Other·November 3, 2023

On 9/23/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to immediately transfer Resident 1 via 911 (telephone number used to reach emergency medical, fire, and police services) to a General Acute Care Hospital (GACH) in accordance with the American Heart Association (AHA- an organization that funds cardiovascular [cardio (heart) vascular (blood vessels)] medical research, educates consumers on healthy living and fosters appropriate cardiac [pertaining to the heart] care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke) stroke (a medical emergency in which poor blood flow to the brain causes cell death) guidelines dated 2023. Resident 1 experienced signs (something a doctor, or other person, notices not limited to numbness or weakness of the face, arm or leg, confusion, trouble speaking or understanding speech) and symptoms (is what a person/patient feels not limited to sudden loss of balance/trouble walking, dizziness, severe headache, memory loss, changes in mood or personality, or trouble seeing in one or both eyes) of stroke (when blood supply to part of the brain is briefly interrupted) on 8/28/2023 at 4:35 p.m. This failure resulted in a delay of five hours and thirteen minutes for the facility to transfer Resident 1 to GACH 1 for further evaluation and management. GACH 1 diagnosed Resident 1 with acute (sudden onset/abrupt) on subacute (rather recent onset or somewhat rapid change) left basal ganglia infarct (death of brain tissue resulting from a failure of blood supply) and was admitted in telemetry unit (area in a hospital for patients who require constant monitoring of various bodily functions) at GACH 1. A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 8/8/2023 and readmitted Resident 1 on 9/12/2023 with diagnoses including personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, hypertension (HTN - elevated blood pressure) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/11/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required extensive two staff assist for bed mobility, dressing and transfers. The MDS further indicated Resident 1 had clear speech. A review of Resident 1's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 8/28/2023 at 10:09 p.m., indicated Registered Nurse Supervisor 1 (RNS 1) documented that on 8/28/2023 at 4:35 p.m., Certified Nursing Assistant 1 (CNA 1) informed RNS 1 that Resident 1's family member (FM) reported that Resident 1 was not talking normally, and that Resident 1 was stuttering which was unusual for the resident. On 8/28/2023 at 6:46 p.m., RNS 1 relayed Resident 1's condition to Nurse Practitioner (NP) who gave an order to contact the case manager (CM) for Resident 1's Medical Doctor (MD) to make arrangements to transfer Resident 1 to GACH. RNS 1 documented that per the CM, the estimated time of arrival (ETA) for transport was 12 a.m. because GACH was on diversion and that MD and NP were aware. RNS 1 also documented that MD said, "if [Resident 1] is having slurred speech, just call 911." A review of Resident 1's transfer/discharge summary notes dated 8/28/2023 at 6:40 p.m., indicated Resident 1 was transported to GACH 1 via 911 on 8/28/2023 at 9:48 p.m. (five hours and thirteen minutes delay for the facility to transfer Resident 1 to GACH 1). A review of GACH 1 "Neurology (branch of medicine concerned with the study and treatment of disorders of the nervous [brain and spinal cord] system) Consult Note" for Resident 1 dated 8/29/2023, indicated Resident 1 was brought in on 8/28/2023 due to "right sided weakness, numbness [loss of sensation or feeling in an area of the body] and slurred [difficulty saying words] speech". The Magnetic Resonance Imaging (MRI -a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) brain scan performed at GACH 1, revealed acute on subacute left basal ganglia infarct. Resident 1 was examined in telemetry unit. Resident 1 was awake, alert, interactive, and oriented to person, place, and time. Resident 1 continued to complain of "slow speech. ..." Resident 1 was found with right (R) hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) on exam but was unaware of these deficits and maintained that her deficits and their presentation were on the left (L) side. Resident 1 also said, "that yesterday, I could not see my thoughts". A review of Resident 1's Licensed Nursing Note dated 9/6/2023 at 9:21 p.m., indicated that on 8/28/2023 at around 8:50 p.m., the facility called 911 and paramedics arrived at the facility at "9 p.m. ..." FM at bedside wanted Resident 1 transferred to GACH. On 9/23/2023, at 8:30 a.m., during a telephone interview with Resident 1's FM, FM stated that on 8/28/2023 around 6 p.m., she was in Resident 1's room visiting Resident 1 when Resident 1 started to show "signs of a stroke such as stuttering, confusion and change in speech." FM stated it took the facility three hours before calling 911 and to transfer Resident 1 to GACH. On 9/23/2023 at 9:06 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 8/28/2023 around 5 p.m. to 5:30 p.m., CNA 1 reported to her that Resident 1 was "different and was stuttering when speaking." LVN 1 stated she noticed that Resident 1 was taking long to speak, and Resident 1, "took longer for words to come out [speak] and that was different from usual." LVN 1 further stated some signs and symptoms (S/S) of a stroke included slurred speech. LVN 1 stated 911 must be called immediately for anyone experiencing S/S of stroke. LVN 1 stated she left RNS 1 to care for Resident 1 because she needed to go and administer medications to the other residents. On 9/23/2023 at 1:30 p.m., during an interview with CNA 1, CNA 1 stated that on 8/28/2023 around 4:45 p.m. to 5:30 p.m., FM was at Resident 1's bedside, and that FM asked her (CNA 1) to come into Resident 1's room because Resident 1 "did not look right." CNA 1 stated she went to Resident 1's room and observed that Resident 1's, "face was droopy [falling to a position that is lower than normal], and Resident 1, "was stuttering [significant problems with normal fluency and flow of speech]. Not bringing out words at all." CNA 1 stated, "this is not [Resident 1's] usual speech or appearance at all. I think she is having a stroke." CNA 1 immediately went to the nurses' station and notified RNS 1 and LVN 1 about Resident 1's condition. On 9/25/2023 at 3:44 p.m., during a concurrent interview and record review with RNS 1, Resident 1's COC dated 8/28/2023 was reviewed. RNS 1 stated that on 8/28/2023 at 6 p.m., CNA 1 informed her that FM was concerned that Resident 1's speech was stuttered which was unlike Resident 1. RNS 1 stated she assessed Resident 1, and the resident was no longer stuttering. RNS 1 stated FM requested Resident 1 be transferred to GACH. RNS 1 stated she telephoned Registered Nurse Practitioner (RNP), but RNP did not answer. RNS 1 stated she then texted RNP on 8/28/2023 at 6:46 p.m. and RNP texted back and instructed her to call the CM. RNS 1 stated she contacted the CM, but the CM did not answer. RNS 1 stated she then contacted MD on 8/28/2023 at 8:40 p.m., who instructed her to call 911 and transfer Resident 1 to GACH because Resident 1 was having slurred speech. RNS 1 stated she called 911 and Resident 1 was transported to GACH 1 on 8/28/2023 at 9 p.m. RNS 1 stated risk factors for stroke include heart diseases, HTN, and overweight. RNS 1 stated S/S of stroke include facial droop, confusion, weakness, unsteady gait (a manner of walking), speech alteration and to immediately call 911 if a resident/person had S/S of stroke. RNS 1 stated failure to immediately call 911 when a resident/person is experiencing S/S of stroke could result in stroke and death. On 9/26/2023 at 11:28 a.m., during an interview with MD, MD stated individuals at higher risk of stroke include and not limited to advanced age and history of a stroke. MD stated when RNS 1 notified him that Resident 1 had slurred speech on 8/28/2023, he instructed RNS 1 to call 911 and transfer Resident 1 to GACH for immediate evaluation particularly because FM was the one concerned about Resident 1's condition. MD further stated, "the probability of getting another stroke increases for someone who has had a stroke as opposed to someone who has never had a stroke." MD further stated delaying immediate care for someone experiencing S/S of stroke could result in major neurological (involving the brain and spinal cord) deficits including paralysis (inability to move the affected body part/s), weakness, sensory impairment, right or left sided weakness and death. On 9/26/2023 at 4:39 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated she was unable to find any documented evidence that facility staff were inserviced on S/S stroke/ TIA prior to 8/28/2023. The DSD further stated she uses the AHA guidelines when providing inservice on stroke/TIA to staff and that the last inservice was on 9/8/2023. On 9/26/2023 at 5:15 p.m., during an interview with the Director of Nursing (DON), the DON stated when a resident has S/S of a stroke, the immediate action is to call 911. The DON stated potential adverse outcomes due to delayed care for a person/resident experiencing S/S of stroke include death. On 9/27/2023 at 9:13 a.m., during an interview with RNP, RNP stated that on 8/28/2023, RNS 1 notified her via text message that Resident 1 was stuttering. RNP stated, "I have seen [Resident 1] and she does not stutter. I was thinking [Resident 1] was having signs of a stroke." RNP stated she advised RNS 1 to call the MD's CM and arrange to transfer Resident 1 to GACH. RNP then stated the facility has called 911 because regular ambulance transportation, "takes time and, "time is critical." RNP stated a person experiencing S/S of stroke have two hours to receive "treatment" and must be transferred to an acute care facility (GACH). RNP stated the potential adverse outcome for delayed care could result in permanent neurological damage, paralysis, weakness, sensory impairment, and death. A review of facility's Registered Nurse (RN) Job Description approved 8/23/2011, indicated ... the following: "-Makes assessments and interventions related to changes in patient conditions: ...acute changes in condition. -Identifies/assesses emergency medical situations. ...". A review of the facility's policy and procedures, titled, "Transfer or Discharge, Emergency," revised 8/2018, indicated "Emergency transfers of discharges may be necessary to protect the health and/or wellbeing of the resident(s). Resident will not be transferred unless : the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility." A review of the facility's policy and procedures, titled, "Stroke/TIA clinical protocol," revised 11/2018, indicated "signs and symptoms of acute ischemic stroke may include ...difficulty speaking ... many symptoms associated with stroke are not specific, and could represent other causes such as ... infection. A review of the facility's policy and procedures, titled, "Change of Condition," revised 3/2023, indicated "to ensure proper assessment and follow through for any resident with a change in condition ... a change of condition is a sudden or marked difference in residents: ...level of functioning ... in cases of emergency changes in the condition of a resident ... the nurse may dial 911." A review of the American Heart Association (AHA) Stroke guidelines "Heart attack, Stroke and Cardiac Arrest Symptoms" dated 2023, indicated "if these warning signs are present call 911 ... . Stroke symptoms ... speech slurred, are they unable to speak, or are they hard to understand ...if the person shows any of these symptoms, even if the symptoms go away, call 911 and get them to the hospital immediately." The facility failed to immediately transfer Resident 1 via 911 to a GACH in accordance with the American Heart Association Stroke guidelines dated 2023. Resident 1 experienced signs and symptoms of stroke on 8/28/2023 at 4:35 p.m. This failure resulted in a delay of five hours and thirteen minutes for the facility to transfer Resident 1 to GACH 1 for further evaluation and management. GACH 1 diagnosed Resident 1 with acute on subacute left basal ganglia infarct and was admitted in telemetry unit at GACH 1. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1.