Health inspection·February 24, 2022

F 684 483.25 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. Title 22: 72301 Quality of Care § 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 12/20/21, the Department received a complaint regarding staff hitting Resident 1. On 12/21/2021, the Department conducted an unannounced visit to the facility to investigate an allegation of abuse. During the visit an unrelated incident was identified related to quality of care. The facility failed to: 1. Intervene for over 22 hours after Resident 1 had a change of condition and did not implement the care plan, Potential Risk for Gastrointestinal (stomach and the intestines) Discomfort, dated 9/28/2021. Resident 1, who was on a blood thinner medication and at risk for gastrointestinal bleeding, was throwing up black colored vomitus, which contained blood. 2. Immediately notify the physician as required by the policy and procedures "Notification of Changes” and transfer the resident to the general acute care hospital (GACH). As a result, Resident 1 was admitted to the GACH’s Intensive Care Unit (ICU) on 12/19/2021 at 3:11 a.m. due to hypotension (low blood pressure) and Gastrointestinal (GI) bleed. During a review of the Resident's 1 Admission record, the face sheet indicated Resident 1 was a 79-year-old male, admitted to the facility on 12/8/2014 and readmitted on 7/24/2020. Resident 1’s diagnoses included chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), major depressive disorder (loss of interest in activities, causing significant impairment in daily life). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/9/2021, the MDS indicated Resident 1 had severe impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 1 needed limited assistance with bed mobility, extensive assistance with transfer, dressing, bathing, toilet use, and personal hygiene. During a review of Resident 1’s Physician Orders, dated 9/28/2021, Resident 1 was on Eliquis (blood thinner) 2.5 milligram (unit of mass) two times a day. During an interview on 12/21/2021 at 3:36 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, Resident 1 vomited black colored vomitus with food particles on 12/18/2021 at 12:15 a.m. LVN 1 stated that it was endorsed to her, and the attending physician was paged but no return call. LVN 1 stated there was no vomiting on her 7-3 shift. LVN 1 stated, she did not call the attending physician on her shift. LVN 1 stated Resident 1 vomited again on 12/18/2021 at 5:00 p.m. LVN 1 stated that she informed the nursing supervisor of Resident 1's condition. LVN 1 stated that she did not call attending physician since she informed the nursing supervisor. During a review of Resident 1's "Nurses Progress Notes" dated 12/18/21. The nurse's notes indicated the following: At 12:15 a.m., Certified nursing assistant (CNA) reported to LVN that Resident 1 threw up. LVN assessed the resident and noted a dark vomitus with undigested food. Vital signs were taken, Temperature (Temp.) 96.9 degrees Fahrenheit (F), Pulse rate (PR) 86, Respiratory rate (RR) 20, Blood pressure (BP) 100/60. At 7:00 a.m., Endorsed to incoming nurse, notified 'physician' waiting for the reply. At 3:00 p.m., No vomiting the whole 7-3 shift. Vital signs were taken, BP 108/62, RR 17, PR 98, and Temp. 97.4. At 5:30 p.m., Resident 1 vomited twice. Resident 1 stated "I feel a little weak,” when asked by Registered Nurse Supervisor (RN Sup) how does he feels? Vital signs were taken, BP 101/60, PR 101, RR 17, and Temp 97.2. At 9:15 p.m., "Resident with another episode of vomiting three times, small to moderate amount of black colored vomitus.” Follow up message sent to attending physician. Vital signs BP 85/58, PR 103, RR 17, and Temp 97.0. At 11:00 p.m., Order received from physician's nurse practitioner, to transfer resident to acute hospital via paramedic. At 11:20 p.m., Estimated time of departure to transport resident to the GACH. During an interview on 12/21/2021 at 4:19 p.m. with the Director of Nursing (DON) 1, DON 1 stated that any change of condition should be reported to the attending physician. DON 1 stated that if the attending physician is not responding, licensed staff should call the medical director. DON acknowledged there was a delay of transferring the resident to higher level of care after a change in medical condition. DON 1 stated it is important that the resident be sent to the hospital as soon as possible when there is a change of condition to be evaluated and get the care needed. During a telephone interview on 1/3/2022 at 10:19 a.m. with the Registered Nurse Supervisor (RN Sup), RN Sup stated he received a report on 12/18/2021 from 7:00 a.m.-3:00 p.m. shift licensed staff, that Resident 1 vomited on 12/18/2021 on the 11p.m.-7a.m. shift. RN Sup. stated that Resident 1 vomited again twice on 12/18/2021 at 5:00 p.m. RN Sup. stated, he called the attending physician on 12/18/2021 at 5:45 p.m. but did not receive a return call. RN Sup. stated, Resident 1 vomited again at 9:15 p.m. RN Sup stated, a follow up message was sent to the attending physician. RN Sup stated, he did not call the medical director when the attending physician was not calling back. RN Sup stated, Resident 1 could have had cardiogenic shock (inability of the heart to pump sufficient blood for the needs of the body) due to the delay of transfer to the acute care hospital. During a review of the SBAR Communication Tool form dated 12/18/2021 at 12:30 a.m. indicated, Resident 1 threw up to black liquid with food particles." During a review of the GACH's Emergency Department Encounter dated 12/19/2021 at 1:54 a.m., the Emergency Department Encounter indicated patient (Resident 1) here for hematemesis (vomiting of blood), the resident was supposedly on Eliquis (medication that thins the blood). Systolic blood pressure (pressure exerted when the heart beats) remains low in the 80's (improved from 60's). Hypotension (low blood pressure) appears most likely related to dehydration (dangerous loss of body fluid) and gastrointestinal bleed (GI) bleeding from stomach and intestines). Resident 1 was admitted to Intensive Care Unit on 12/19/2021 at 3:11 a.m. due to hypotension and GI bleed. During a review of Resident 1's care plan titled, Potential for Bleeding/Bruise/Skin Tear due to Anticoagulant (blood thinner) use undated, indicated interventions includes monitor for hematuria (bleeding in the urine), bleeding of gums, emesis (throwing up), black tarry stools, gastrointestinal (GI) distress. During a review of Resident 1's care plan titled, Potential Risk for Gastrointestinal (stomach and the intestines) Discomfort, dated 9/28/2021, indicated Resident 1 had a potential risk for GI discomfort, interventions include report to medical doctor any changes in condition. A review of the facility's policy and procedure (P&P) titled, "Notification of Changes (Revised 2021), the P&P indicated, "The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member when there is a change requiring such notification. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, this may include life threatening conditions, clinical complications. The facility failed to: 1. Intervene for over 22 hours after Resident 1 had a change of condition. Resident 1, who was on a blood thinner medication and at risk for gastrointestinal bleeding, was throwing up black colored vomitus, which contained blood. 2. Immediately notify the physician as required by the policy and procedures and transfer the resident to the general acute care hospital (GACH). As a result, Resident 1 was admitted to the GACH’s Intensive Care Unit ([ICU]) on 12/19/2021 at 3:11 a.m. due to hypotension (low blood pressure) and Gastrointestinal (GI) bleed. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.