Health inspection·November 5, 2024

Code of Federal Regulations, Title 42, Section §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives. California Code of Regulations, Title 22, Section 72311. Nursing Service – General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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: (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. On 9/20/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding a resident’s death. As a result of the investigation, the CDPH determined the facility failed to provide immediate cardiopulmonary resuscitation (CPR) to Resident 1 who was a full code. On 9/20/2024, Certified Nursing Assistant 1 (CNA 1), Licensed Psychiatric Technician (LPT 1) and Licensed Vocational Nurse 1 (LVN 1) did not provide CPR immediately when Resident 1 was found unresponsive in Resident 1's room as indicated in the facility's Policy and Procedures (P&P) titled "Advance Directives (AD)/Individual Health Care Instructions” and "Emergency Response Policy and Procedure." On 9/20/2024 at 6:49 am, Resident 1 was pronounced expired after the paramedics performed unsuccessful CPR to Resident 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 35-year-old male on 4/15/2022 with diagnoses that included paranoid schizophrenia, bipolar disorder unspecified, and obesity. A review of Resident 1's Minimum Data Set dated 7/12/2024 indicated Resident 1's cognition was intact, had clear speech, and had the ability to understand and be understood by others. The MDS indicated Resident 1 did not have any impairments on the upper extremities and lower extremities. A review of Resident 1's Emergency Medical Technician Fire Department run report dated 9/20/2024, timed at 6:36 am indicated EMTs arrived at the facility on 9/20/2024 at 6:43 am and were at Resident 1's bedside to evaluate Resident 1 at 6:44 am. The report indicated the EMTs found Resident 1 on the floor, unresponsive, and pulseless. The report's narrative indicated CPR was given to Resident 1 and Resident 1's first monitored heart rhythm was asystole. The report's narrative indicated Resident 1 was dead prior to the EMTs arrival and the EMTs called a time of death at 6:49 am. The report indicated staff alleged had seen Resident 1 ten minutes prior to the EMT's arrival but Resident 1 had rigor (fourth stage of death, recognizable sign of death characterized by stiffening of the limbs caused by chemical changes in the muscles and can occur as soon as four hours after death) and lividity (bluish purple discoloration of the skin after death). A review of Resident 1's Progress Note written by LPT 1, dated 9/20/2024, timed at 8:29 am, indicated at 6:25 am, CNA 1 alerted LPT 1 to check on Resident 1. The PN indicated Resident 1 was found bent over in the corner, between the bed and the closet in Resident 1's room. The PN indicated LPT 1 tapped Resident 1 on the back, but there was no response from Resident 1. The PN indicated Resident 1 had no vital signs and staff called for help, called a code blue, and CPR was started (no time specified). The note indicated paramedics arrived at the facility around 6:30 am (per the EMT report, EMT arrival time was 6:43 am), Resident 1 was pronounced expired, and the coroner's office was called. During a telephone interview on 9/20/2024 at 1:28 pm, with LPT 1, LPT 1 stated CNA 1 informed LPT 1 to check on Resident 1 after CNA 1 found Resident 1 unresponsive. LPT 1 stated, LPT 1 was assigned to care for Resident 1 on 9/20/2024 during the night shift. LPT 1 stated during the shift, "nothing was triggered" and LPT 1 just walked by Resident 1's room. LPT 1 stated at 2 am and 4 am, LPT 1 passed by Resident 1's room and LPT 1 did not see anything unusual. LPT 1 stated, during LPT 1's shift, LPT 1 did not see Resident 1 come outside of Resident 1's room. LPT 1 stated in the early morning LPT 1 entered Resident 1's room and saw Resident 1 faced down on the floor between the bed and closet. LPT 1 stated LPT 1 tapped Resident 1 but Resident 1 was unresponsive. LPT 1 stated LPT 1 left Resident 1's room, walked to the door leading to the east unit and instructed CNA 4 to notify LVN 1 there was an emergency. LPT 1 stated he and LVN 1 went back to Resident 1's room and started performing CPR. According to the American Red Cross Training Services, undated, for a person who was found unresponsive and not breathing CPR should be started and an AED should be used immediately. https://www.redcross.org/take-a-class/resources/learn-first-aid/unresponsive-and-breathing-person During an interview on 9/20/2024 at 1:48 pm with Housekeeper 1 (HK 1), HK 1 stated, today at around 6:30 am when HK 1 entered Resident 1's room, HK 1 saw Resident 1 on the floor next to Resident 1's bed and HK 1 told Resident 1 to get up and go to Resident 1's bed. HK 1 stated Resident 1's hands were blue, and HK 1 did not see Resident 1's face because it was tucked in Resident 1's chest. HK 1 stated Resident 1's bottom was facing up. HK 1 stated HK 1 told CNA 1 to check on Resident 1 because Resident 1 did not move when HK 1 said anything [to Resident 1] and, "something was wrong with Resident 1." HK 1 stated HK 1 did not touch Resident 1. During an interview on 9/20/24 at 1:56 pm, the Director of Staff Development (DSD) stated, on 9/20/2024 at 6:25 am, the DSD went to the nurse's station to put up the staff assignment when CNA 1 called the DSD and told the DSD CNA 1 needed help. The DSD stated the DSD went to Resident 1's room, LPT 1 and LVN 1 were inside Resident 1's room and Resident 1 was the floor kneeling toward Resident 1's head of the bed and was slumped over. The DSD stated Resident 1 was blue, "not a normal color" and Resident 1 had no pulse. The DSD stated LPT 1 and LVN 1 were standing next to Resident 1's body checking Resident 1, and the DSD instructed LPT 1 and LVN 1 to start CPR while the DSD ran outside Resident 1's room to get an oxygen tank and instructed someone else to call 911. During an interview on 9/20/2024 at 2:17 pm, HK 2 stated HK 2 went inside Resident 1's room with HK 1 to clean Resident 1's restroom. HK 2 stated HK 1 started mopping Resident 1's room and HK 2 heard HK 1 talking to Resident 1 but Resident 1 was not responding. HK 2 stated HK 2 came out of the restroom to check the situation, saw Resident 1 in a "baby position," and HK 2 only saw Resident 1's back. During a concurrent observation and interview on 9/20/2024 at 2:20 pm with the DSD in the Administrator's office desk, the DSD and surveyor watched the facility's surveillance video, dated 9/20/2024 from 5:42 am to 7:08 am. The video showed the following sequence of events, on 9/20/2024: - At 6:28:00 am - HK 1 entered Resident 1's room. - At 6:28:35 am - CNA 1 entered Resident 1's room. - At 6:28:37 am - HK 1 was at Resident 1's doorframe talking to Housekeeping Supervisor (HKS). - At 6:29:02 am - CNA 1 exited Resident 1's room and walked towards the nurse's station. - At 6:29:03 am - HK 1 and HKS entered Resident 1's room. - At 6:29:33 am - CNA 1 entered Resident 1's room. - At 6:29:44 am -LPT 1 entered Resident 1's room. - At 6:30:09 am - CNA 1 exited Resident 1's room and walked down the hall. - At 6:30:20 am - HK 1 exited Resident 1's room. - At 6:30:25 - LPT 1 exited Resident 1's room. - From 6:30:25 am to 6:30:59 am - LPT 1 was pacing the hallway, then opened the east unit's door and entered the unit to notify LVN 1. - At 6:31:05 am - CNA 1 returned and entered Resident 1's room. - At 6:31:08 am - HKS exited Resident 1's room. - At 6:31:09 am - LPT 1 entered Resident 1's room. - At 6:31:21 am - LPT 1 exited Resident 1's room and walked toward the east unit. - At 6:31:31 am to 6:31:35 am - CNA 4 and LPT 1 walked out of the east unit, walked toward Resident 1's room, and entered Resident 1's room. - At 6:32:01 am - LVN 1 entered Resident 1's the room. CNA 4 exited Resident 1's room and walked toward to east unit. - At 6:33:00 am - CNA 5 entered Resident 1's room, exited at 6:33:22 am, entered at 6:33:30 am, exited at 6:33:40 am, and entered again at 6:33:28 am. - At 6:33:27 am - the DSD entered Resident 1's room. - At 6:33:40 am - the DSD exited Resident 1's room and ran toward the nurse's station. - At 6:34:03 am - CNA 1 exited Resident 1's room. - At 6:34:12 am - LVN 1 exited Resident 1's room and walked down the hallway. - At 6:34:25 am - LPT 1 entered Resident 1's room. - At 6:34:41 am - LPT 1 walked out of Resident 1's room and stood in the hallway. - At 6:35:01 am - LPT 1 and LVN 1 walked back into Resident 1's room. - At 6:35:19 am - the Infection Preventionist (IPN) entered Resident 1's room. - At 6:35:48 am - the IPN walked out of Resident 1's room. - At 6:36:25 am - the DSD entered Resident 1's room. - At 6:36:40 am - a staff member brought an oxygen tank into Resident 1's room. - At 6:41:51 am - LVN 1 left Resident 1's room, walked toward CNA 1, and spoke with CNA 1 in the hallway. - At 6:42:15 am - LVN 1 returned and entered Resident 1's room. - At 6:42:28 am - the DSD and LVN 1 exited Resident 1's room. - At 6:43:54 am - the EMTs entered Resident 1's room. - At 6:44:04 am - Los Angeles Fire Department (LAFD) arrived and entered Resident 1's room. - At 7:08:46 am - the Police Department arrived. During an interview on 9/20/2024 at 2:20 pm, DSD stated when the DSD entered Resident 1's room at 6:33 am, the DSD instructed LPT 1 and LVN 1 to start CPR because neither one had started CPR The DSD stated CPR should have been started by CNA 1 because CNA 1 was the first staff member at the scene. The DSD stated CPR was important because it was the first action that had to be done after checking for breathing and checking for a pulse. During an interview on 9/20/2024 at 4:19 pm, CNA 1 stated on 9/20/2024 around 6:30 am, HK 1 told CNA 1 to check Resident 1 and when CNA 1 entered Resident 1's room, CNA 1 saw Resident 1 on the floor. CNA 1 stated CNA 1 called Resident 1's name three times and Resident 1 did not respond, CNA 1 left Resident 1's room to inform LPT 1. CNA 1 stated CNA 1 did not perform CPR and did not touch Resident 1 because CNA 1 did not know if Resident 1 fell or had any injuries. CNA 1 stated this was the first time CNA 1 found an unresponsive resident. CNA 1 stated CNAs were trained to provide CPR and stated when finding an unresponsive resident: CNAs needed to provide CPR by checking a pulse, starting chest compressions, and needed to call a code 99. A review of the facility's CPR certifications indicated CNA 1 had Basic life Support certification from the American Heart Association, issue date 4/26/2023, renew by 4/2025. During a follow-up interview on 9/20/2024 at 4:38 pm with LPT 1, LPT 1 stated when LPT 1 entered Resident 1's room and saw Resident 1 on the floor, in a fetal position, the situation looked like an emergency and LPT 1 decided LPT 1 needed help from LVN 1. LPT 1 stated LPT 1 left Resident 1's room to the east unit and told CNA 4, who was close to the door located between west and the east unit, to notify LVN 1 there was an emergency. LPT 1 stated if Resident 1 was not breathing and had no pulse, LPT 1 needed to check Resident 1's airway, breathing, circulation, check Resident 1's pulse, and start CPR immediately. LPT 1 stated CPR could save a life and it was the last defense for Resident 1 to get oxygen and pump blood to the heart. During an interview on 9/21/2024 at 6:21 am, CNA 1 stated on 9/20/2024 for the 11 pm to 7 am shift, CNA 1 was assigned to care for Resident. CNA 1 stated the last time CNA 1 saw Resident 1 was at the start of CNA 1's shift at 11 pm. During this time, Resident 1 was lying on Resident 1's bed, sleeping, and snoring. CNA 1 stated CNA 1 did not see Resident 1 after 11 pm. CNA 1 stated on 9/20/2024 CNA 1 visually checked residents assigned to CNA 1 by sitting in the hallway located two rooms away from Resident 1's room but did not actually observe Resident 1 while the resident was inside the room. A review of Resident 1's Follow Up Question Report dated 9/20/2024 indicated CNA 1 documented Resident 1 was inside Resident 1's room from 9/19/2024 at 9 pm to 9/20/2024 at 6 am. During an interview on 9/21/2024 at 8:25 am, with CNA 3, CNA 3 stated it was around 6:30 am when CNA 3 returned from the laundry area and heard CNA 1 call for help. CNA 3 entered Resident 1's room and CNA 3 saw LPT 1, LVN 1, and Resident 1 lying on the floor. CNA 3 stated LVN 1 tapped Resident 1 and LVN 1 asked Resident 1, "Are you okay?" CNA 3 stated CNA 3 left the room when LPT 1 and LVN 1 started to turn Resident 1 on his back and CNA 3 saw the DSD on the DSD's way to Resident 1's room. During an interview with the Quality Assurance Nurse (QAN) on 9/21/2024 at 11:30 am, the QAN was asked for Resident 1's POLST. The QAN stated Resident 1 did not have a POLST and stated all residents residing at the facility were considered full codes unless there was an AD. The QAN stated Resident 1 did not have an AD. During a telephone interview on 9/21/2024 at 1:30 pm, LVN 1 stated, on 9/20/2024, LVN 1 went to Resident 1's room when LVN 1 was notified by CNA 4 there was a medical emergency. LVN 1 stated LVN 1 saw Resident 1 on the floor with Resident 1's face down and told Resident 1 to get up but Resident 1 did not respond. LVN 1 stated Resident 1 had no pulse, was not breathing, and LVN 1 instructed the staff who were inside the room to call 911. LVN 1 stated Resident 1 was turned over and there was yellowish, clear liquid approximately half a cup with small spots of blood underneath Resident 1. LVN 1 stated the DSD came to Resident 1's room and instructed LVN 1 and LPT 1 to start CPR and Resident 1 was turned on Resident 1's back. LVN 1 stated LVN 1 initiated CPR but could not recall what time LVN 1 initiated CPR. LVN 1 stated it was around 6:30 am when CNA 4 informed him there was a medical emergency. During an interview on 9/21/24 at 2:49 pm, with the Director of Nursing (DON), the DON stated the facility staff needed to check responsiveness by calling the resident's name and if there was no response, staff needed to tap the resident, if there was still no response, staff needed to check for airway, breathing, and circulation. The DON stated if there was no pulse and no breathing, staff needed to call a code blue and start CPR to restart circulation and keep the heart beating. A review of the facility's undated P&P titled, "Advance Directive/Individual Health Care Instructions” indicated each resident will receive and the facility must provide the necessary care and services to attain or maintain the highest possible practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care by providing basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directive. A review of the facility's P&P titled, "Emergency Response Policy and Procedure" dated 9/2024 indicated the facility will provide basic life support, including CPR, to all residents requiring such emergency care prior to the arrival of emergency medical p