns about a potential stroke (loss of blood flow to a part of the brain). On 1/22/2025, the CDPH conducted an unannounced visit to investigate the complaint allegations. During the investigation, CDPH determined the facility delayed Resident 1's transfer to a general acute care hospital (GACH) for several hours after Resident 1 reported having a slurred speech, a headache, and severe pain in left arm to prevent Resident 1 from having an ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke. The facility failed to: 1. Identify Resident 1's care needs when nursing staff did not perform a timely assessment when Resident 1 complained of having a headache, difficulty speaking, and severe pain in left arm rated nine out of 10 on a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and verbalized not feeling right. 2. Ensure that the facility's nursing staff notified the physician of Resident 1's change in condition. 3.Ensure the licensed nurses timely transferred Resident 1 to the GACH when Resident 1 and FM 1 reported the resident was having symptoms of a stroke, such as slurred speech and difficulty speaking. 4. Ensure staff followed the facility's policy and procedure (P&P) titled "Emergency Care," revised 9/2017, which indicated "to provide emergent care to a resident in need of urgent service; if a resident's condition is observed to have changed, assess the resident, notify the resident's attending physician, and report any changes in condition and provide emergency care as necessary." 5. Ensure staff followed the facility's P&P titled "Change in Condition," revised 3/2021, which indicated "the changes in the resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management; thorough assessment will include all important information related to the resident such as onset of current symptoms, including vital signs." As a result of these failures, there was a delay of several hours before transferring Resident 1 to a GACH from the time Resident 1 reported having slurred speech and difficulty speaking. Resident 1 was diagnosed with left frontal lobe ischemic stroke and has permanent brain damage. A review of Resident 1's Admission Record indicated Resident 1, a 69-year-old female, was admitted to the facility on 11/21/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, where blood flow to the brain is interrupted causing brain tissue to die) affecting the left side of the body, and trigeminal neuralgia (a chronic pain disorder affecting trigeminal nerve [provides sensation and controls muscles in the face and head]). A review of Resident 1's Minimum Data Set ([MDS] - resident assessment tool) dated 11/28/2024, indicated Resident 1 had intact cognition (ability to think and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff with lying to sitting on the side of the bed, from sitting to standing, and with transferring from the bed to chair. A review of Resident 1's Care Plan titled "High risk for compromised health condition associated by diagnosis of cerebrovascular disease (stroke) dated 12/2/2024, indicated interventions included to monitor vital signs as indicated, monitor for changes in condition and notify medical doctor accordingly. A review of Resident 1's Nurses Progress Note dated 1/9/2025 and timed for 7 a.m. to 3 p.m. shift, indicated Resident 1 was being monitored by LVN 1 when Certified Nursing Assistant (CNA) 1 reported Resident 1 was not able to speak. A review of Resident 1's Nurses Progress Note dated 1/9/2025 timed at 2:30 p.m., indicated CNA 1 reported to LVN 2 that Resident 1 wanted to speak to a supervisor or desk nurse. The Nursing Progress Note indicated LVN 2 assessed Resident 1 and Resident 1 did not have any new onset of symptoms. A review of phone text messages dated 1/9/2025 and timed at 2:31 p.m., between LVN 2 and the Nurse Practitioner (NP) 1, indicated LVN 2 wrote Resident 1 complaint of hard time speaking after lunch and felt she was having another TIA. LVN 2 wrote Resident 1 was "speaking right now and feels fine." NP 1 wrote back to "keep an eye on Resident 1 and do neuro checks (series of tests that assess the nervous system [brain, spinal cord] that can help identify disorders of the brain) every four hours." A review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) form dated 1/9/2025 and timed at 3 p.m., indicated Licensed Vocational Nurse (LVN) 1 notified Physician (MD) 1 about Resident 1's inability to speak and a high blood pressure (BP) of 152/96 millimeters of mercury ([mm/Hg]- a unit of pressure used to measure blood pressure. Reference range for normal BP is less than 120/80 mm/Hg). The SBAR indicated MD 1 recommendations included to monitor Resident 1. A review of Resident 1's Nurses Progress Note dated 1/9/2025 and timed at 3:15 p.m., indicated, LVN 2 asked RN 1 to assess Resident 1 because FM 1 voiced concerns of Resident 1 having slurred speech. The Nursing Progress Note indicated Resident 1's blood pressure was 152/88 mm/Hg. The Nurses Progress Note indicated Resident 1 was awake, alert, oriented to person, place, and time, was coherent, had clear speech, and did not have expressive aphasia (a language disorder that makes it difficult to understand or express language). A review of phone text message dated 1/9/2025 and timed at 3:43 p.m., between LVN 2 to NP 1, indicated LVN 2 informed NP 1 of Resident 1's having slurred speech and difficulty remembering. LVN 2 wrote RN 1 "assessed Resident 1 which revealed no slurred speech, strong hand grip on the right hand and weak hand grip on the left hand due to previous stroke." Resident 1 was "able to move right side extremities with no problem and no impaired vision." NP 1 responded Resident 1 "was fine when she saw the resident the morning of 1/9/2025." NP 1 wrote if LVN 2 felt there was a "change" Resident 1 should have a Computerized Tomography (CT scan- medical imaging). LVN 2 responded that she did not see any issue with Resident 1 now. A review of phone text message dated 1/9/2025 and timed at 3:50 p.m. between LVN 2 to NP 1, indicated LVN 2 wrote "FM 1 was adamant that something was wrong" with Resident 1. LVN 2 wrote FM 1 was requesting Resident 1 be transfer to GACH, NP 1 responded "fine." A review of Resident 1's Nurses Progress Note dated 1/9/2025, indicated 911 was called at 4:43 p.m. and Resident 1 was transferred to the GACH for slurred speech at 5:08 p.m. A review of Resident 1's Emergency Transport Record (Paramedic Run Sheet) dated 1/9/2025, indicated Paramedics were dispatched to the facility at 4:42 p.m. The Emergency Transport Record indicated at 4:55 p.m. Resident 1 had a blood pressure of 210/110 mmHg. The Emergency Transport Record indicated Resident 1 reported to the Paramedics of having trouble speaking around noon on 1/9/2025, and headache that has been unresolved throughout the day. A review of Resident 1's Emergency Department (ED) Encounter Notes dated 1/9/2025, indicated Resident 1 presented to the GACH at 5:16 p.m. with a complaint of expressive aphasia (a disorder that makes it difficult to speak, usually seen in patients who are experiencing a TIA or stroke) and inability to speak full sentences. The ED note indicated Resident 1 had a last known well time (medical term used to describe the last time a patient was known to be free of stroke symptoms) of 12 p.m. and was not a candidate for intravenous ([IV] - medication and/or fluids given directly into the vein) thrombolytic due to the last known well time of greater than three hours. A review of Resident 1's GACH Magnetic Resonance Imaging ([MRI] - a non-invasive test that uses radio waves and magnets to create a detailed image of the brain) dated 1/10/2025 and timed at 1:01 a.m., indicated Resident 1 had a new six millimeter (mm-unit of measurement) focus of restricted diffusion in the left frontal (at the front) cortical (outer layer of the cerebrum)/subcortical (region of the brain below the cortex ) region suggesting small acute or subacute infarct (lack of adequate blood supply to the brain). A review of Resident 1's GACH Discharge Summary Note dated 1/14/2025 and timed at 3:36 p.m., indicated Resident 1's principal diagnosis was acute left frontal lobe (the largest section of the brain which is located in the front of the head) ischemic stroke (when a blood vessel that supplies blood to the brain is blocked, cutting off oxygen and nutrients to brain cells). During an interview on 1/22/2025 at 10:16 a.m. Certified Nursing Assistant (CNA) 1, stated after lunch, around 1 p.m. to 1:30 p.m. Resident 1 verbalized not wanting to go back to bed which was unusual for Resident 1. CNA 1 stated Resident 1 complained of having severe pain 9 out of10 on a pain rating scale on her left arm. CNA 1 stated Resident 1 verbalized "not feeling right." CNA 1 stated she reported it to a charge nurse (LVN) but could not remember which LVN she spoke to. During an interview on 1/22/2025 at 10:53 p.m. FM 1, stated on 1/9/2025 around 1:30 p.m. he received a phone call from Resident 1 stating she believed she was having a stroke. FM 1 arrived at the facility around 2:30 p.m. and noticed Resident 1 was having slurred speech, difficulty in finishing her sentences, and difficulty remembering events throughout the day. FM 1 stated he asked the nurses to talk to the doctor, as he was concerned about Resident 1's worsening condition and requested Resident 1 to be transfer to the GACH as soon as possible. FM 1 stated the nurse (unknown) told him the NP 1 said to continue to monitor Resident 1. FM 1 stated he insisted a second time to the licensed nurses to transfer Resident 1 to the GACH and Resident 1 was eventually transferred to the GACH at 5:03 p.m. via 911 (four hours after Resident 1 started to verbalize having difficulty to talk and not feeling well). During an interview on 1/22/2025 at 1:35 p.m., the NP 1 stated she saw Resident 1 on 1/9/2025 in the a.m. (time unknown) when Resident 1 reported to have a headache. The NP 1 stated Resident 1 had a history of trigeminal neuralgia, so she ordered her pain medication. NP 1 stated she had received a phone text messages around 2:30 p.m. on 1/9/2025 from unknown nursing staff who stated Resident 1 complained of difficulty to talk. NP 1 stated vital signs were not provided in the phone text messages, but nurse (LVN 2) stated Resident 1 "seems fine," so she recommended to monitor Resident 1 every four hours. NP 1 stated she believed Resident 1 was having a TIA). NP 1 stated it was not a medical emergency because she did not present neurological symptoms based on nurse's report and therefore it must have resolved. NP 1 stated the reason why she did not recommend sending Resident 1 to the GACH emergency department was because they would just treat it with blood thinners, and the resident was already on Aspirin (a blood thinner). NP 1 stated around 3:30 p.m. she received a phone text message again from nursing staff (LVN 2) who stated FM 1 was insisting on Resident 1's transfer to the hospital, so she agreed since FM 1 insisted. During an interview on 1/22/2025 at 2:59 p.m., MD 1 stated he does not recall getting notified about Resident 1's change of condition on 1/9/2025. MD 1 stated if he would have been notified that Resident 1 was having slurred speech, he would order to send the resident to the hospital right away because monitoring would be a loss of time when Resident 1 was having a cerebral infarction. During an interview on 1/22/2025 at 3:50 p.m. RN 1 stated when she arrived to work at 3 p.m. LVN 2 reported to her Resident 1 was complaining about slurred speech. RN 1 stated she went to check on Resident 1 around that time, but her assessment was negative for any neurological changes. RN 1 stated she informed LVN 3 to check Resident 1's vital signs but did not actually witness vital signs being taken and does not know what time the vital signs were taken. RN 1 stated she was not the one to contact the physician or communicate to the physician about Resident 1's change of condition. During an interview on 1/22/2025 at 4:22 p.m., LVN 2 stated CNA 1 reported to her around 2:30 p.m. that the Resident 1 was having trouble speaking and she was the one who was in contact with NP 1 throughout the day. LVN 2 stated she told LVN 1 to take Resident 1's vital signs and fill out the SBAR form, but she did not relay the vital signs to NP 1. During an interview on 1/23/2025 at 9:28 a.m., RN 2 stated if Resident 1 reported having slurred speech, which could be a sign of a stroke, she would still send a resident to the hospital right away for evaluation. RN 2 stated there is a four-hour window