Health inspection·May 4, 2022

F695 §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a patient who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the patients’ goals and preferences, and 483.65 of this subpart. T22 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. The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: CA00772034 Event ID: Z0YC11 Representing the Department, HFEN #33670 State Citation B was written On 2/5/2022 at 11:20 am, an unannounced visit was conducted at the facility to investigate a complaint regarding Patient 1’s death and infection control. The facility failed to provide the necessary respiratory care and services for Patient 1 who had diagnoses including acute respiratory failure (a failure of the lungs to supply oxygen to the blood) and Corona Virus19 (COVID-19, a severe infection affecting the lungs) infection as indicated in the patient's Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) by failing to: a. Ensure Patient 1's respiratory status was evaluated and reported to the physician or to the Nurse Practitioner (NP) or any licensed facility staff for assistance when patient had productive cough (a wet cough, is a cough that brings up mucus or phlegm), unable to expel (spit out) excessive secretions (saliva) and difficulty suctioning (a routine clinical procedure that is crucial for keeping the airway open) out the sputum to clear the patient's airway. b. Ensure Patient 1's primary care provider was informed when the patient refused to use the non-rebreather mask (a mask that delivers high oxygen level and constant flow supplemental O2 (oxygen) in an acute medical emergency) to keep proper oxygenation (the addition of oxygen to any system, including the human body). c. Ensure Patient 1's POLST was reviewed and implemented according to the patient and responsible party's wishes, to be suctioned and transfer to the hospital if comfort could not be achieved at the facility. As a result, Patient 1 experienced excessive secretion in the trachea (the long tube that connects your larynx [voice box] to the bronchi that send air to the lungs) and could not expel the excessive secretion. A review of Patient 1's Admission Record indicated the patient was a sixty-seven-year-old-male admitted to the facility on 1/21/2022 with diagnoses that included, acute respiratory failure, COVID 19, heart failure (failure of the heart to pump effectively to meet the body's demand), and dysphagia (difficulty swallowing). A review of the "Medical Provider Report," indicated Patient 1 tested positive of COVID 19 on 1/21/2022 via antigen test (test to diagnose respiratory pathogens [disease causing organism] such as COVID 19). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/27/2022, indicated the patient had severe impairment in cognitive skills (ability to make daily decisions), and required extensive assistance (patient involved with activity, staff provided weight-bearing support) from staff for dressing, eating, toilet use, and personal hygiene. A review of Patient 1's plan of care, dated 1/27/22, titled "Patient Diagnosed with COVID 19," indicated if the patient experience decompensation or rapid decline, transfer the patient to the hospital. A review of the Physician Orders for Life Sustaining Treatment (POLST) signed by the responsible party on 1/28/2022 and signed by the physician 2/1/2022, indicated to provide Comfort-Focused Treatment- with the primarily goal of maximizing comfort by relieving pain and suffering with medication of any route as needed; use oxygen; suctioning; manual treatment of airway obstruction; and request transfer to hospital only if comfort needs cannot be met in current location. A review of Patient 1's plan of care, dated 1/30/2022, titled "Alteration in Gas Exchange" related to Acute Respiratory Failure" indicated the facility will maintain adequate respiratory function to the patient every day, would suction the patient as ordered, will evaluate the respiratory status and treatments of the patient. A review of Patient 1's physician order, dated 1/30/2022, indicated to deliver oxygen at 2-10 liters per minute (LPM) per nasal cannula (a plastic tube inserted to nares used to deliver oxygen to the lungs) or mask continuously to keep oxygen saturation (a level of oxygen in the blood) to keep saturation at 90% every shift. During an interview and concurrent record review of Patient 1's clinical record conducted with Licensed Vocational Nurse 1 (LVN 1) on 2/5/2022 at 11:59 pm indicated the following: a. Nursing Progress Notes, dated 1/21/2022 to 2/2/2022 indicated Patient 1 had productive cough, congestion (irritation of the nasal tissues that could be due to colds, respiratory infection, or runny nose and, crackles (lungs sound that indicate presence of fluid in the lungs that makes it hard to breath) sound on the bases of the lungs. b. Nursing Progress Notes, dated 1/28/2022 timed at 9:15 pm, indicated Patient 1 refused care. c. Nursing Progress Notes, dated 1/29/2022 timed at 8:36 am, indicated Patient 1's chest x-ray result conducted on 1/29/2022, showed upper and lower lung atelectasis (a condition of having a collapsed lungs caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the lung) or scarring with probable granuloma (abnormal cell growth) on the right lung upper lung. The NP (Nurse Practitioner) was informed. d. Nursing Progress Notes, dated 1/30/2022, timed at 10:15 pm, Patient 1 continued to refuse care. During a concurrent interview and record review with LVN 1, stated the following: e. Nursing Progress Notes, (documented by Registered Nurse-RN 3), dated 1/30/2022, timed at 10:40 pm, indicated Patient 1's oxygen saturation decreased to 77% (normal range 90-100%) at room air. NP was informed and ordered to administer ten liters of oxygen given via non-rebreather face mask which increased Patient 1's oxygen saturation level to 98%. Patient 1's representative party (RP) was called and asked not to transfer Patient 1 to the hospital for tonight only, NP aware. Patient 1 continued to have congestion and cough with crackles from the lungs and given Albuterol Puff (medication used to prevent and treat difficulty breathing, shortness of breath, wheezing [a high-pitched whistling sound during breathing] coughing, and chest tightness caused by lung disease). e. On 1/31/2022 timed at 6:36 pm, indicated Patient 1 remained on 10 liters oxygen on nonrebreather mask with oxygen saturation at 94%. NP ordered Patient 1 to be suctioned as PRN (as needed). f. Nursing Progress Notes, dated 2/1/2022 timed at 2:24 am, indicated Patient 1 continued to have chest congestion, crackles to both lower lobes and productive cough. Patient 1 was placed on 10 liters oxygen via nasal cannula due Patient 1 "kept taking off" the non-breather mask. In a concurrent interview LVN 1 stated there was no documented evidence the MD, NP, RN, or another licensed nurse were informed of the Patient 1's refusal to use the non-rebreather mask or if the patient tolerated the oxygen administered via nasal cannula, there was no recorded oxygen saturation level. LVN 1 stated there was no documented evidence if Patient 1's ability to spit out the sputum, color, consistency of the sputum and or suctioned to clear the airway from secretion. During an interview and concurrent record review on 2/5/2022 at 12:15 pm, with LVN 1, the Nursing Progress Notes, dated 2/2/2022 timed at 7:02 pm, indicated Patient 1 was receiving 10 liters per minute oxygen via nasal cannula with oxygen saturation of 96%. At 12:50 pm, the note indicated Patient 1 had productive cough, crackles (abnormal lung sounds) on both lower lobes, noted very congested, constantly coughing, and trying to clear his throat, attempted suction the patient, no secretion obtained in the oral cavity, all secretion in the trachea per auscultation. The NP was notified and ordered Lasix (medication that cause one to urinate "water pill") and Atropine (relaxes muscle and reduce secretion) for excessive secretion. At 2 pm, the Certified Nursing Assistant (CNA) called the charge nurse to assess patient. "Unable to obtain Vital signs, patient is DNR (no not resuscitate)." During a concurrent interview on 2/5/2022 at 2:30 pm, LVN 1 stated the day Patient 1 expired (died), she could hear the patient had excessive secretion in that settled in the trachea that she could not suction out since she could not do a deep suction. LVN 1 stated there was no other licensed staff assisted her to assess Patient 1 for difficulty in expectorating or suctioning the sputum. LVN 1 stated, the CNA informed her that Patient 1 refused to eat and when she checked on Patient 1, he was not responsive and no pulse. LVN 1 stated Patient 1 had a DNR status so CPR (cardiopulmonary resuscitation or transfer to the hospital was not implemented and the RP was not informed if the patient could be transferred to the hospital. LVN 1 stated she did not call the DON or any other staff to assist and assess Patient 1 before he expired. During a review and concurrent interview of the Nursing Progress Notes with Registered Nurse 1 (RN1) on 2/9/22 at 4:01 pm, stated on 1/30/2022, Patient 1 was observed pale (light color) congested, coughing productively and unable to spit out his sputum with oxygen saturation as low as 73%. RN 3 stated the NP was ordered to administer oxygen via non-rebreather mask at 10 liters per minute which helped increase the oxygen saturation of the patient to 98%. RN 3 stated she did not orally suction Patient 1 to clear his airway because there was no physician order to suction the patient and no available suction at the bedside. RN 3 stated, Patient 1's responsible party informed her not to transfer Patient 1 to the hospital, "just for the night (1/30/2022)" until the RP was able to meet with the rest of the family to make a decision about hospice care (a special kind of care that focuses on the quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness.). During an interview with the Director of Nursing (DON) on 2/9/2022 at 4:20 pm, the DON stated when a patient was having a difficulty expectorating the sputum the staff should inform the physician of the patient's respiratory status to ensure patient received treatment to loosen up the secretion and notify the physician again if the patient continue to have difficulty expectorating the sputum or suction out the secretion. During an interview and concurrent record review of Patient 1's POLST, dated 2/9/2022 at 4:29 PM, conducted with the Director of Nursing (DON) stated, Comfort Focused Treatment means the patients are provided comfort by repositioning, relieving pain and oral suctioning to provide comfort and ease with breathing if the patient is having productive cough and unable to spit out the sputum and if needed the patient should be transferred to the hospital. The DON stated, she was not informed that the staff had difficulty suctioning Patient 1 orally. The DON explained, Patient 1 was already expired when she saw him. During a telephone interview with the NP on 3/2/2022 at 12:52 pm, stated he was informed by the facility that Patient 1 had productive cough, so he ordered to suction the patient as needed. NP stated, he did not receive a report that Patient 1 had difficulty expelling his secretion or if the staff had difficulty suctioning the patient orally. The NP explained, if the POLST indicated if comfort could not be achieved at the facility, the staff should have honored the POLST and called the RP again to get clarification if the patient could be transferred to the hospital. A review of the Physician Orders for Life Sustaining Treatment (POLST) signed by the responsible party on 1/28/2022 and signed by the physician 2/1/2022, indicated to provide Comfort-Focused Treatment- a primarily goal of maximizing comfort by relieving pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. A review of the policy and procedure, dated 10/2010, titled "Suctioning the Upper Airway (oral pharygeal suctioning)" indicated the purpose of the procedure was to clear the upper airway of mucus secretions and prevent the development of respiratory distress (difficulty breathing). The policy indicated the facility will identify the risk factor for impaired airway clearance and aspiration and signs and symptoms of respiratory distress, will document the amount, color and characteristics of the sputum and will notify the supervisor if the patient refused the procedure. The facility failed to provide the necessary respiratory care and services to Patient 1 who had diagnoses including acute respiratory failure (a failure of the lungs to supply oxygen to the blood) and Corona Virus19 (COVID-19, a severe infection affecting the lungs) infection as indicated in the patient’s Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) by failing to: a. Ensure Patient 1's respiratory status was evaluated and reported to the physician or the Nurse Practitioner (NP) or any licensed facility staff for assistance when patient had productive cough (a wet cough, is a cough that brings up mucus or phlegm), unable to expel (spit out) excessive secretions and difficulty suctioning (a routine clinical procedure that is crucial for keeping the airway open) out the sputum to clear the patient's airway. b. Ensure Patient 1's primary care provider was informed when the patient refused to use the non-rebreather mask (a mask that delivers high oxygen level and constant flow supplemental O2 (oxygen) in an acute medical emergency) to keep proper oxygenation. c. Ensure Patient 1's POLST was reviewed and implemented according to the patient and responsible party's wishes, to be suctioned and transfer to the hospital if comfort could not be achieved at the facility. As a result, Patient 1 experienced excessive secretion in the trachea (the long tube that connects your larynx [voice box] to the bronchi that send air to the lungs), and could not expel the excessive secretion. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.