Health inspection·April 30, 2021

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40.

F726 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. § 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 (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (B) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (D) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. On 1/21/2021, the Department received a complaint alleging a 67-year-old male resident (Resident 2) died at the hands of the facility. The complaint alleged an increase of COVID-19 deaths in the facility. On 1/21/2021, an unannounced investigation was conducted at the facility. The facility failed to: 1. Implement interventions to prevent the decline of residents who were confirmed with COVID-19 (a highly contagious virus that causes severe respiratory illness affecting the lungs and airways) in accordance with the facility’s policies and procedures for monitoring COVID-19 residents. 2. Follow the physician orders and transfer Resident 2 to the general acute care hospital (GACH), on 1/19/2020, after the resident had a Change of Condition (COC), and complained about being short of breath ([SOB]-difficulty breathing) and his oxygen saturations (amount of oxygen in the blood) declined. 3. Follow physician’s orders and COVID- 19 care plans to monitor vital signs every four (4) hours for COVID-19 as indicated by the physician. As a result, there was a delay in care and treatment and Resident 2 was found unresponsive one (1) hour after complaining of SOB on 1/19/2021 and was pronounced deceased on 1/19/2021 at 10:30 a.m. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on 11/26/04 and last readmitted on 10/28/2020. Resident 2's diagnoses included dementia (group of conditions characterized memory loss, forgetfulness, limited social skills, and thinking abilities that interferes with daily functioning) atrial fibrillation (irregular, rapid heart rate commonly causing poor blood flow) and acute kidney failure (condition in which the kidneys [two bean-shaped organs located below the rib cage, one on each side of the spine] suddenly can't filter waste from the blood). During a review of Resident 2's Physician Orders for Life Sustaining Treatment POLST, dated 8/26/16 indicated under the area of Cardiopulmonary Resuscitation (CPR), Resident 2 was the receive full treatment with the primary goal of prolonging life by all medically effective needs and long term artificial nutrition, including feeding tubes. During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/2/2020, the MDS indicated Resident 2 was able to make himself understood and understand others. The MDS indicated Resident 2 was totally dependent on a one-person physical assist for bed mobility, transferring and personal hygiene. There was no indication that Resident 2 was on hospice. During a review of Resident 2's Order Summary Report (resident’s medication sheet of all medications), the report indicated an order on 11/20/2020 to monitor for symptoms and signs of COVID-19 every four (4) hours and document temperatures above 99.6 degrees Fahrenheit ([F] unit of measurement [normal reference range] NRR- 98.6 F to 99 F), respiratory rate (breaths per minute [bpm] NRR is 12-20), and oxygen saturations (NRR 96-100%). During a review of Resident 2's Order Summary Report, the report indicated an order on 11/20/2020 to monitor for symptoms of COVID-19 such as cough, difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestions or runny nose, diarrhea, nausea and vomiting. If any of the symptoms present, notify physician and document on the nurses notes every shift. During a review of Resident 2's Order Summary Report, the report indicated an order on 10/28/2020 and started on 11/20/2020 for Albuterol Sulfate (medication use for relaxing muscles around the airways and open up the airways to make breathing easier) Nebulization (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) Solution 2.5 milligrams/3 milliliters (a unit of measurement) one unit inhaled orally every four (4) hours as needed for SOB. During a review of Resident 2's Medication Administration Record (MAR) for 1/19/2021, the MAR indicated Resident 2 did not received Albuterol Sulfate when he experienced a COC of SOB on 1/19/2021 at 9:20 a.m. During a review of Resident 2's care plan titled, "COVID-19 Pandemic," dated 7/1/2020, the care plan indicated Resident 2 was at risk for SOB, irregular respiration, cough, activity intolerance, fever, nausea and sore throat. The goal was to keep Resident 2 free of any signs or symptoms of COVID-19. The interventions indicated to apply oxygen as needed and ordered, assess for SOB, medication and breathing treatment as ordered, monitor oxygen saturations and respirations as needed and inform physician promptly. During a review of Resident 2's COC form, dated 1/19/2021and timed at 9:20 a.m., the COC form indicated Resident 2 had decreased oxygen saturation ranging from 85 % to 88% and was placed on three liters ([L] units of measurement) of oxygen via nasal. The COC form indicated the plan of treatment was to monitor Resident 2's vital signs and transfer to the GACH emergency room (ER). The COC form dated 1/19/2021 indicated the following: At 9:20 a.m., Resident 2 complained of SOB, respirations 22 breaths per minute, and a non-breathable (non-rebreather mask is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag filled with a high concentration of oxygen) oxygen mask administered 15 L. At 9:30 a.m., the physician was notified and ordered to transfer Resident 2 to the GACHs ER for evaluation. At 9:40 a.m., Resident 2's oxygen saturation increased at 98-100 %, oxygen decreased to 10 L. At 10 a.m., Registered Nurse 1 (RN 1) informed Resident 2 of Physician’s 1 order to transfer him to the GACH ER for evaluation. At 10:22 a.m., Resident 2 was noted non-responsive, not breathing, and unable to obtained vital signs and paramedics called [sic]. At 10:30 a.m., paramedics pronounced Resident 2 deceased. During an interview on 1/25/2021 at 12:56 p.m., Respiratory Therapist 4 ([RT] specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine) stated he was called to Residents 2's room on 1/19/21 at 9 a.m. RT 4 stated Resident 2 was complaining of SOB and was not able to breathe. RT 4 stated he placed Resident 2 on a non-rebreather mask with 15 L to increase the oxygen saturations from 85% to 100% and gave instructions to LVN 2 to monitor the resident closely due to desaturation (a decrease in oxygen levels in the blood). During an interview on 1/25/2021 at 2:20 p.m., CNA’s 6 and 7 stated on 1/19/2021, at approximately 9 a.m., Resident 2 was complaining of not being able to breathe. CNA 6 stated RN 1 went into the room and was cleaning Resident 2's wound instead of addressing his SOB. CNA 7 stated the facility’s staff did not provide care for the resident and ignored his call for help when Resident 2 was unable to breathe. During a review of Resident 2’s Prehospital Care Report Summary, dated 1/19/2021, the summary indicated paramedics encountered Resident 2 on 1/19/2021 at 10:19 a.m. The report summary indicated Resident 2 was obviously dead, no vital signs appreciated and was seen last one hour prior to calling 911. The report indicated Resident 2 was pronounced deceased at 10:30 a.m., on 1/19/2021. During a review of Resident’s 2 certification of death, the certification indicated Resident 2 died on 1/19/2021 at 11:30 a.m., and the immediate cause of death was respiratory failure (condition in which the blood doesn't have enough oxygen) and chronic renal failure (kidneys [pair of organs found on either side of the spine] are no longer able to filter waste and balance fluids). During an interview on 1/21/2021 at 2 p.m., the DON stated COCs included SOB, high temperature, and respiratory distress. The DON stated residents should have been monitored every hour or every 30 minutes during a COC and until the resident was stable. The DON stated the licensed nurses should monitor and document the resident's condition for 72 hours during the COC period in the progress notes. During an interview and review of Resident 2's COC, MAR’s and facility's policy and procedures (P/P), on 1/25/2021 at 9:41 a.m., RN 1 stated Resident 2's primary physician ordered a transfer to the GACH on 1/19/2021 at 9:30 a.m. for COC evaluation. RN 1 stated SOB was considered a COC requiring an immediate attention. RN 1 stated she did not call for Resident 2's transfer to the GACH ER as ordered by the physician because she was preparing the transferring paperwork first and cleaning Resident 2’s wound to ensure it was cleaned before the arrival of the paramedics. During an interview on 1/25/2021 at 12:42 p.m., Physician 1 stated he was notified on 1/19/2021 of Resident 2's SOB. Physician 1 stated he gave an order to transfer the resident to the GACH ER for further evaluation. Physician 1 stated the facility's licensed nurses were aware to transfer residents to the GACH via 911 (emergency services) when there was a critical COC, such as the one Resident 2 experienced. During an interview and review of the facility's P/P for COC, on 1/25/2021 at 1:20 p.m., the DON stated based on the facility's P/P, COCs such as low oxygen, SOB, and unresponsiveness should be handled promptly. The DON stated RN 1 did not follow the facility's P/P and the physician orders to transfer Resident 2 to the GACH for evaluation. During an interview on 1/25/2021, at 3:15 p.m., LVN 2 stated Resident 2's oxygen level was low, and the resident stated he could not breathe. LVN 2 stated RT 4 provided Resident 2 with oxygen and RN 1 notified the physician. LVN 2 stated she did not document the monitoring conducted for Resident 2's COC. LVN 2 stated RN 1 waited to transfer Resident 2, but she was not sure why. LVN 2 stated Resident 2 was pale and stiff when the paramedics arrived at the facility. LVN 2 stated prior to the resident dying, RN 1 clean Resident's 2 wounds and changed his bandage instead of taking care of the resident's SOB. During an interview on 1/26/2021 at 6:30 a.m. LVN 2 stated CNAs 6 and 7 notified her of Resident 2 complaining of SOB. LVN 2 stated no breathing treatment was administered to Resident 2 as ordered by Physician 1 for SOB. During a review of RN 1's written declaration, dated 1/25/2021 at 10:23 a.m. indicated the paramedics pronounced Resident 2 deceased. RN 1 stated the paramedics did not performed resuscitation measures on Resident 2 because of the assessment that indicated the resident had been dead for over an hour. RN 1’s declaration indicated no CPR was initiated by the paramedics. During a concurrent interview with the Medical Records Director (MRD) and record review of Resident 2’s vital signs, physician orders and MARs, in the presence of the Infection Preventionist Nurse ([IPN] nurse in charge of infection prevention for the facility) on 1/25/2021 at 12:34 p.m., the MRD stated Resident 2’s vital signs were not taken and documented as ordered by the physician every four hours. The IPN and MDR confirmed there was no documentation found in Resident 2’s medical record that the vital signs were taken. During a concurrent interview and record review on 1/25/2021 at 7:00 p.m. with the DON and the facility’s consultant, The Transportation of Patients with a POLST (physician orders for life sustaining treatment) and Comfort Focused Care Directive dated 1/4/21was reviewed. The Transportation of Patients with a POLST and Comfort Focused Care Directive indicated, effective immediately and until further notice, all 911 patients that have a POLST requesting only comfort focused care and whose needs are related to end -of-life care, will not be transported by 911 providers to an acute care facility. The DON stated all residents in the red zone died because of the COVID pandemic. The consultant stated she had in-serviced staff on documentation in the resident's charts, but she stated the residents changed very quickly because of their comorbidities (the simultaneous presence of two or more diseases or medical conditions) and because there was a new strain of COVID-19. The facility's consultant stated for some of the residents' COC, the paramedics were not called due to a letter sent by the Emergency Medical Services Agency indicated no resident at their end-of-life and hospice would be transferred to the GACH. The consultant stated being aware of the letter released in 1/2021, indicated any other residents would be transferred to the GACH. Resident 2 was not on hospic