Health inspection·August 18, 2023

On 6/23/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about a resident's death (Resident 1). The facility failed to ensure Resident 1, received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any intervention used to restart a person's heartbeat and breathing after one or both have stopped), as requested by family member 2 (FM 2) who was Resident 1's legal representative. As a result, on 6/17/2023 at 11:40 a.m., when the facility was unable to obtain a blood pressure reading for Resident 1, CPR was not attempted. Resident 1 was pronounced dead on 6/17/2023, at 11:50 a.m. A review of Resident 1's Admission Record indicated the facility admitted the resident on 5/17/2023 with diagnoses including Alzheimer dementia (a progressive disease that destroys memory and other important mental functions), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), and gastroenteritis (intestinal infection that includes symptoms such as watery diarrhea, stomach cramps, nausea or vomiting), and dysphagia (difficulty or abnormality of swallowing) oropharyngeal phase (characterized by difficulty initiating a swallow - occurring in the mouth and/or the throat). The Admission Record indicated FM 2 was Resident 1's emergency contact person. A review of Resident 1's Standard Admission Agreement, dated 5/17/2023, indicated that on 6/8/2023, FM 2 electronically signed the standard admission agreement as the legal representative for Resident 1. The standard admission agreement further indicated, "The resident consents to routine nursing care ..., as well as emergency care that is required... If you are, or become, incapable of making your own medical decisions, we [facility] will follow the direction of a person with legal authority to make medical treatment decisions on your behalf, such as guardian, ..., next of kin, ..." A review of Resident 1's care plan, initiated on 5/17/2023, titled "Cognitive Loss" indicated Resident 1 had short and long term, poor memory and decision making skill recall impairment, problem understanding others and problem making self-understood. The care plan further indicated Resident 1 had Alzheimer's disease and dementia. A review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST - is 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) form prepared by the facility's Social Services Assistant (SSA) on 5/18/2023 indicated: - Section A Cardiopulmonary Resuscitation (CPR): Do not attempt resuscitation/DNR (allow natural death). - Section B Medical intervention: Comfort focused treatment - Section C Artificially Administered Nutrition: No artificially means of nutrition including feeding tubes (flexible tubes inserted in the nose or through the stomach for nutrition, medication, and hydration). - Section D Information and Signatures: discussed with patient (patient has capacity); Patient has no advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury). Resident 1 signed with a date of 5/17/2023 overwritten on the date of 5/18/2023. However, the physician signed on 5/18/2023. The signature box indicated, "I am aware that this form is voluntary. By signing this form, the person legally recognized acknowledges that this form regarding resuscitative measures is consistent with the known desires of. and with the best interest of. the individual who is the subject of this form." A review of Resident 1's "Advanced Directive Acknowledgement" form dated 5/18/2023, indicated FM 2 checked "I have not executed an Advanced Directive. I do not have an executed POLST." A review of the facility's "Audit Report," dated 5/18/2023, timed at 12:48pm, indicated Resident 1 was, "Alert and oriented x2 (two) with episodes of forgetfulness." A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/22/2023, indicated Resident 1 had moderately impaired cognition (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the Physician's Order for Resident 1, dated 5/25/2023, indicated DNR and comfort focused treatment. A review of the Physician's Order for Resident 1 dated 6/12/2023, indicated to give intravenous fluid (IVF - administer into a vein) Dextrose (sugar) 5% with Sodium Chloride (salt) 0.9% solution (D5w/NS) at 50 milliliters (ml - unit of measurement) per hour (ml/hr) every shift for poor oral intake for five days. A review of Resident 1's Medication Administration Record (MAR) dated 6/2023, indicated Resident 1's blood sugar was 441 mg/dl at 11:30 a.m., on 6/17/2023. The MAR indicated to administer Insulin (medication to control/lower blood sugar) 10 units subcutaneously (SQ- into body fat). A review of Resident 1's nursing Progress Notes, dated 6/17/2023 and timed at 8 a.m., indicated Resident 1 was in "sleeping state," able to arouse, receiving IVF, and Resident 1's grandkids were at bedside. There was no documentation the licensed nurse called Resident 1's attending physician about the resident being in a sleeping state (asleep). A review of Resident 1's nursing Progress Notes, dated 6/17/2023 and timed at 10:45 a.m., indicated Resident 1 was sleeping, able to open eyes, answer yes / no questions, and did not eat her breakfast. At 11 a.m., Resident 1 was noted with labored (difficult) breathing, her Oxygen (O2) Sat was 85%. Resident 1 was administered oxygen (O2) at 2 liters per minute (2L/min) through a nasal cannula (device placed in the nostrils). At 11:30 a.m., Resident 1's O2 Sat increased to 92%, the resident was still in a lethargic state with a weak pulse, the heart rate was 67 beats per minute (bpm, normal rate 60-100 bpm), the breathing rate was 16 breath per minute (normal range 16 to 20 breaths/min), the blood pressure was 85/60 millimeters of mercury (mmHg - unit of measurement [normal blood pressure less than 120/80 mmHg), the body temp 97.8 degrees Fahrenheit (°F, normal range 97°F to 99°F), and the O2 Sat was 82%. FM 2 arrived and requested to transfer Resident 1 to hospital. Called 911 (telephone number for emergencies to request emergency medical services [EMS, paramedics - are healthcare professionals who respond to emergency calls for medical help outside of a hospital]) and came. At 11:40 a.m., the paramedics were unable to obtain Resident 1's blood pressure. At 11:52 a.m. unable to check apical pulse (taken in the left center of the chest, just below the nipple) and the resident was not breathing. Family at bedside. At 12 p.m., the paramedics called the police who arrived at 12:30 p.m. The police called and spoke to Resident 1's attending physician. Family called the mortuary and cleaned Resident 1's body. At 2:40 p.m., the mortuary picked up Resident 1's body. A review of Resident 1's SSD notes dated 6/19/2023, a late entry for 5/19/2023, indicated SSD communicated with FM 2 on 5/19/2023 during a care conference and SSD informed FM 2 that Resident 1 clearly did not want to be full code (do CPR). SSD explained that if CPR was checked on the POLST, then a resident would receive full treatment, with the option of intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) and advance respiratory interventions. FM 2 stated he would speak with Resident 1. On 6/23/2023, at 9:30 a.m., during a telephone interview, FM 1 stated that on 6/17/2023, at 10:56 a.m., she was at Resident 1's bedside since earlier in the day. FM 1 stated Licensed Vocational Nurse 2 (LVN 2) checked on Resident 1 and told FM 1 that Resident 1 did not look well. LVN 2 checked Resident 1's vital signs (include blood pressure, heart and respiratory rate, body temperature). LVN 2 placed Resident 1 on oxygen and the bed in Trendelenburg position (the patient lays flat on the back on a 15-30-degree incline with the feet elevated above the head). LVN 2 told FM 1 to call the rest of family members. FM 1 stated FM 2 arrived at the facility at 11:25 a.m. and asked the nurses if they had called 911 and Registered Nurse 2 (RN 2) provided FM 2 with Resident 1's POLST and asked FM 2 if he still wanted RN 2 to call 911. FM 1 stated FM 2 questioned RN 2 about the validity of Resident 1's POLST document because FM 2 was Resident 1's legal representative. FM 1 stated FM 2 told RN 2 to call 911. FM 1 stated that when paramedics arrived, the paramedics told FM 2 that Resident 1 was pulseless (no heart beat) and unresponsive (not reacting when touched, spoken to, etc.) and asked if FM 2 wanted them to initiate CPR and FM 2 said no. FM 1 stated that FM 1, FM 2, and other family members visited Resident 1 every day and the staff did not inform any of them that Resident 1 had signed a POLST and was a DNR with comfort focused care. On 6/23/2023, at 12:55 p.m., during an interview with RN 1 and concurrent review of Resident 1's POLST, RN 1 stated she was familiar with the care of Resident 1 and was aware the family was very involved in Resident 1's care. RN 1 stated Resident 1's family members visited and checked on Resident 1 every day. RN 1 stated Resident 1 was deemed by the attending physician as unable to make decisions and could not sign a POLST (date not provided). On 6/23/2023, at 1:25 p.m., during an interview, SSD stated that on 5/19/2023 the facility conducted interdisciplinary team (IDT - a group of health care professionals from various disciplines who work together on the care of the resident) care conference and she (SSD) informed FM 2 about the POLST Resident 1 signed. SSD further stated FM 2 said he wanted CPR done for Resident 1 and he would discuss the signed POLST with Resident 1. On 6/23/2023, at 3:10 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 did not have the mental capacity to make decisions or consent to a POLST. On 6/24/2023, at 10:34 a.m., during an interview, RN 2 stated she was the supervisor on 6/17/2023, when Resident 1 experienced a change of condition and subsequently died. RN 2 stated Resident 1 signed POLST for DNR and comfort measures and that was the reason they did not call the physician or paramedics. RN 2 stated that when the paramedics arrived, Resident 1 had no heartbeats and was not breathing. Paramedics asked FM 2, if he wanted the paramedics to initiate CPR but FM 2 declined. On 6/24/2023, at 11:30 a.m., during an interview, LVN 2 stated that on 6/17/2023, when she returned from her break at 10:59 a.m., she went to check Resident 1's blood sugar Resident 1 responded sluggishly to her compared to how Resident 1 was at 8 a.m. when LVN 2 last spoke to Resident 1. LVN 2 stated Resident 1's blood sugar was 441 milligrams per deciliters (mg/dl), and she administered Resident 1 a dose of 12 units of insulin (medication to decrease the blood sugar) as ordered and notified RN 2. LVN 2 stated when FM 2 arrived at the facility and yelled out loudly, "why is no one doing anything? Did you call 911?" On 6/26/2023, at 10 a.m., during an interview, the SSD stated she and the assistant SS (ASS) interviewed Resident 1 regarding the POLST. The SSD stated the ASS spoke Resident 1's native language and also interpreted for the SSD. The SSD stated that during Resident 1's assessment interview, Resident 1 was able to state her name. The SSD stated Resident 1 said had a weak heart and knew that she was in a hospital but could not know which hospital. The SSD stated that based on Resident 1's response, she determined Resident 1 was capable of understanding and making decisions and SSD had Resident 1 sign the POLST. The SSD stated Resident 1 agreed to a DNR status with comfort measures only (refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). The SSD stated she did not review Resident 1's medical record to check if Resident 1 had the capacity to understand and make decisions. On 6/26/2023, at 10:30 a.m., during an interview, the DON stated Resident 1 expired unexpectedly in the facility and paramedics pronounced (declared) Resident 1 dead on 6/17/2023, at 11:50 a.m. On 6/26/2023, at 11:15 a.m., during an interview, FM 2 stated on 5/19/2023, the facility conducted an IDT meeting with him and discussed Resident 1's treatment plan, care plan plans and goals. FM 2 stated during the IDT meeting he expressed his desired goal for Resident 1 to eat more, get stronger, and return to the Assisted living Facility (ALF, housing and services for people who need some help with daily care) the resident lived before going to the hospital. FM 2 stated FM 1 called him on 6/17/2023, at 11 a.m., to inform him Resident 2 did not look well and the nurses were asking for him (FM 2) to come to the facility. FM 2 stated he arrived at the facility at about 11:25 a.m. and asked the nurses if they had called 911 and RN 2 gave him Resident 1's POLST form. FM 2 stated RN 2 refused to answer when he questioned the validity of the POLST why no one had discussed Resident 1's POLST with him as the resident's legal representative and he was the signatory of all the other documents pertaining to Resident 1's admission to the facility. FM 2 stated when the paramedics arrived, Resident 1 was already dead and that was the reason he declined when paramedics asked him if he wanted them to initiate CPR. A review of the paramedics Patient Care Report dated 6/28/2023, indicated dispatch was notified at 11:30 a.m., paramedics arrived at Resident 1's bedside at 11:46 a.m., to find an 88-year-old female on bed supine (face up) unresponsive, apneic (not breathing), pale, pupils dilated (when the black/dark center of the eyes are larger than normal), non-responsive, pulseless, asystole (no heartbeat) on monitor. On 7/5/2023, at 3:47 p.m., during an interview, the facility's Medical Director (FMD) stated a medical assessment is required to determine a resident's capability to understand and make decisions. The FMD stated it was important to involve the resident's family members in the care of the resident. The FMD stated if medical interventions have been attempted and a resident does not respond positively to the treatment/interventions, the resident should be transferred to a hospital for further evaluation and diagnostic tests to rule out any medical problems. A review of facility's policy and procedures (P&P) titled, "Informed Consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment)" dated 12/19/2022, indicated, "it is the responsibility of the healthcare professional who proposes any medical interventions or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment." A review of the facility's P&P titled, "Residents' Rights Regarding Treatment and Advanced Directives" dated 12/19/2022 indicated, "In the event the resident is unable to formulate an Advance Directive (AD) due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative." A review of facility's P&P titled, "Residents' Rights Regarding Treatment and advanced Directives," dated 12/19/2022, indicated, "Policy Explanation and Compliance Guidelines: 1. ... a. In the event the resident is unable