Other·May 6, 2022

22 California Code of Regulations § 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: (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. (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. (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). 22 California Code of Regulations § 72517 Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (9) Signs and symptoms of cardiopulmonary distress. 22 California Code of Regulations § 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 2/9/2022 at 11:45 a.m., an onsite visit to the facility was conducted for a complaint and a facility-reported incident regarding Patient 1’s death. The facility failed to provide the necessary nursing services to Patient 1 by failing to: 1. Contact 911 timely (35 minutes delay) when Patient 1 experienced shortness of breath, pallor (pale appearance), cold extremities, and lethargy (state of sleepiness or deep unresponsiveness and inactivity). 2. Notify Patient 1's primary care provider (MD 1) promptly regarding Patient 1's weakness, refusal to eat four (4) consecutive meals, and refusal to get out of bed (OOB) from 2/6/2022 to 2/7/2022 prior to Patient 1's immediate deterioration when the patient experienced shortness of breath, pallor, cold extremities, and lethargy on 2/7/2022. 3. Document all attempts to notify all licensed healthcare practitioners in the Patient 1's health records with the time, method of communication, and person acknowledging contact when Patient 1 experienced a change of condition. 4. Develop, review, evaluate and implement a comprehensive and patient-centered care plan to address Patient 1's consecutive meal refusals, weakness and refusal to get OOB. 5. Provide all facility staff ongoing and planned trainings on identifying the signs and symptoms of cardiopulmonary distress (life-threatening condition related to a heart and/or lung problem and manifested by shortness of breath, labored breathing, pale or bluish skin color, low blood pressure, fainting, confusion, and/or extreme tiredness) and determining the necessary interventions. As a result, there was a delay in the delivery of the necessary care and services resulting in patient 1’s immediate deterioration and experience of shortness of breath, pallor, cold extremities, and lethargy, leading to Patient 1’s death. A review of the Admission Record indicated a fifty-year-old-male Patient 1 was initially admitted to the facility on 1/12/2016 with multiple diagnoses including paranoid schizophrenia (serious mental illness wherein individual interprets reality abnormally with some false beliefs and unwarranted suspicions or mistrust of other people), type 2 diabetes mellitus (chronic condition wherein blood sugar regulation is impaired, causing abnormally high or low blood sugar levels), high blood pressure, and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). A review of the Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/8/2021, indicated Patient 1 had no impairment in his cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Patient 1 was assessed as independent with bed mobility, transfer, walking, eating, toileting, and personal hygiene. A review of Patient 1's Physician Progress Note, dated 12/15/2021, indicated the patient had no complaints. The Progress Note indicated primary care provider did not have any abnormal findings with Patient 1's heart, chest, neck, abdomen, and neurological function upon examination. A review of Patient 1's Neurological Evaluation Flow Sheet, dated 2/7/2022, indicated Registered Nurse 1 (RN 1) documented Patient 1 was lethargic, not able to follow simple commands, and had no sensation or response to pain at 4:45 p.m. The Flow Sheet indicated RN 1 documented that at 4:55 p.m., staff was unable to find pulse and called 911. A review of Patient 1’s Progress Notes, Late Entry, dated as 2/7/2022, timed at 4:20 p.m., indicated at 4:45 p.m. (Progress Notes indicated RN 1 entered at 4:20 p.m. the notes regarding the incident that happened at 4:45 p.m.), Patient 1’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) “was dropping,” and Patient 1 “was lethargic and having difficulty breathing.” A review of the facility's form titled, "Resident Supervision Rounds & Area Safety/Security Rounds," from 2/5/2022 - 2/7/2022 indicated Patient 1 refused to eat lunch and dinner meals on 2/6/2022 and breakfast and lunch meals on 2/7/2022 (total of four consecutive meals). A review of Patient 1's Situation-Background-Assessment and Recommendation (SBAR) Communication Form, dated 2/7/2022, indicated Patient 1 had low blood pressure, was lethargic and short of breath. The SBAR indicated Patient 1 stayed in bed most of the time. The SBAR indicated RN 1 documented she notified the Primary Care Clinician (MD 1) on 2/7/2022 at 4:30 p.m. and obtained the recommendations to "administer oxygen, if available, “and "call 911 to transfer Patient 1 to the hospital." The SBAR indicated RN 1 documented at 5 p.m., staff was unable to obtain Patient 1's pulse and immediately initiated cardiopulmonary resuscitation (CPR, emergency procedure done in an attempt to restore the blood circulation and breathing of a person whose heart stopped beating) and called 911. The SBAR indicated RN 1 documented paramedics announced the time of death at 5:30 p.m. A review of the facility's form titled, "Interview/Debriefing Narrative Record," dated 2/8/2022, indicated the Unit Supervisor (Unit Sup) notified RN 1 of Patient 1 having trouble breathing on 2/7/2022 at 4:15 p.m. RN 1 documented Patient 1 was assessed and did not have trouble breathing. According to the documentation, Certified Nursing Assistant 1 (CNA 1) took Patient 1's vital sign and found them normal. RN 1 documented at 4:30 p.m. that she was calling 911 because Patient 1's vital signs were dropping as obtained by Licensed Vocational Nurse 1 (LVN 1) and CNA 1. RN 1 documented the Unit Sup and CNA 2 performed CPR around 4:45 p.m., and paramedics took over the CPR when they arrived. RN 1 documented paramedics pronounced Patient 1's death at 5:30 p.m. A review of the Fire Department Paramedic's Prehospital Care Report, dated 2/7/2022, indicated the facility's 911 call was received at 5:20 p.m., and the paramedic unit was dispatched at 5:22 p.m. The Report indicated Patient 1's cardiac arrest (when the heart stops beating suddenly) onset was at 5:18 p.m. and death was at 5:53 p.m. A review of the Police Department's Incident Report, dated 2/7/2022, indicated RN 1 reported Patient 1 "had been feeling ill for the last two days. He had not been eating even when staff continued to encourage him to eat. He also did not want to drink fluids." The Report indicated RN 1 stated Patient 1 was found on the floor in his room, his skin appeared to be pale, and was having difficulty breathing. The Report indicated RN 1 stated Patient 1's blood pressure was low, and Patient 1 stopped breathing on 2/7/2022 as she was calling 911. The Report indicated Patient 1 was pronounced dead at 5:53 p.m. by the paramedics. A review of Patient 1's Progress Notes, dated 2/8/2022, timed at 11:58 a.m., and completed by RN 1, indicated "On 2/7/2020 at approx. 1500 (3 p.m.) during rounds by CNA (unidentified) noted resident alert and awake in his room and laying on his bed." The Progress Notes did not indicate it was a late entry and the year 2020 was typed in error according to the medical records manager (MRM) on 4/8/2022 via telephone interview. A review of Patient 1's Certificate of Death, indicated the date of death was 2/7/2022, at 5:53 pm, and the cause of death was acute respiratory failure (lungs cannot release oxygen into the blood and organs cannot get enough oxygen-rich blood to function). During an interview on 2/9/2022 at 3:25 p.m., RN 1 stated LVN 1 and LVN 2 assessed Patient 1 for any injuries from the fall on 2/7/2022 around 4:20 p.m. RN 1 stated Patient 1's vital signs were taken by CNA 1 on 2/7/2022 at 4:30 p.m. before RN 1 arrived in the patient's room. Patient 1's vital signs were as follow: blood pressure 120/76, heart rate 68, respiratory rate 22, temperature 97.5 degrees Fahrenheit, and oxygen saturation at 96%. RN 1 stated LVN 1 informed her Patient 1 had not been eating. RN 1 stated at 4:45 p.m., Patient 1 became lethargic and pale with some difficulty breathing. RN 1 stated they (unidentified staff) then retook Patient 1's vital sign, which were as follow: blood pressure 90/60, heart rate 60, respirations 16, and oxygen saturation at 93%. RN 1 stated Patient 1 was "short of breath." RN 1 stated she called 911 at 4:50 p.m. RN 1 stated Code Blue (emergency code when a patient goes into cardiac arrest), was initiated at 4:55 p.m. RN 1 stated she was not able to talk to MD 1 (as RN 1 documented in the SBAR) and Patient 1's Psychiatrist/Medical Director (MD 2). RN 1 stated she was unable to reach the Director of Nursing (DON) at the time of the incident. RN 1 stated the DON informed the physicians when Patient 1 had already passed away. RN 1 stated she did not perform CPR on Patient 1 and could not remember who performed it. RN 1 stated paramedics arrived at 5 p.m. and Patient 1 was pronounced dead on 2/7/2022 at 5:30 p.m. During a telephone interview on 2/10/2022 at 9:34 a.m. CNA 2 stated LVN 2 informed her at the start of her shift on 2/7/2022 at 3:09 p.m. Patient 1 had been refusing his meals. CNA 2 stated around 4:15 p.m., she heard a staff member state Patient 1 was on the floor. CNA 2 stated she saw Patient 1 lying on the floor and two staff members assisting him back to bed. CNA 2 stated she informed the Unit Sup who went in Patient 1's room to check on the incident. CNA 2 stated she called RN 1 on 2/7/2022 at 4:36 p.m., to assess Patient 1. CNA 2 stated RN 1 arrived shortly but did not "assess" Patient 1. CNA 2 stated RN 1 did not conduct a head-to-toe assessment to check for any other injuries and did not perform any blood sugar checks (a procedure that measures the amount of sugar, or glucose, in the blood). CNA 2 stated RN 1 had stated Patient 1 was, "only dehydrated and needed some water and food." CNA 2 stated RN 1 asked for Patient 1 to be showered first before she could assess him. CNA 2 stated when his second set of vital signs were taken after the fall, his blood pressure started declining. CNA 2 stated some staff then had him sit on a chair. CNA 2 stated Patient 1 "looked so pale," and he started having "labored breathing." CNA 2 stated RN 1 placed the 911 call around 5:20 p.m. - 5:25 p.m. CNA 2 stated around this time, she heard Personal Counselor 3 (PC 3) saying Patient 1 had no pulse. CNA 2 stated she summoned the team to perform CPR on Patient 1 until paramedics arrived within 10 minutes. CNA 2 stated Patient 1 was pronounced dead on 2/7/2022 at 5:55 p.m. During a telephone interview on 2/10/2022 at 10:54 a.m., LVN 2 stated around 4:20 p.m. on 2/7/2022, together with LVN 1, they both went to Patient 1's room and inspected Patient 1. LVN 2 stated Patient 1 did not have any injuries as a result of the fall. LVN 2 stated Patient 1 did not state why and how he got on the floor, but Patient 1 kept saying he was thirsty and kept asking for water. LVN 2 stated he was not aware of any care plans developed for Patient 1’s meal refusals and/or refusals to get OOB. During a telephone interview on 2/10/2022 at 2:20 p.m., CNA 1 stated he assisted Patient 1 after the fall on 2/7/2022. CNA 1 stated Patient 1 "looked pale, was not doing well, and was not sitting upright" at the time. CNA 1 stated Patient 1 had not been eating solid foods since the day prior to the incident. During a telephone interview on 2/10/2022 at 3:09 p.m., Unit Sup stated he walked into Patient 1's room on 2/7/2021 at around 4:35 p.m. Unit Sup stated Patient 1 had pale and cold skin and difficulty breathing as if he had been exercising and could not catch his breath. Unit Sup stated around 4:45 p.m., a second set of vital signs was then taken: blood pressure 86/60, heart rate 58, and staff was unable to get an oxygen saturation reading. Unit Sup stated he palpated Patient 1's pulse and found it very weak. Unit Sup stated Patient 1 had a hard time breathing, was very pale in color, and his lips were white. Unit Sup stated at this point, RN 1 went to the nurses' station to call the primary physicians (not specified) and the DON. Unit Sup stated at around 5:10 p.m.-5:15 p.m., Patient 1 became pulseless, and staff immediately initiated CPR. Unit Sup stated he reported this to RN 1, who at that time stated she was unsuccessful in reaching the physicians and the DON. Unit Sup stated RN 1 then decided to call 911. Unit Sup stated the paramedics came within 15 mins after initiating the CPR. Unit Sup stated Patient 1 was pronounced dead about 30 minutes after the paramedics took over the CPR. Unit Sup stated he wished they could have called 911 before the patient's condition worsened. During a telephone interview on 3/10/2022 at 12:22 p.m., LVN 2 stated he did not receive a report that Patient 1 had been refusing meals since lunch time on 2/6/2022. LVN 2 stated if he was made aware that Patient 1 was diabetic, weak, and was about to refuse his 3rd meal (breakfast on 2/7/2022), he would have checked Patient 1's blood sugar level and called MD 1 on 2/7/2022 in the morning to ask for any clinical recommendations, such as transfer to the hospital, lab draw, or any oral medications to be withheld. During a telephone interview on 3/10/2022 at 4:47 p.m., Unit Sup stated from the time he walked into Patient 1's room on 2/7/2022 at 4:36 p.m., Patient 1 was experiencing shortness of breath and difficulty finishing his sentences due to the need to take a breath that lasted throughout the incident. Unit Sup stated RN 1 wanted staff to shower Patient 1, but Patient 1 was not able to stand up on his own and the patient kept trying to lie down. Unit Sup 1 stated RN 1 was attempting to get a hold of the primary physicians, but she was unsuccessful. Unit Sup stated RN 1 was also attempting to call the DON and the Administrator prior to calling 911. Unit Sup stated he was "feeling a sense of urgency" but felt there was a delay in transferring the resident to the hospital, where there was available equipment to address Patient 1's emergent needs. During a telephone interview on 3/17/2022 at 2:10 p.m., MD 1 stated if Patient 1 had refused more than one (1) meal, the licensed nurses should have notified her and she could have ordered a complete blood count (CBC, full blood count to evaluate overall health), comprehensive metabolic panel (CMP, blood test to evaluate the body's chemical balance and metabolism), u