Other·September 20, 2023

Title 42 CFR §483.10 Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). Title 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. (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. Title 22 CCR §72311 – Nursing Service – General (a) Nursing service shall include, but not limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse changes in signs, symptoms or behavior exhibited by a patient. The California Department of Public Health (CDPH) received a complaint on 7/27/2023 regarding Resident 1 who was unarousable and was transferred to General Acute Care Hospital (GACH). On 7/27/2023, at 9:30 a.m., CDPH conducted an unannounced investigation at the facility. During the investigation, it was discovered that Resident 1 had experienced a change of condition for over four hours before Resident 1 was transferred to GACH. The facility failed to: 1. Immediately inform and consult the primary physician when Resident 1 experienced a significant change of condition (COC, a clinical deviation from a resident's baseline). 2. Follow its policy and procedures, titled, “Emergency Physician Care”, to contact the on-call physician or Medical Director when Resident 1’s primary physician did not respond to the nurse or was not available to report a change in condition. On 4/22/2023, 8:30 a.m., Resident 1 experienced a decline in vital signs (clinical measurements, of the heart rate, temperature, respiration rate, and blood pressure (BP), the amount of pressure in the arteries during contraction of the heart, that indicates the state of a person's essential body functions) that were not within normal limits. Resident 1’s BP was 96/42 millimeters of mercury (mmHg, unit of measurement) which was below Resident 1’s baseline of 104 to148 systolic, (pressure when the heart muscle contracts) and 56 to 86 diastolic, (pressure when the heart muscle relaxes). The heart rate was 117 beats per minute (bpm) with a normal reference range (NRR) between 60 to 100 bpm, oxygen saturation (O2 sat, the amount of oxygen level present in the body with a normal range of 94-100 percent [%]) was 90% on room air, which meant Resident 1 had an increased need for O2 and the physician was not notified promptly. This failure resulted in the delay of evaluation, interventions of care, and treatment for Resident 1. Resident 1 was exhibiting a COC for over four (4) hours before Resident 1 was transferred to the general acute care hospital (GACH) by 911 (an emergency phone number to contact for medical emergencies, situations requiring immediate assistance from the police, fire department or ambulance). Resident 1 was admitted to the GACH with acute hypoxic respiratory failure (blood does not have enough oxygen) due to mucus plugging (a buildup of mucus that plugs the airways) and likely aspiration pneumonia, (lung infection caused by inhaling foreign materials into the lungs). Resident 1 eventually was placed on hospice care (a type of health care that focuses on the palliation of a terminally ill patients [patients with 6 months or less to live] and prioritizes comfort and quality of life by reducing pain and suffering) and passed away on 5/5/2023, due to hypoxic respiratory failure and pneumonia. A review of Resident 1’s admission record (Face Sheet), dated 7/27/2023, indicated Resident 1 was an 85-year-old male patient, admitted to the facility on 4/4/2023, with diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), bipolar disorder (a mental illness that causes unusual shifts in a person’s mood, energy, activity levels, and concentration), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), hyperlipidemia (an elevated level of lipids), anemia (a condition in which the body does not have enough healthy red blood cells), gastro-esophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus), atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries), history of transient ischemic attack (TIA- a temporary disruption in the blood supply to part of the brain) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it) without residual deficits. A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 4/11/2023, indicated the cognitive (the ability to think and process information), skills for daily decisions making was severely impaired and required limited assistance of one-person physical assist for activities of daily living (ADL). The MDS indicated Resident 1 did not have pulmonary (pertaining to the lungs) concerns and did not have shortness of breath. A review of Resident 1’s “History and Physical” (H&P), dated 4/5/2023, indicated, Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s vital signs from 4/10/2023 to 4/21/2023 indicated the following: 4/10/2023 at 08:41 a.m., BP was 118/64 mmHg. 4/11/2023 at 08:35 a.m., BP was 122/68 mmHg. 4/12/2023 at 09:02 a.m., BP was 120/74 mmHg. 4/13/2023 at 08:52 a.m., BP was 148/86 mmHg. 4/14/2023 at 08:38 a.m., BP was 138/82 mmHg. 4/15/2023 at 10:32 a.m., BP was 130/76 mmHg. 4/16/2023 at10:49 a.m., BP was 134/70 mmHg. 4/17/2023 at 08:30 a.m., BP was 128/78 mmHg. 4/18/2023 at 08:33 a.m., BP was 104/56 mmHg. 4/19/2023 at 10:42 a.m., BP was 106/58 mmHg. 4/20/2023 at 0846 a.m., BP was 118/72 mmHg. 4/21/2023 at 10:59 a.m., BP was 124/72 mmHg. A review of Resident 1’s COC form dated 4/22/2023, indicated that on 4/22/2023, at 08:30 a.m., Resident 1’s BP was 96/42 mmHg, Pulse was 117 bpm, Respiratory rate of 16 and the O2 sat was 90% at room air. Resident 1’s lower extremities were elevated and two (2) liters per minute (lpm) of oxygen was administered via nasal cannula (a device used to deliver supplemental oxygen into the nose). The COC form indicated on 4/22/2023 at 12:00 p.m., Resident 1’s BP was 102/52, Pulse 124 bpm and oxygen saturation was fluctuating between 78 to 85% on five (5) lpm via nasal cannula and head of the bed (HOB) was elevated. The COC form indicated Resident 1 was difficult to arouse and was only responsive to painful stimuli, 911 was called and Resident 1 was transferred to GACH at 12:33 p.m. The physician and family were made aware. A review of Resident 1’s Nurses Notes (NN), dated 4/22/2023, at 2:28 p.m., indicated that Licensed Vocational Nurse (LVN) 2 documented Resident 1 was in bed, respirations labored, vital signs were assessed and stable, but Resident 1 was unarousable. LVN 2 raised Resident 1’s head of bed and continued to monitor Resident 1. The NN indicated O2 sat decreased to 85% and was still unable to arouse Resident 1. Physician 1 was notified and 911 was called. During a concurrent interview and record review on 7/28/2023, at 9:57 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1’s COC form dated 4/22/2023, and Resident 1’s Nurses Note dated 4/22/2023, at 14:28 p.m. were reviewed. LVN 2 stated on 4/22/2023, at 8:30 a.m., Resident 1’s vital signs were BP 96/42 mmHg, and O2 sat was 90%. LVN 2 stated she elevated Resident 1’s feet and gave him two (2) lpm of oxygen. Then she (LVN 2) notified Resident 1’s physician (Physician 1) by sending Physician 1 a text message about Resident 1’s low blood pressure and low oxygen saturation. LVN 2 stated she did not get a response from Physician 1 and continued to monitor Resident 1 every 15 minutes, but the blood pressure and oxygen saturation did not go up until 10:30 a.m. LVN 2 stated Resident 1’s blood pressure went up to 106/56 mmHg, O2 sat of 98% on 2 liters oxygen via nasal cannula. LVN 2 stated she did not document Resident 1’s monitoring for vital signs. LVN 2 stated she waited for Physician 1 to call back to get an order to transfer Resident 1 to the hospital by regular ambulance and not by 911. LVN 2 stated on 4/22/2023, at 12:00 p.m., Resident 1 became unresponsive, O2 saturation dropped between 78% to 85% on five (5) liters of oxygen. LVN 2 stated she called 911 at 12:00 p.m. when Resident 2 became unresponsive. During an interview on 8/9/2023, at 1:30 p.m., with LVN 2 regarding the incident on 4/22/2023, LVN 2 stated she was not sure what to do if a physician does not call back. LVN 2 stated there was no protocol or policy when to call 911. She (LVN 2) and Registered Nurse Supervisor (RN 1-Resident 1’s primary nurse on 4/22/2023) would use a nursing assessment to make the decision when to call 911. LVN 2 stated she was not aware she should call the medical director and did not know who the on-call physician was. During an interview on 8/10/2023, at 10:30 a.m., with RN 1, RN 1 stated she could not remember the incident on 4/22/2023, about Resident 1, and was unable to recall what interventions were done when Resident 1 had a COC. RN 1 was unable to say if any nurses were able to speak to the primary physician when Resident 1 was having a COC. RN 1 stated that if she was informed about Resident 1’s COC, she should have called the primary physician. If unable to reach the primary physician, she would call the house doctor (medical director). RN 1 stated if Resident 1 was unresponsive she would have called 911 immediately and then inform the physician. During an interview on 8/9/2023, at 12:01 p.m., with the Director of Nursing (DON), the DON stated that if the physician does not respond when nurses had tried to reach Physician 1, the nurses should have called the medical director. The DON stated the nurses should know when to check the resident and when to call 911. The nurses do not have to wait for the physician to call and should have called 911 right away when Resident 1 had a COC. The DON stated the COC and monitoring should have been documented. During an interview on 8/9/2023, at 4:05 p.m. with the Administrator (ADM), the ADM stated there was a policy for emergency physician care, if the nurse cannot reach the physician, the nurses should call medical director and 911. The ADM stated if a resident had a change in condition, it should be documented in the COC form. During an interview on 8/10/2023, at 12:25 p.m., Physician 1 stated if he was not available, the nurses should have called 911 when there was a medical emergency. Physician 1 also stated the nurses should have not waited to send Resident 1 to the hospital. A review of Resident 1’s GACH record indicated Resident 1 was seen on 4/22/2023, at 12:56 p.m., in the Emergency Department (ED), Resident 1’s O2 sat was 93%, pulse 108 bpm, no BP was recorded, respiratory rate 40 breaths per minute. The GACH record indicated Resident 1’s general condition indicated moderate distress, on a nonrebreather mask (a non-invasive oxygen supplementation device that is used to provide continuous oxygen flow) and was not alert. The ED notes indicated Resident 1 had dried blood in his mouth, mildly tachycardic (elevated heart rate) with hypotension (low BP), was hypoxic and has altered mental status. Resident 1 was started on 30 cubic centimeter per kilogram (cc/kg) of intravenous (IV, within a vein) fluids to treat dehydration (caused by not drinking enough fluid or by losing more fluid than you take in) and electrolyte imbalances (occurs when you have too much or not enough of certain minerals in your body). A review of Resident 1’s CT scan of the chest, dated 4/22/2023, taken 6:44 p.m., indicated a significant mucous plugging. Findings could represent pneumonia and or aspiration pneumonitis (a general term that refers to inflammation of lung tissue), left atelectasis (a condition where lungs collapse partially or completely,) …and left pleural effusion (the build-up of excess fluid between the layers of the pleura outside the lungs). A review of Resident 1’s GACH Discharge Summary dated 5/2/2023, indicated Resident 1 was admitted to the GACH on 4/22/2023. Resident 1’s Chest Computed tomography (CT- a test used to enhance certain anatomic views) noted bilateral pneumonia and mucous plugging. Resident 1 was admitted for treatment of respiratory failure due to pneumonia likely aspiration, severe dehydration, acute kidney injury (a condition when an abrupt reduction in kidneys’ ability to filter waste products occurs within a few hours or a few days) and hypernatremia (having too much sodium in the blood, a mineral that helps regulate fluid balance and nerve signals in the body). Resident 1 was started on antibiotics and had remained encephalopathic (altered mental state). The GACH record indicated Resident 1 was placed on GIP (general inpatient) hospice care. A review of the facility’s policy and procedures (P&P) titled, “Emergency Physician Care” dated 4/2016, indicated, “Emergency physician care is available to all residents when their attending physician are unavailable. Should the resident’s attending physician be unavailable, the nurse supervisor/charge nurse must first attempt to contact the physician’s designated referral physician or practitioner. Should the designated referral physician be unavailable to assist in the emergency, the on-call physician or medical director shall be contacted. A review of the facility’s P&P titled “Change in a Resident’s Condition or Status” dated 2/2021, indicated the facility will promptly notify the resident, his or her attending physician, and the representative of changes in the resident’s medical/mental condition and/or status. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR ([situation-background-assessment-recommendation]-a form of communication between members of the health care team). A review of the facility’s P&P titled “Acute Condition Changes – Clinical Protocol”, dated 3/2018, indicated the nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a response (within approximately one-half hour or less). The facility failed to: 1. Immediately inform and consult the primary physician when Resident 1 experienced a significant COC. 2. Follow its policy and procedures, “Emergency Physician Care”, to contact the on-call physician or Medical Director when one of the three sampled residents, Resident 1’s primary physician did not respond to the nurse or was not available to report a change in condition. These 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.