Health inspection·May 31, 2024

F656 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident.

F803 42 CFR §483.60 Menus Meet Res Needs/Prep in Advance/Followed §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of Patients in accordance with established national guidelines; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the Patient population, as well as input received from Patients and Patient groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the Patient’s right to make personal dietary choices. T22 22 CCR §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. T22 22 CCR §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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72517-Staff Development 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: (1) Problems and needs of the aged, chronically ill, acutely ill, and disabled patients. (9) Signs and symptoms of cardiopulmonary distress. (10) Choking prevention and intervention. On 4/18/2024, at 1:30 pm, an unannounced visit was made to investigate a facility reported incident regarding a death allegation. As a result of the investigation, the California Department of Public Health (CDPH) determined the facility failed to: 1. Follow the physician's order to give mechanical soft texture (food item that has been blended, mashed, mixed, or processed into a smooth and uniform texture) diet for Patient 1 in accordance with the care plan and facility’s policy titled, “Nutrition Management of Dysphagia (difficulty swallowing).” 2. Ensure Certified Nursing Assistant (CNA 1) did not instruct Uncertified Assistive Personnel 1 (UAP 1) to obtain a sandwich from the facility's refrigerator for Patient 1 to consume on 4/17/24. 3. Verify Patient 1's diet order for the patient to receive no added salt (NAS, food is seasoned as regular food), consistent or controlled carbohydrate (one of several substances such as sugar or starch that provide the body with energy) diet (CCHO, a restrictive diet that involves eating the same numbers of carbohydrate daily) mechanical soft texture, nectar thick consistency (easily pourable and are comparable to heavy syrup found in canned fruits) prior to handing the patient a sandwich of regular texture and unknown content as a snack on 4/17/24. 4. Ensure facility staff immediately start cardiopulmonary resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse]), in accordance with the standard of practice on basic life support and the facility's policy titled, “Cardiopulmonary Resuscitation,” when Patient 1 was found unresponsive (no movement or response to stimuli and no pulse or respirations) after choking on a sandwich. Instead, Licensed Vocational Nurse 1 (LVN 1) walked to the nurses' station, which was about 30 feet away from the Patient to check on the Patient's code status (type of emergent treatment a Patient would or would not receive if their heart or breathing were to stop) before starting CPR. Patient 1 was then moved from outside his room to the Patient's room, which was about 10 feet away, and placed on the bed prior to starting CPR. As a result of these failures, Patient 1 choked (difficulty breathing because of constricted or obstructed throat or a lack of air) on 4/17/24 resulting in loss of consciousness. Patient 1 did not receive immediate CPR and was pronounced dead by the paramedics (healthcare professional that respond to emergency calls and performs CPR to the victims) on 4/17/24 at 9:23 PM, 35 minutes after Patient 1 became unresponsive, due to cardiac and respiratory arrest (heart and lungs stopped functioning) related to asphyxia (the state or process of dying from not having enough air or unable to breathe). A review of Patient 1's Admission Record indicated the Patient was admitted to the facility on 1/19/24 with diagnoses that included dysphagia oropharyngeal phase (difficulty transferring food from the mouth into the pharynx [passage leading from the mouth and nose to the esophagus {organ that food travels through to reach the stomach for further digestion] and the larynx [voice box]) and esophagus to initiate an involuntary swallowing process) and generalized muscle weakness. A review of Patient 1's Physician's Order, dated 3/21/24, indicated a diet order for ”NAS, CCHO, mechanical soft texture nectar thick consistency.” A review of Patient 1's Physician's Order, dated 3/21/24, indicated a CPR order. A review of Patient 1's History and Physical (H&P), dated 3/22/24, indicated Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1's Speech Therapy (ST) Notes, dated 3/22/24, included diet precautions for the patient to receive NAS CCHO mechanical soft texture and nectar thick consistency liquid. A review of Patient 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/28/24, indicated the Patient had severely impaired cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Patient 1 required supervision (helper provides verbal cues) with eating and oral hygiene and required substantial assistance (helper does more than half the effort) with toileting, hygiene, shower, lower body dressing, and putting on/taking off footwear. Patient 1 required partial assistance (helper does less than half the effort) with upper body dressing. A review of Patient 1's Care Plan titled, "Potential for Nutritional Problem related to Aging, Dysphagia, and Dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a Patient's daily functioning)," revised 3/30/24, indicated staff interventions were to monitor, document, report signs and symptoms of dysphagia, explain and reinforce to patient the importance of maintaining the diet ordered, and to provide and serve diet as ordered. A review of Patient 1's Change in Condition (COC) Evaluation, dated 4/18/24 at 1:20 AM, indicated on 4/17/24 at 8:48 PM, CNA 1 called for assistance to check on Patient 1 who had a COC. COC evaluation indicated Patient 1 did not have a pulse. CPR was initiated by facility staff until paramedics arrived. Patient 1 was pronounced dead by the paramedics on 4/17/24 at 9:23 PM. During an interview on 4/18/24 at 2:25 PM, CNA 1 stated on 4/17/24 at around 8:40 pm, she was sitting next to Patient 1, just outside of his room. Patient 1 was on a recliner wheelchair eating a sandwich when the Patient started coughing. CNA 1 stated she saw a third of the sandwich inside Patient 1's mouth so CNA 1 removed it. CNA 1 stated she asked Uncertified Assistive Personnel 1 (UAP 1) who was sitting near her to assist in getting Patient 1 up so CNA 1 can perform the Heimlich maneuver (a procedure used to force a foreign object from a choking victim's airway [organ that allow airflow to the lungs] by performing abdominal thrusts) because Patient 1 did not respond when CNA1 asked him if he was okay. CNA 1 stated she then performed the Heimlich maneuver to Patient 1. CNA 1 stated Registered Nurse 1 (RN 1) arrived and saw the Patient unresponsive with his lip turning blue. CNA 1 stated Patient 1 was moved back to room onto the bed, which was 10 feet away from the hallway, in accordance with RN 1's instructions. During an interview on 4/18/24 at 2:57 PM, UAP 1 stated, CNA1 instructed her to pick up a sandwich for Patient 1 from the Patients' refrigerator around 8:15 PM on 4/17/24. UAP 1 stated she grabbed extra sandwiches to hand out to other Patients. UAP 1 stated she gave Patient 1's sandwich of regular texture with unknown content to CNA 1. UAP 1 stated CNA 1 gave Patient 1 the sandwich. UAP 1 further stated she saw Patient 1 eating the sandwich and after a few minutes, saw Patient 1 coughing. UAP 1 stated CNA 1 removed a piece of sandwich from Patient 1's mouth and performed the Heimlich maneuver because the Patient was unresponsive. During an interview on 4/18/24 at 3:54 PM, LVN 1 stated she rushed to check on Patient 1 who was just outside his room. LVN 1 stated Patient 1 was unresponsive, so she went back to the nurses' station to check on Patient 1's code status. LVN 1 stated as soon as she found out that Patient 1 was a full code (if a Patient's heart stopped beating or stopped breathing, all resuscitation procedures will be provided to keep the Patient alive), she went back to the Patient who was being wheeled by the staff back to his room. LVN 1 stated she called 911 (number to contact for emergency services) at this time. LVN 1 stated as soon as Patient 1 became unresponsive and without a pulse, CPR should have been initiated by the staff because every second counts. LVN 1 stated staff should have left Patient 1 where he was, which was outside his room, instead of moving him back in his room on to his bed. During an interview on 4/18/24 at 3:56 PM, LVN 1 stated Patient 1 was on dysphagia (difficulty swallowing) mechanical soft diet with nectar thick consistency liquids and should not have been given a sandwich because of the patient's difficulty with swallowing. LVN 1 stated Patient 1 could not swallow a sandwich because it is considered a regular texture. LVN 1 also stated, according to CNA 1, UAP 1 gave the sandwich to Patient 1. During an interview on 4/18/24 at 4:43 PM, the Dietary Service Supervisor (DSS) stated, “Patient 1's diet order for NAS, CCHO mechanical soft texture, nectar thick consistency was between pureed (smooth, crushed, or blended food) and mechanical soft.” DSS stated Patient 1 should not have been given a sandwich because sandwiches were not to be given for patients on dysphagia mechanical soft diet. During an interview on 4/18/24 at 5 PM, RN 1 stated on 4/17/24 around 8:48 PM, LVN 1 called her to check on Patient 1 due to change of condition. RN 1 stated that when she arrived outside Patient 1's room, RN 1 observed Patient 1 was already cyanotic (bluish skin color due to inadequate oxygen in the blood) and unresponsive. RN 1 further stated she tried to check Patient 1's mouth but did not see any obstruction or foreign body and instructed CNA 1 and the other CNAs helping out to transfer Patient 1 back to his room and placed on to his bed. RN 1 stated she then instructed LVN 1 to get Patient 1's chart at the nurses' station to check on the Patient's advanced directives (a legal document that indicates Patient's wishes about receiving medical care if the Patient is no longer able to) and to verify code status. RN 1 stated she then initiated CPR to Patient 1 after LVN 1 arrived in the Patient's room confirming Patient 1 was a full code. During an interview on 4/18/24 at 5:03 PM, RN 1 stated they did not initiate CPR outside Patient 1's room, where he was found unresponsive but instead initiated it when Patient 1 was moved back in his room to his bed, for privacy because there were other Patients around watching. During an interview on 4/18/24 at 5:57 PM, the Director of Nursing (DON) stated CNA 1 should have checked the diet of Patient 1 before the patient was given a sandwich for the patient's safety. A review of the facility's undated Snack Spreadsheet indicated that sandwiches was not recommended for patients on dysphagia with thick liquid diet. During an interview on 4/18/24 at 10:26 PM, CNA 1 stated Patient 1 turned blue and became unresponsive while she was doing the Heimlich maneuver. CNA 1 stated she was instructed by RN 1 to move Patient 1 back in his room and place on his bed when Patient 1 turned cyanotic and unresponsive. CNA 1 stated RN 1 initiated CPR when Patient 1 was placed back on his bed. During a concurrent observation and interview on 4/19/24 at 8:10 PM, the DON stated there was about 30 feet from the nurses' station to Patient 1's room. A review of the facility's Policy and Procedure titled," Dysphagia Diets and Thickened Liquids," revised 1/1/2012, indicated its purpose was to provide appropriate food and fluid consistencies to Patients with dysphagia or swallowing problems, to ensure adequate hydration and diminish the risk of asphyxiation (deprivation of oxygen that can result in unconsciousness and often death). A review of the facility's Policy and Procedure titled," Nutrition Management of Dysphagia," dated 2023, indicated that dysphagia mechanical diet is a diet that consists of food that are moist, mechanically altered, easily mashed, or pureed. The policy also indicated that the dysphagia mechanical diet was necessary to form a cohesive bolus (breakdown of solid material into a size suitable for subsequent propulsion through the coordinated actions of the tongue, teeth, and cheeks while mixing the partially prepared matter with saliva) requiring little chewing and food must not be sticky or bulky increasing the risk of airway obstruction. A review of the facility's Policy and Procedure titled, "Cardiopulmonary Resuscitation," dated April 10, 2023, indicated steps in responding to cardiopulmonary emergencies to include checking the victim for responsiveness, respirations, and pulse. The policy also indicated that if the victim was unresponsive to activate the emergency response team by: 1. Calling for help and sending someone to contact the Emergency Medical Services (EMS) or 911 for emergency medical assistance. 2. Sending someone for the emergency cart (used to transport and dispense emergency medications and supplies) and supplies, and to announce your facility code for medical emergencies. 3. Initiate CPR in accordance with the American heart Association (AHA) guidelines. A review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: High-quality CPR with minimal interruptions and early defibrillation (administering a controlled electric shock to allow restoration of the normal rhythm.) are the actions most closely related to good resuscitation outcomes. High quality CPR if started immediately after cardiac arrest combined with early defibrillation can double or triple the chances of survival. These time-sensitive interventions can be provided both by members of the public and by healthcare providers. Bystanders who are not trained in CPR should at least provide chest compressions (act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation). Even without training, bystanders can perform chest compressions with guidance from emergency telecommunicators over the phone; the signs of severe airway obstruction included clutching the throat with the thumb and fingers, making the universal choking sign, unable to speak or cry, weak/ineffective cough or no cough at all, and the re