Other·January 19, 2024

California Code of Regulations, Title 22, Section 72311 Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at the 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. 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: (9) Signs and symptoms of cardiopulmonary distress. (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. 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. F678 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 subject to related physician orders and the resident’s advance directives. On 12/5/2024 at 12:25 p.m., The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality care and death. As a result of the investigation, the Department determined the facility failed to provide immediate and continuous cardiopulmonary resuscitation (CPR) to Resident 1, who had a full code status (the resident or his/her representative wished for all lifesaving procedures to be provided to keep the resident alive when the resident’s heart stopped beating and/or the resident stopped breathing) by failing to ensure: 1. Registered Nurse Supervisor (RNS) 1 and Certified Nursing Assistant (CNA) 1 started CPR after RNS 1 and CNA 1 found Resident 1 on the floor, in Resident 1’s room, unresponsive with a weak pulse and not breathing on 12/3/2023 at 5:45 am (as indicated in the facility video recording). 2. Licensed Vocational Nurse (LVN) 1, CNA 1, and CNA 2 started CPR on 12/3/2023, after LVN 1, CNA 1, and CNA 2 put Resident 1 in bed, and found Resident 1 without a pulse and not breathing. 3. Three of 35 LVNs (LVN 3, LVN 4, and LVN 5) had current CPR certification cards. As a result of these failures, on 12/3/2023 at 6:30 am, Resident 1 was pronounced dead in Resident 1’s room after the Paramedics (emergency medical technicians [EMT] who provide emergency medical services) provided unsuccessful CPR. A review of Resident 1’s Admission Record indicated the facility initially admitted 55 years old, male to the facility on 1/18/2023, and readmitted Resident 1 on 9/20/2023 with diagnoses which included type 2 diabetes, end stage renal disease (ESRD, a medical condition in which a person’s kidneys permanently stop working), and difficulty in walking. A review of Resident 1’s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient’s lifesaving treatment wishes are), dated 1/20/2023, indicated Resident 1 had full code status and wanted all lifesaving procedures to be provided to Resident 1 if Resident 1’s heart stopped and/or if Resident 1 stopped breathing. A review of Resident 1’s History and Physical (H&P, physician’s clinical evaluation and examination of the resident), dated 9/20/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/11/2023, indicated Resident 1 required touching or steadying assistance with toileting, dressing and personal hygiene. The MDS indicated Resident 1 required partial assistance to transfer to and from bed to chair/wheelchair, and to get on and off a toilet. A review of Resident 1’s EMTs run report (a standard document used by emergency medical service care providers), dated 12/3/2023 and timed 5:59 am, the report indicated EMTs arrived at the facility on 12/3/2023 at 6:07 am and was at Resident 1’s bedside to evaluate Resident 1 at 6:08 am. The report indicated the EMTs found Resident 1 in bed, unresponsive and pulseless (without a pulse), and the EMTs started CPR on Resident 1 on 12/3/2023 at 6:10 am. The report indicated Resident 1’s first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) and Resident 1 remained with no heartbeat after 20 minutes of CPR. The report indicated the time of Resident 1’s death was 12/3/2023 at 6:30 am. A review of Resident 1’s Situation, Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) form signed by LVN 1, dated 12/3/2023 and timed 6:30 am, indicated Resident 1 had a change of condition identified on 12/3/2023 at 5:55 am. The SBAR indicated Resident fell, had a change in level of consciousness (LOC, a medical term that describes a person’s stated of awareness, alertness, and wakefulness), and had full code status with a blood oxygen level of zero (0, healthy blood oxygen level is 75–100 millimeters of mercury [mm Hg, unit of pressure] or 95–100 %). The SBAR indicated at “5:55 am," CNA 1 reported to RNS 1 Resident 1 was on the floor. Resident 1 was assessed by RNS 1, noted unresponsive, with initial vital signs of: blood pressure (BP, ideal BP is considered to be between 90/60 mm Hg, unit of and 120/80mmHg) of 46/26 mmHg, pulse at 39 (normal resting heart rate is from 60 to 100 beats per minute [BPM]), blood sugar at 222 milligrams per deciliter (mg/dl – units of measurement, normal fasting blood glucose concentration are between 70 mg/dL and 100 mg/dL). The SBAR indicated RNS 1 rechecked Resident 1’s vital signs (heart rate/HR, respiration rate/RR and BP) and Resident 1 had no pulse, or zero (0 breaths per minute) signs of breathing noted (normal RR for adults at rest is 12 to 18 breaths per minute). The SBAR indicated CPR was initiated, 911 was called and the paramedics arrived at 6:07 am. The SBAR indicated the paramedics took over care, however, Resident 1 was unable to be revived (restore to life or consciousness) and pronounced dead by the paramedics at 6:30 am. A review of Resident 1’s Licensed Nursing Note written by RNS 1, dated 12/3/2023 and timed 6:50 am, indicated at “5:55 am,” (nurse assigned to Resident 1, CNA 1) reported to supervisor (RNS 1) that the resident was on the floor. The note indicated RNS 1 got to Resident 1’s room immediately and Resident 1 was on the floor. The note indicated RNS 1 assessed Resident 1, patted Resident 1’s shoulder, but Resident 1 was not responsive. The note indicated “Resident 1’s pulse can hardly be appreciated (palpable, felt by touch)” by RNS 1 and rise and fall (describes the physical action of breathing) of Resident 1’s chest was absent. The note indicated Resident 1’s BP was 46/26 mm Hg, the HR was 39 BPM. The note indicated (unspecified person) started CPR and called 911.The paramedics arrived at 6:07 am and took over care. The note indicated the paramedic started IV (intravenous line - a soft, flexible tube placed inside a vein, usually in the hand or arm, used by health care providers to give a person medicine or fluids), but was unable to revive Resident 1. Resident 1 was pronounced dead at 6:30 AM and Resident 1’s primary care physician (PCP) 1 and Family Member (FAM) 1 were notified by leaving a message. During a phone interview on 12/5/2023 at 4:20 pm, LVN 1 stated on 12/3/2023, “between 5 am to 6 am” (unable to recall the exact time), RNS 1 told LVN 1 to go to Resident 1’s room. LVN 1 stated when LVN 1 got to Resident 1’s room, LVN 1 found Resident 1 lying on the floor and CNA 1 was “standing around” inside Resident 1’s room and was not performing CPR. LVN 1 stated LVN 1 did not start CPR after LVN 1 found Resident 1 on the floor because LVN 1 left Resident 1’s room to ask RNS 1 what LVN 1 was supposed to do. LVN 1 stated LVN 1 went back inside Resident 1’s room with CNA 2, and LVN 1, CNA 1, and CNA 2 put Resident 1 back in bed. LVN 1 stated LVN 1 realized Resident 1 did not have a pulse after Resident 1 was in bed. LVN 1 stated LVN 1 started chest compressions on Resident 1 until the paramedics arrived and the EMTs told LVN 1 to stop CPR. LVN 1 stated from what LVN 1 remembered from CPR training, chest compressions had to be performed immediately once a person stopped breathing and had no pulse. During a phone interview on 12/5/2023 at 7:19 pm, RNS 1 stated on 12/3/2023 at 5:55 am, CNA 1 notified RNS 1 Resident 1 was lying on the floor. RNS 1 stated RNS 1 went to Resident 1’s room with CNA 1 and found Resident 1 lying on the floor. RNS 1 stated RNS 1 checked for Resident 1’s pulse on Resident 1’s neck and wrist. RNS 1 stated Resident 1’s pulse was weak and the rise and fall of Resident 1’s chest was hard to notice. RNS 1 stated Resident 1 did not respond nor “say anything” when RNS 1 spoke to or shook Resident 1 and Resident 1’s eyes remained closed. RNS 1 stated they left CNA 1 in the room with Resident 1 and went to call 911. RNS 1 stated RNS 1 called a code blue and found LVN 1 and told LVN 1 to provide CPR to Resident 1. RNS 1 stated, RNS 1 did not start CPR because Resident 1 was still warm and RNS 1 was able to feel a faint (weak) pulse. RNS 1 stated, Resident 1 was yawning, meaning Resident 1 was still alive. RNS 1 stated when RNS 1 went back to Resident 1’s room, Resident 1 was in bed and LVN 1 was performing compressions on Resident 1’s chest. RNS 1 stated “It was important to start CPR right away to save the patient.” During a phone interview on 12/6/2023 at 9:45 am, CNA 1 stated when CNA 1 walked inside Resident 1’s room to answer Resident 1’s call light, on 12/3/2023 “between 5 am to 6 am” (CNA 1 was unable to recall the exact time), CNA 1 found Resident 1 sliding out of the bed. CNA 1 stated CNA 1 turned Resident 1’s overbed light on and when CNA 1 turned around, Resident 1 was “lying on [his] back on the floor.” CNA 1 stated Resident 1’s eyes were closed, and Resident 1 was unresponsive. CNA 1 stated CNA 1 left Resident 1’s room to get help and informed RNS 1 Resident 1 fell and was unresponsive. CNA 1 stated, when RNS 1 and CNA 1 went back into Resident 1’s room, RNS 1 and CNA 1 could not find Resident 1’s pulse and Resident 1 started gasping for air three (3) to four (4) times. CNA 1 stated neither RNS 1 nor CNA 1 started CPR on Resident 1. CNA 1 stated RNS 1 left Resident 1’s room to call 911 and CNA 1 left Resident 1’s room. CNA 1 stated LVN 1, CNA 1, and CNA 2 put on disposable isolation gowns (one-use gown used by health care personnel to protect the wearer from coming in contact with blood, body fluids, and other infectious material) and put Resident 1 back to bed. CNA 1 stated Resident 1 remained unresponsive while LVN 1, CNA 1, and CNA 2 put Resident 1 to bed. CNA 1 stated once in bed, LVN 1, CNA 1, and CNA 2 did not see Resident 1’s chest rise and fall. CNA 1 stated LVN 1 did not start CPR as soon as Resident 1 was put back to bed. CNA 1 stated LVN 1 provided Resident 1 with two “one and two” compressions, immediately before EMTs arrived. During a phone interview on 12/6/2023 at 12:48 pm, CNA 2 stated on 12/3/2023, between 5:30 am to 6 am (unable to recall the exact time), LVN 1 asked CNA 2 to help put Resident 1 in bed. CNA 2 stated once CNA 2, CNA 1, and LVN 1 put Resident 1 in bed, CNA 2, CNA 1, and LVN 1 did not see Resident 1’s chest rise for breath. CNA 2 stated CNA 2 and LVN 1 checked Resident 1’s neck and wrist for a pulse, and CNA 2 could not find Resident 1’s pulse. CNA 2 stated CNA 2 did not know if LVN 1 found Resident 1’s pulse. CNA 2 stated LVN 1 left the room after they put Resident 1 to bed. CNA 2 stated, “In CPR class, if unable to find pulse, begin chest compressions right away.” CNA 2 stated CNA 2 did not start CPR on Resident 1. CNA 2 stated Resident 1’s room did not have an oxygen tank and neither LVN 1, CNA 1, nor CNA 2 provided Resident 1 with rescue breathing. CNA 2 stated LVN 1 returned to Resident 1’s room and started CPR on Resident 1 only for a few seconds, no more than a minute. During a concurrent observation and interview on 12/6/2023 at 2:10 pm with the Assistant Director of Nursing (ADON) and the Medical Records Director (MRD), in the front office of the facility, the ADON and the MRD watched the video recording, dated 12/3/2023 between 5:42 am to 6:09 am, from Station 1’s security camera (a camera used to monitor activity in Nursing Station [NS] 1’s hallway, hallway where Resident 1’s room was located). The video showed the following on 12/3/2023: 1. At 5:42:14 am, Resident 1’s call light turned on. 2. At 5:44:26 am, CNA 1 went inside Resident 1’s room. 3. At 5:44:46 am, CNA 1 was seen in Resident 1’s doorway, looking out towards the nurses’ station. 4. At 5:44:50 am, CNA 1 went inside Resident 1’s room. 5. At 5:45:42 am, CNA 1 walked out of Resident 1’s room and walked towards NS 1. 6. At 5:45:42 am, CNA 1 went back inside Resident 1’s room. 7. At 5:45:48 am, RNS 1 went inside Resident 1’s room. 8. At 5:47:41 am, RNS 1 walked out of Resident 1’s room and opened the Medication Cart (MC) 1 located in the hallway, against the wall to the right side of Resident 1’s room doorway. 9. At 5:48:24 am, RNS 1 went back inside Resident 1’s room. 10. At 5:49:13 am, RNS 1 walked out of Resident 1’s room and went to MC 1. 11. At 5:50:05 am, RNS 1 walked towards NS 1 and walked back towards Resident 1’s room with a blood pressure machine (device that automatically measures a person’s blood pressure at set times and records the readings). 12. At 5:50:30 am, RNS 1 went inside Resident 1’s room with a BP machine. 13. At 5:52:48 am, RNS 1 walked out of Resident 1’s room with BP machine and went to MC 1. 14. At 5:52:56 am, CNA 1 walked out of Resident 1’s room and walked towards the NS 1. 15. At 5:53:25 am, RNS 1 left MC 1 and walked towards the NS 1. 16. At 5:54:39 am, LVN 1 and CNA 1 went inside Resident 1’s room. 17. At 5:55:52 am, LVN 1 walked out of Resident 1’s room and walked towards NS 1. 18. At 5:57:08 am, LVN 1 went inside Resident 1’s room with CNA 2. 19. At 5:58:01 am, CNA 2 walked out of Resident 1’s room to don (put on) a yellow disposable isolation gown. 20. At 5:58:17 am, LVN 1 walked out of Resident 1’s room to don a yellow disposable isolation gown. 21. At 5:58:42 am, CNA 2 went inside Resident 1’s room. 22. At 5:58:58 am, CNA 1 walked out of Resident 1’s room to don a yellow disposable isolation gown. 23. At 5:59:37 am, CNA 1 went inside Resident 1’s room. 24. At 5:59:40 am, LVN 1 went inside Resident 1’s room. 25. At 6:02:36 am, RNS 1 walked in through the front door of Station 1 which led to the front lobby. 26. At 6:02:51 am, LVN 1 walked out of Resident 1’s room and grabbed an item (unidentified) from MC 1. 27. At 6:02:52 am, LVN 1 went inside Resident 1’s room. 28. At 6:02:55 am, LVN 1 walked out of Resident 1’s room and went to MC 1. 29. At 6:03:23 am, RNS 1 went inside Resident 1’s room, walked out of Resident 1’s room, and stopped to talk to LVN 1 who was in front of MC 1. 30. At 6:03:53 am, RNS 1 walked toward NS 1. 31. At 6:04:09 am, LVN 1 went inside Resident 1’s room. 32. At 6:04:30 am, RNS 1 went inside Resident 1’s room. 33. At 6:05:21 am, CNA 2 walked out of Resident 1’s room. 34. At 6:05:25 am, RNS 1 walked out of Resident 1’s room with a BP machine and CNA 2 went inside Resident 1’s room. 35. At 6:05:31 am, RNS 1 opened MC 1. 36. At 6:05:37 am, LVN 1 walked out of Resident 1’s room and went to MC 1 where RNS 1 was. 37. At 6:05:44 am, RNS 1 walked towards NS 1. 38. At 6:05:46 am, LVN 1 went inside Resident 1’s room with a BP machine. 39. At 6:05:55 am, CNA 2