Other·November 21, 2022

42 CFR § 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 42 CFR § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident 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 residents' goals and preferences, and 483.65 of this subpart. 22 CCR § 72515. Admission of Patients. The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. 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. 22 CCR § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: 22 CCR § 72309. Nursing Service. Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the 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). On 9/27/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a facility reported incident about a resident's death. The facility failed to ensure Resident 1, a 62-year old female newly admitted to the facility, who was diabetic (a group of diseases that affect how the body uses blood sugar [glucose]) and needed blood sugar level monitoring for insulin (preparation of the protein hormone insulin that is used to treat high blood glucose) administration, and a BiPAP machine (Bi [two] Level Positive Airway Pressure; also called positive pressure ventilation, a device designed to help push air into the lungs for people who have trouble breathing; a mask or nasal plugs are connected to the machine) due to chronic obstructive respiratory disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), received appropriate treatment and care, including respiratory care, to meet Resident 1's needs. The facility failed to: 1. Ensure all licensed nurses were trained and competent to safely operate the BiPAP machine before Resident 1 was admitted to the facility on 5/23/2022. 2. Ensure Resident 1's respiratory status was monitored while on the BiPAP machine. 3. Ensure Resident 1's attending Physician (Physician 1) was contacted to verify the BiPAP order upon arrival from general acute care hospital 1 (GACH 1) including information about the amount of oxygen, if needed, to be administrated while on the BiPAP machine and monitoring of Resident 1's respiratory status while on the machine. 4. Ensure Registered Nurse 1 (RN 1- admitting nurse) thoroughly reviewed the admission inquiry report and GACH 1 in patient medical records and discharge records for Resident 1, during Resident 1's admission process to the facility. 5. Ensure RN 1 verified Resident 1's admitting diagnoses and orders with Physician 1 upon Resident 1's admission to the facility. 6. Ensure licensed nurses followed up with the pharmacy to ensure Resident 1's medications were delivered and administered timely. 7. Notify Physician 1 of the delay to administer Resident 1's medications including insulin. 8. Ensure a licensed nurse performed Resident 1's blood sugar check (measure the glucose levels in the blood) after Family Members 1 and 2 (FM 1 and FM 2) alerted Licensed Vocational Nurse 1 (LVN 1) that Resident 1's mental status had declined on 5/25/2022. 9. Notify Physician 1 and 911 called (the telephone number used to reach emergency medical, fire, and police services) that Resident 1's mental status had had declined per FM 1 and FM 2. As a result, Resident 1 did not have her blood sugar levels checked and was not given insulin since her admission on 5/23/2022. Resident 1 also did not receive appropriate BiPAP therapy since admission, and on 5/25/2022 at 11:58 p.m. Resident 1 was found unresponsive, not breathing and without a heartbeat. At midnight, the facility called the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) and at 12:16 (00:16 of 5/26/2022) paramedics pronounced Resident 1 dead. A review of the facility's Quick Check Inquiry Form (the form the facility uses to obtain information about a prospective resident prior to placement), dated 5/20/2022, with the information from GACH 1, indicated Resident 1 was on a BiPAP machine. A review of GACH 1 Discharge Progress Notes (sent with Resident 1 to the facility), dated 5/22/2022, indicated the resident was in stable condition and waiting for the BiPAP machine to be sent to the facility (with the resident). A review of GACH 1 Discharge Notes - Instructions included a list of medications Resident 1 needed and the Daily Progress Note, dated 5/22/2022, timed at 11:49 a.m., indicated Resident 1 was "on 40% FiO2" (fraction of inspired air; the concentration of oxygen in the gas mixture; the gas mixture at room air has a FiO2 of 21%). There were no specific instructions about the use of the BiPAP for Resident 1. A review of GACH 1 "Discharge Notes - Instructions" (sent with the resident) dated 5/23/2022, included a list of medications Resident 1 was receiving. The medications included insulin glargine (Lantus, long-acting [slowly absorbed after being administered, and maintains its effects over a long period of time]) insulin injection 20 milligrams per deciliter (mg/dL [unit of measurement]) subcutaneously (under the skin) every night and insulin lispro (Humalog, short acting insulin) injection 0-12 mg/dL subcutaneously based on the result of the blood glucose test (using a glucose meter or glucometer, a medical device for determining the approximate concentration of glucose in the blood; a small drop of blood, obtained by pricking the skin with a lancet [a pointed piece of surgical steel encased in plastic, used to puncture the skin on one's finger], is placed on a disposable test strip that the meter reads) to be done before each meal and at hour of sleep (a total of four times a day). The specific dose of insulin based on blood glucose level (sliding scale) was not included in the transfer orders from GACH 1. The discharge instructions also indicated "have someone call 911 if you have the following symptoms: Problems breathing or unable to breath, Feeling faint or become unresponsive ..." A review of Resident's 1 Admission Record (Face Sheet) indicated the facility admitted the resident, a 63-year-old female, on 5/23/2022 with diagnoses including sleep apnea (serious sleep-related breathing disorder in which breathing repeatedly stops and starts), COPD, chronic respiratory failure, chronic kidney disease, and shortness of breath. Resident 1 was at GACH 1 from 5/1/2022 to 5/23/2022. Resident 1 was self-responsible and was admitted under the care of Physician 1. The admitting diagnoses also included diabetes mellitus, morbid obesity (excessive body weight, 100 pounds heavier than the recommended body weight), and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Resident 1 was incontinent (unable to control) of bladder and bowel functions, and was alert and oriented to self, place, date, and time. Resident 1's weight was 205 pounds; the last blood sugar level performed at GACH 1 before discharge was 216 mg/dL and received four units of insulin (type of insulin was not specified) at GACH 1 (date and time not specified). Resident 1 was Full Code status (if the heart stopped beating and/or stopped breathing, all resuscitation procedures will be provided to keep them alive). Resident 1 was coming to the facility from GACH 1 with an estimated time of arrival was 6:45 p.m. (arrival date not indicated) A review of Resident 1's Admission Report (report received from GACH 1's nurse) indicated the resident had diagnoses including diabetes mellitus, morbid obesity, and atrial fibrillation. Resident 1 was incontinent of bladder and bowel functions, and was alert and oriented to self, place, date, and time. Resident 1's weight was 205 pounds. Resident 1 was Full Code status, had a BiPAP in the room and oxygen (O2) at 4 liters per minute (L/min). Resident 1's last blood sugar level performed at GACH 1 before discharge was 216 mg/dL and the resident had received four units of insulin (type of insulin was not specified) at GACH 1 (date and time not specified). Resident 1 was Full Code status. Resident 1 was coming to the facility from GACH 1 with an estimated time of arrival was 6:45 p.m. (arrival date not indicated). A review of the Physician's Telephone Orders for Resident 1 dated 5/23/2022 timed at 9:48 p.m. documented by RN 2 indicated RN 2 verified the admission orders with Physician 1. The orders included O2 at 4 L/min and to keep the oxygen saturation (measures the percentage of oxygen is in the blood carried by the red blood cells to all body tissues) above 90% every shift and apply a BiPAP machine at Hour of Sleep (HS -nighttime) and remove per schedule. However, the BiPAP orders indicated "I" (inspiratory - breath in) = ____ (left blank -no number/figure indicated) and "E" (expiratory - breath out) = ____ (left blank- no number/figure indicated). The physician telephone orders did not include insulin medications or sliding scale and blood sugar tests as reflected on Resident 1's Admission Report received from GACH 1. A review of Resident 1's Progress Notes Post Admission Patient/Family Conference, dated 5/25/2022, timed at 9:35 a.m., indicated the resident was admitted for a short-term stay (between 31-100 days) and would return home at previous living arrangement with husband. The note did not address Resident 1's diagnoses of diabetes and insulin use. A review of Resident 1's nursing Progress Notes dated 5/26/2022, timed at 00:37 a.m., a late entry documented by Licensed Vocational Nurse 3 (LVN 3) for 5/25/2022 at 3:00 p.m. to 11:00 p.m. shift, indicated Resident 1 was received in bed at 8 p.m. (on 5/25/2022) on O2 at 4 L/min via nasal cannula (a lightweight flexible tube which on one end splits into two prongs which are placed in the nostrils to deliver supplemental O2). The BiPAP machine was in place at 10 p.m. LVN 3 did not document an evaluation of Resident 1's breathing condition, breathing sounds, O2 saturation, if the BiPAP was turned on and connected to the O2, the amount of O2 flowing through the BiPAP machine, or the BiPAP machine settings. A review of Resident 1's nursing Progress Notes, dated 5/26/2022, timed at 4:54 a.m. indicated at 11:20 p.m. (on 5/25/2022) Resident 1's BiPAP was secured and in place, the O2 saturation was 97% (the normal range is above 92%) with the BiPAP machine on. The note did not include if the O2 was connected to the BiPAP machine and the BiPAP settings. At 11:58 p.m. (on 5/25/2022) Resident 1 was not breathing, was unresponsive, and did not have pulse (heartbeat). Resident 1 was Full Code and a Code Blue (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention). Cardiopulmonary resuscitation (CPR - an emergency procedure that can help save a person's life if their breathing or heart stops) was initiated. At midnight, the facility called the paramedics and at 12:16 a.m., (00:16 of 5/26/2022) paramedics pronounced Resident 1 dead. A review of Resident 1's Certificate of Death indicated Resident 1 died on 5/26/2022 at 00:16 a.m. The immediate cause of death was acute on chronic hypercapnic (excessive amount of carbon dioxide [CO2, a colorless, odorless gas waste product made by the body]) respiratory failure. Underlying cause were obesity hypoventilation syndrome (causes poor breathing in some people with obesity; it leads to lower oxygen and higher carbon dioxide levels in the blood) and morbid obesity. On 9/27/2022, at 1:19 p.m., during an interview, LVN 1 stated she did not receive any training on how to operate or set up a BiPAP machine. LVN 1 stated she could not identify if a BiPAP machine was functioning correctly and did not know its indications and when to stop a BiPAP therapy. On 9/27/2022, at 2:23 p.m., during an interview, RN 1 stated on 5/23/2022, an outside vendor delivered Resident 1's BiPAP machine, set it up, and did not provide instructions on how to operate it. RN 1 stated she had not received any training on the use and settings of a BiPAP machine. RN 1 stated the facility did not have a Respiratory Therapist (RT - a certified medical professional who provides relief to those who have difficulty breathing or cannot breathe on their own due to impaired or non-functioning lungs including include oxygen therapy and breathing treatments). On 9/28/2022, at 8:58 a.m., during a telephone interview, LVN 2 stated he did not know how to use or operate a BiPAP machine. LVN 2 stated he had never been inserviced on how to operate or use a BiPAP machine, and all he knew "to do is turn it (BiPAP machine) on." On 9/28/2022, at 9:15 a.m., during a telephone interview, RN 2 stated on 5/23/2022 a vendor delivered and set up Resident 1's BiPAP. RN 2 stated she assisted RN 1 during Resident 1's admission to the facility in the evening of 5/23/2022. RN 2 stated she did not see an order for a BiPAP machine. On 9/28/2022, at 9:32 a.m., during a telephone interview, Director of Nursing 1 (DON 1) stated she would not admit a resident who required BiPAP therapy without an RT in the facility. DON 1 stated the facility did not have the BiPAP manufacturer's manual for the staff to refer to. DON 1 stated the facility did not have a policy on BiPAP use. On 9/28/2022, at 12:52 p.m., during a telephone interview, FM 1 stated that on 5/25/2022 morning, FM 2 had tried to call Resident 1 on her cell phone and did not get an answer. FM 1 contacted the facility to talk to Resident 1 and was