Other·June 3, 2022

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the patient’s physician; and notify, consistent with his or her authority, the patient representative(s) when there is— (A) An accident involving the patient which results in injury and has the potential for requiring physician intervention; (B) A significant change in the patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the patient from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the patient and the patient representative. § 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. (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). The facility failed to immediately inform the physician of the change in condition (COC, sudden change in physical or mental status from the patient's baseline) for Patient 1 who had complained of difficulty swallowing as indicated in the facility's Change of Condition policy and procedure by failing to: a. Ensure Licensed Vocational Nurse (LVN) 3 notified the Patient 1’s physician (Physician 1) on 4/14/2022 when the patient complained of having difficulty swallowing food. b. Ensure LVN 3 informed Physician 1 on 4/17/2022, when Patient 1 was moaning and was weak, and complained of a stomachache, sore throat, esophagus (a muscular tube that conveys food from the mouth to the stomach) pain and or acid reflux (gastric fluid flows backward into the esophagus). c. Ensure LVN 6 immediately notify Physician 1 on 4/19/2022, when Patient 1 was tired, refused food, and was unable to drink Ensure (a type of nutrition drink that has vitamins, mineral protein, and fats) out of a straw due to weakness. As a result, Patient 1 received delay in treatment. On 4/19/2022, Patient 1 was transferred to the General Acute Care Hospital (GACH) 1. GACH 1’s Notes indicated Patient 1's clinical impression included Melena (dark stool), upper gastrointestinal bleeding (a medical condition in which heavy bleeding occurs in the upper parts of the digestive tract and of the esophagus, the stomach or the small intestine) and anemia (a condition in which the body does not have enough healthy red blood cells). The patient immediately received blood transfusion (transferring the blood of a person into the veins of another) and was placed in the Intensive Care Unit (ICU, special unit that cater to residents/patients with severe or life-threatening illnesses) upon arrival to hospital. A review of Patient 1's Admission Record indicated the facility admitted the patient on 3/28/2022 with diagnoses that included acute (sudden) respiratory (relating to organs that help you breathe) failure with hypoxia (a condition where there is not enough oxygen in the blood), unspecified atrial fibrillation (an irregular, often rapid heartbeat) and anemia (a condition in which the body does not have enough healthy red blood cells). A review of Patient 1's Minimum Data Set (MDS, an assessment and care planning tool), dated 4/4/2022, indicated the patient had cognitive (ability to think and process information) impairment. The patient required assistance from staff for activities of daily living (ADL, skills required to manage one's basic physical needs). A review of Patient 1's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Notes, dated 4/7/2022, indicated Patient 1 was alert, verbally responsive and able to make his needs known. Patient 1 denied any pain or discomfort during the assessment period. The notes indicated Patient 1 was admitted to the facility for ADL retraining. A review of Patient 1's Nurse's Progress Notes, dated 4/9/2022, entered by LVN 8, indicated the patient was in stable condition with no shortness of breath, no pain or discomfort, no acute distress, no change in level of consciousness. A review of Patient 1's Nurse's Progress Notes dated 4/13/2022, entered by LVN 2, indicated Family Member (FM) 1 called and requested for staff to give Patient 1 a (nutritional) supplement due to Patient 1's low appetite. A review of Patient 1's Nurse's Progress Notes, dated 4/14/2022, entered by LVN 3, indicated FM 2 came to the facility and brought hot soup for the resident. The notes indicated FM 2 communicated with LVN 3 via hand gestures due to a language barrier and gestured that Patient 1 had chest discomfort. LVN 3 used the facility's paid Translator (T1) to translated for FM 2 and T1 informed LVN 3 that Patient 1 denied having chest pain but complained of difficulty swallowing. The notes did not indicate LVN 3 notified Physician 1 regarding Patient 1 ' s complaint difficulty swallowing. A review of Patient 1's Nutritional - Amount of Oral Intake, dated from 4/14/2022 to 4/19/2022, indicated the percentage of the patient ' s food intake as follows: 1. For 4/14/2022 - Breakfast 75%; Lunch 90%; Dinner 50% 2. For 4/15/2022 - Breakfast 50%; Lunch 75%; Dinner 50% 3. For 4/16/2022 - Breakfast 100%; Lunch 100%; Dinner 60% 4. For 4/17/2022 - No documentation 5. For 4/18/2022 - Breakfast 20%; Lunch 35%; Dinner 100% 6. For 4/19/2022 - Breakfast 25%; Lunch 20%; No documentation for dinner. A review of Patient 1's Change of Condition Report, dated 4/19/2022 at 8:06 p.m., entered by LVN 6, indicated on 4/19/2022, Patient 1 began having symptoms of poor oral intake and increased weakness at 5:30 a.m. The report indicated Patient 1 was unable to use utensils to feed himself, staff (unidentified) assisted Patient 1 for dinner but the patient pocketed food (holding food in the mouth without swallowing) and was unable to drink via straw. A review of GACH 1 ' s Emergency Room Physician's Notes, dated 4/20/2022, indicated Patient 1 arrived at the hospital on 4/19/2022 at 11:55 p.m. The notes indicated Patient 1's clinical impression included melena, upper gastrointestinal bleeding and anemia. A review of GACH 1 s Emergency Room Records, dated 4/20/2022, indicated Patient 1 arrived via ambulance and was seen in the emergency room at 12:15 a.m. for evaluation due to decreased oral intake and generalized weakness that started "yesterday”. A review of Patient 1's Blood Test results dated 4/20/2022, timed at 12:25 a.m., indicated Patient 1 arrived at the hospital (GACH 1) with a Hemoglobin level of 4.5 grams per deciliter (g/dl). The regular range for adult male was 14.0- 18.0 mg/dl. GACH 1 ' s Emergency Room Records, dated 4/20/2022, indicated Patient 1 received blood transfusion in the Emergency Room and admitted to the ICU. During a telephone interview on 4/21/2022 at 8:48 a.m., FM 1 stated family members visited Patient 1 daily. Patient 1 had stopped eating on 4/15/2022 and the family was concerned that Patient 1 ' s condition was getting worse. FM 1 stated a male nurse (unidentified) assured FM 1 that the patient was doing "okay," and Patient 1 ' s physician (Physician 1) would be notified if the patient ' s condition worsened. During an interview on 4/22/2022 at 11:16 a.m., LVN 3 stated she had cared for Patient 1 often including on 4/17/2022. LVN 3 stated on 4/17/2022, Patient 1 was moaning and weak, so she had three translators (T1, T2, and T3) helping her throughout the day (to translate for Patient 1) to find out what the patient ' s complaints were. LVN 3 stated Patient 1 complained of "a sore throat, esophagus pain and or acid reflux and a stomachache." LVN 3 stated she administered TUMS (a medication used to treat symptoms caused by too much stomach acid, such as heart burn [a burning pain in the chest], upset stomach, or indigestion [(pain or discomfort in the stomach associated with difficulty in digesting food)]) to Patient 1. LVN 3 stated she did not notify Physician 1 regarding Patient 1's complaints During an interview on 4/22/2022 at 1:30 p.m., the Director of Nursing (DON) stated when Patient 1 experienced stomach pain, indigestion, and moaning (on 4/17/2022), LVN 3 needed to complete the Change of Condition form and notify Physician 1 (on 4/17/2022). A review of Patient 1's Change on Condition, for the month of April 2022, indicated there was no COC documented for Patient 1 on 4/17/2022. During an interview with LVN3 on 4/27/22 at 3:42 p.m., LVN 3 stated she didn't document a COC for Patient 1 on 4/17/2022. During a telephone interview on 4/21/2022 at 8:48 a.m., FM 1 stated family members visited Patient 1 daily. FM 1 stated on 4/19/2022 at 8 p.m. after a visit with the patient earlier that day, FM 1 called facility to tell staff (LVN 6) that the condition of Patient 1 had worsened, and she demanded for him (LVN 6) to transfer Patient 1 to the hospital. During a telephone interview on 4/21/2022 at 9:52 a.m., FM 1 stated on 4/19/2022, her request to transfer Patient 1 to the hospital was disregarded by the LVN 6. FM 1 became concerned and asked to speak to Registered Nurse Supervisor (RNS) 2. FM 1 stated RNS 2 failed to provide updates to FM 1 regarding Patient 1 ' s condition causing FM 1 to call facility back several times. FM 1 stated at 10 p.m., FM 1 was informed that facility was awaiting the ambulance arrival. FM 1 stated on 4/20/2022, the hospital informed FM 1 that Patient 1's Hgb was low, the patient received blood transfusions, and had dark stools requiring admission to the ICU. FM 1 stated that Patient 1 had made multiple complaints regarding stomach pain and bloating (a condition where the belly feels full and tight) to nursing staff (unidentified) but no action was taken. During a telephone interview on 4/25/2022 at 8:35 a.m., LVN 6 stated on 4/17/2022, during a change-of-shift (time when responsibility for the care of the patient is transferred from one nurse to another), LVN 3 informed him (LVN 6) that Patient 1 complained of heart burn or indigestion LVN 6 stated Patient 1 did not have the same symptoms during his shift. LVN 6 stated on 4/19/2022 (time was not mentioned), Patient 1 was tired, refused food and was unable to drink Ensure out of a straw due to weakness. LVN 6 stated he asked RNS 2 for her opinion regarding Patient 1's condition. During a telephone interview on 4/27/2022 at 9:01 a.m., RNS 2 stated she was the Registered Nurse Supervisor on the night of 4/19/2022. RNS 2 stated she remembered the night Patient 1 was transferred to the hospital because at 8 p.m., FM 1 called her and was very upset, stating Patient 1 needed to be transferred to a GACH. RNS 2 stated FM 1 accused the nursing staff of not caring for Patient 1. RNS 2 assured FM 1 that she would assess the patient and get an order from the doctor to transfer the patient to the hospital, but to give her two hours to get everything done and arrange for the transfer. RNS 2 stated after the conversation with FM 1, she remembered that LVN 6 asked her to help assess Patient 1 because FM 1 was on the phone requesting a transfer. During the telephone interview on 4/27/2022 at 9:01 a.m., RNS 2 stated she and LVN 6 assessed the patient and she stated Patient 1 was very sleepy RN 2 stated this was the first time that she had heard about the patient having a change in condition. RNS 2 proceeded to contact multiple ambulance agencies until an ambulance was secured for transfer. RNS 2 stated 911 transfer (emergency transfer) was not initiated. RNS 2 stated FM 1 called her on multiple occasions for a status update on obtaining orders for transfer. RNS 2 stated she left the facility at 11:30 p.m. and the transportation arrived at the facility to transport Patient 1 to the hospital after she left (time was not mentioned). During a review of the facility's policy and procedure, titled "Change of Condition," revised on 1/24/2017, the policy and procedure indicated a change of condition is a sudden or marked difference in patient ' s complaints (e.g., nausea, vomiting, dizziness). The policy and procedure indicated that all changes of condition in a patient shall be handled promptly, and the physician should also be called promptly. A Change of Condition/Situation, Background, Assessment and Recommendation (documentation informing of the change of condition) will be completed as indicated. The facility failed to immediately inform the physician of the change in condition (COC, sudden change in physical or mental status from the patient's baseline) for Patient 1 who had complained of difficulty swallowing as indicated in the facility's Change of Condition policy and procedure by failing to: a. Ensure Licensed Vocational Nurse (LVN) 3 notified the Patient 1’s physician (Physician 1) on 4/14/2022 when the patient complained of having difficulty swallowing food. b. Ensure LVN 3 informed Physician 1 on 4/17/2022, when Patient 1 was moaning and was weak, and complained of a stomachache, sore throat, esophagus (a muscular tube that conveys food from the mouth to the stomach) pain and or acid reflux (gastric fluid flows backward into the esophagus). c. Ensure LVN 6 immediately notify Physician 1 on 4/19/2022, when Patient 1 was tired, refused food, and was unable to drink Ensure (a type of nutrition drink that has vitamins, mineral protein, and fats) out of a straw due to weakness. As a result, Patient 1 received delay in treatment. On 4/19/2022, Patient 1 was transferred to GACH 1. GACH 1’s Notes indicated Patient 1's clinical impression included Melena, upper gastrointestinal bleeding and anemia. The patient immediately received blood transfusion and was placed in the Intensive Care Unit upon arrival to hospital. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.