Other·April 20, 2023

F684 §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: T22 §72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. T22 §72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. T22 §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 3/7/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the facility’s annual recertification survey. The facility failed to provide care and services for Patient 19 who had history of aspiration pneumonia (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed), by failing to: Ensure Licensed Vocational Nurse 1 (LVN 1) transcribed (put into written or printed form) and followed Medical Doctor 1's (MD 1's) verbal order (spoken orders given by a physician to a person authorized to receive and record the orders in accordance with applicable policies, laws, and regulations) according to the facility's policy and procedure titled, "Physician Orders and Telephone Orders." MD 1 gave LVN 1 a verbal order for Patient 19 to remain sitting upright for one to two hours after eating his meals (breakfast, lunch, and dinner) due to Patient 19 had a history of hospitalizations for sepsis (life-threatening complication of an infection) that resulted from aspiration pneumonia. Patient 19 required intubation (a breathing tube placed through the mouth, down the throat, and into the lungs), the use of a ventilator (a life support machine that moves breathable air in and out of the lungs when a person is unable to breath on his/her own), and admission to the Intensive Care Unit (ICU, a unit of a hospital that provides intensive treatment and close monitoring for seriously ill patients). This violation had the potential to result in recurrent (occurring often or repeatedly) aspiration pneumonia, re-hospitalization (being hospitalized again), intubation, and death for Patient 19. A review of Patient 19's Admission Record indicated the facility admitted Patient 19, a 61 year old male to the facility on 9/22/2017, and readmitted on 12/24/2022 with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (a life-threatening medical emergency in which the body responds improperly to an infection,) respiratory failure (a serious condition that makes it difficult to breathe), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting the mouth and stomach). A review of Patient 19's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive [ability to think and process information], behavioral, or functional domains) Assessment Form, dated 12/6/2022, indicated Patient 19 had shortness of breath (difficulty breathing), and trouble breathing when lying flat. The COC indicated at 11 AM, Patient 19 was sitting up in the wheelchair waiting for lunch. At 12:30 PM, Patient 19 was found breathing fast, looked pale with audible congestion (a sign that something blocks the airway), and rhonchi (low-pitched sounds usually indicating secretions [saliva or mucus] in the airway) in both lungs by auscultation (listening by using a stethoscope [an instrument that's used to hear the heart beats or breathings inside the chest]). The COC indicated the facility called 911 (phone number for emergency services) and the paramedics (a healthcare professional who responds to emergency calls for medical help outside of a hospital) transferred Patient 19 to the hospital. A review of Patient 19's General Acute Care Hospital 1 (GACH 1) Admission History and Physical Exam, dated 12/6/2022, indicated Patient 19 had shortness of breath, was tachypneic (breathing that is abnormally rapid and shallow) and required intubation. Patient 19 was admitted to GACH 1 for aspiration pneumonia. The GACH record indicated Patient 19 had acute (sudden) respiratory failure and depended on a respirator (depended on a mechanical ventilation/breathing machine to sustain respiration/breathing). A review of Patient 19's GACH 1 Multi-Discipline Progress Notes, dated 12/23/2022, indicated Patient 19 received a Modified Barium Swallow Study (MBSS, speech therapy evaluation with special X-ray [image study that takes pictures of the bones and soft tissues] to find the reason for difficulty swallowing) on 12/17/2022. The MBSS results indicated Patient 19 had moderate dysphagia (difficulty swallowing) characterized by poor base of the tongue retraction (action of drawing something back), and silent laryngeal aspiration (when the patients accidentally inhale food or liquid in the airway, and they do not know it) of thin and mildly thick liquids. The note indicated feeding precautions included for Patient 19 to "sit entirely upright," and for staff to monitor Patient 19 for fever spike (sharp rises in body temperature) after meals, coughing, choking (severe difficulty in breathing because an object or food lodges in the throat or windpipe blocking the flow of air) or throat clearing during meals. A review of Patient 19's GACH 1 Discharge Summary, dated 12/24/2023, indicated Patient 1 had sepsis due to aspiration pneumonia, recurrent aspiration pneumonia, acute hypoxemic respiratory failure (low blood oxygen level resulting from sudden impairment of gas exchange between the lungs and the blood which may cause shortness of breath, anxiety [a feeling of worry], confusion, cardiac dysfunction [heart failure], and cardiac arrest [no heartbeat]), and respirator dependence. The discharge summary indicated for Patient 19 to have puree diet with moderately thickened liquid (liquid mixed with thickener to help prevent choking and stop fluid from entering the lungs for safer swallowing), and for staff to observe strict aspiration precautions during and immediately after meals. A review of Patient 19's Minimum Data Set (MDS, a patient assessment and care screening tool), dated 2/22/2023, indicated Patient 19 had severe impaired cognition (ability to understand and process information). Patient 19 required extensive physical assistance (patient involved in activity, staff provide weight-bearing support) from one-person during bed mobility, transfers (moving a patient from one flat surface to another), eating and personal hygiene. A review of Patient 1's MD 1 Progress Notes, dated 1/4/2023, indicated Patient 19 needed oxygen and completed a seven-day course of Levaquin (medication that treats a wide range of infections) to treat the aspiration pneumonia. The note indicated strict aspiration precautions were to be followed given Patient 19's high-risk for re-aspiration. During an observation on 3/7/2023, at 9:32 AM, Patient 19 was lying flat on Patient 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Patient 19's head of bed indicated, per MD 1, "Please have patient up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]." During an observation on 3/7/2023, at 11:40 AM, Patient 19 was sitting up in wheelchair eating his lunch. Patient 19 had puree diet and thicken liquid on Patient 19's meal tray. During an observation and a concurrent interview with Patient 19 on 3/7/2023, at 12:19 PM, Patient 19 was lying flat in his bed. Patient 19 nodded his head when surveyor asked if he wanted to get up. During an interview on 3/7/2023 at 12:22 PM, LVN 2 stated she was aware of MD1's order for Patient 19 to remain sitting upright for one to two hours after meals due to the signage with instruction posted over Patient 19's head of bed. LVN 2 stated Patient 19 had GERD, and history of aspiration pneumonia. LVN 2 stated Patient 19 needed to be sitting upright after meals as aspiration precautions to prevent gastric secretions backflow (a flowing back or returning especially toward a source) to the airway. During a concurrent interview with a second staff, Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she and another staff (unidentified) assisted Patient 19 back to bed after Patient 19 finished his lunch. CNA 5 stated she was aware of MD 1's instruction to have Patient 19 sitting upright in the wheelchair after meals. CNA 5 stated there were two signages with instructions to have Patient 19 "up in wheelchair for meals and to remain sitting upright for 1-2 hrs." posted on the wall above Patient 19's head of bed, and at the back of Patient 19's door. During an interview, on 3/8/2023 at 1:33 PM, and a concurrent review of Patient 19's physician orders, care plans, and nurses progress notes, dated from 12/24/2022 to 3/6/2023, the DON stated the posted signages in Patient 19's room were to remind staff to keep Patient 19 sitting upright in the wheelchair for one to two hours after meals for aspiration precautions. The DON stated not following aspiration precautions could put Patient 19 on a ventilator again and or Patient 19 could die from choking. The DON reviewed Patient 19's physician orders and stated there was no written order for Patient 19 to sit upright in the wheelchair during and after meals. The DON continued to review Patient 19's care plan, nurses’ notes, and stated there was no documentation in the nurse's progress notes and no care plan interventions corelating with the aspiration precautions. The DON stated LVN 1 who received MD 1's instruction/verbal order needed to document MD 1's instruction/verbal order in Patient 19's progress notes. During a telephone interview on 3/9/2023 at 8:44 AM, MD 1 stated Patient 19 had a history of aspiration pneumonia which required hospitalization. MD 1 stated he gave a verbal order to LVN 1 during an onsite visit shortly after Patient 19 readmitted to the facility from the hospital. MD 1 stated he did not remember the date that he gave the verbal order. MD 1 stated the order was to have Patient 19 sitting upright in the wheelchair during meals and to remain sitting upright for one to two hours after meals. During an interview on 3/9/2023 at 9:12 AM, LVN 1 stated after Patient 19 was readmitted to the facility (on 12/24/2022), MD 1 told her to make sure to keep Patient 19 sitting upright in the wheelchair at least one to two hours after meals. LVN 1 stated she did not remember the date when MD 1 gave her the verbal order. LVN 1 stated she did not enter MD 1's verbal order in Patient 19's physician order summary. LVN 1 stated she did not document MD 1's verbal order in the nurse's notes and did not update Patient 19's care plan interventions for aspiration precautions. LVN 1 stated Patient 19 needed to remain sitting upright after meals due to Patient 19's history of GERD, aspiration pneumonia to prevent recurrent aspiration pneumonia, rehospitalization, sepsis, and death. During an interview on 3/9/2023, at 9:46 AM, the DON stated LVN 1 who received MD 1's verbal order needed to update Patient 19's care plan regarding aspiration precautions. A review of the facility's policy and procedure titled, "Aspiration Precaution," undated, indicated "Avoid lying down right after feeding. Remain sitting in an upright position for at least 20 to 30 minutes to prevent aspiration." A review of the facility's policy and procedure titled, "Physician Orders and Telephone Orders," dated 1/2004, indicated "All orders must be specific and complete with necessary details to carry out the prescribed order." The policy indicated "All orders shall indicate how the order was received, the name of the prescriber, the name of the attending physician and the name of the nurse taking the order." The facility failed to provide care and services for Patient 19 who had history of aspiration pneumonia by failing to ensure LVN 1 transcribed and followed MD 1’s verbal order according to the facility's policy and procedure titled, "Physician Orders and Telephone Orders." MD 1 gave LVN 1 a verbal order for Patient 19 to remain sitting upright for one to two hours after eating his meals due to Patient 19 had a history of hospitalizations for sepsis that resulted from aspiration pneumonia. Patient 19 required intubation, the use of a ventilator and admission to the Intensive Care Unit. As a result, this violation had the potential to result in recurrent aspiration pneumonia, re-hospitalization, intubation, and potential death for Patient 19. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 19.