Health inspection·June 18, 2024

F678 Cardio?Pulmonary Resuscitation (CPR) §483.24(a)(3) Personnel provide basic life support, including CPR, to a patient requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the patient’s advance directives.

F684 Quality of Care § 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...

F695 Respiratory care, including tracheostomy care and tracheal suctioning. § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a patient 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 patients' goals and preferences, and 483.65 of this subpart. As a result of the investigation, CDPH determined that the facility failed to assess, implement interventions, and services for Patient 1, who had diagnoses of respiratory failure (failure of the lungs to meet the body’s oxygen demand) with hypoxia (condition in which tissues of the body are starved of oxygen), pneumonia (lung inflammation) and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and was receiving continuous oxygen therapy. The facility also failed to provide immediate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing) when assistance arrived before finding out the code status (a patient's record that describes the type of life saving procedures (if any) the patient or their representative would the health care team to conduct if your heart stopped beating and/or stopped breathing to keep him/her alive) of Patient 1 who had a full code status (code indicating to provide CPR) in accordance with the professional standard of practice, patient’s care plan and the facility's policy and procedure by failing to: 1. Monitor and conduct respiratory assessment for complications associated with the use of oxygen such as hypoxia and notify the primary physician (Physician 1). On 4/18/2024 at 5:30 AM, Patient 1 verbalized not feeling well and asked the Licensed Vocational Nurse (LVN) 1 for assistance to replace her oxygen tank because she, "felt it was empty." 2. Assess and evaluate if Patient 1 was receiving adequate oxygen or there was a need to obtain a physician's order for oxygen therapy from the date of admission to the facility on 4/14/2024. 3. Develop and implement a patient- centered care plan (a formal process that correctly identifies existing needs and recognizes patient's potential needs or risks) to address and identify interventions based upon the patient's assessment and clinical diagnosis, physician’s orders, for Patient 1 with history of respiratory distress (a serious lung condition that causes low blood oxygen), hypoxia and the need for oxygen therapy, as indicated in the facility's policy and procedures on "Oxygen Administration" and "Comprehensive Care Plans." 4. Notify the physician of any changes in the patient's respiratory condition, including changes in vital signs (blood pressure, temperature, pulse, heart rate), oxygen saturation, hypoxia, and evidence of complications associated with the use of oxygen, in accordance with the facility's policy and procedures titled "Oxygen Administration.” On 4/18/24, Patient 1 reported to LVN 1 that she was not feeling well and asked LVN 1 to check her oxygen tank because she believed the oxygen tank was empty. 5. Ensure Patient 1's Advance Directives (document signed by the patient or representative indicating the care treatments that the patient wished in an event of emergency) and/or POLST (a Portable Orders for Life Sustaining Treatment a record signed by the patient/representative and the physician which indicate the patient's medical treatment wishes so that emergency personnel know what treatments the patient desires during medical emergency) and/or code status were known to the facility staff and always available to the staff for review in an event the patient was not breathing and/or had no pulse or heart rate. 6. Ensure Licensed Vocational Nurse (LVN 1) immediately initiated CPR to when LVN 1 found Patient 1 unresponsive, without pulse and not breathing in accordance with the facility’s policy and procedure titled “Medical Emergency Response and “Cardiopulmonary Resuscitation (CPR).” Additionally, Certified Nurse Assistant (CNA) 1 arrived to assist with CPR. LVN 1 instructed CNA 1 to wait and proceeded to check the code status of Patient 1 rather than initiating CPR. 7. Ensure Patient 1's Advance Directive and or POLST and/or code status was known to the facility staff and available to the staff for review in an event of a code. These failures resulted in the delay in assessment, care, and physician notification of Patient 1’s respiratory condition when the patient verbalized her concern to LVN 1 that the patient felt her oxygen tank was empty and was not feeling well, on 4/18/2024 around 5:30 AM. CPR was not initiated immediately, for Patient 1 who was a full code. Patient 1 was transferred to the General Acute Care Hospital (GACH) 1 Emergency Department (ED) on 4/18/2024, after being found unresponsive, without pulse and not breathing. The GACH ED Report indicated 911 was called by the facility at approximately 5:52 AM on 4/18/24 and Patient 1 expired at the GACH on 4/18/2024 at 6:50 AM and was diagnosed with cardiac arrest. A review of GACH Pulmonology Progress Notes dated 4/6/2024 timed at 12:14 PM, indicated Patient 1 was previously admitted to GACH on 3/27/24, with diagnoses including systolic heart failure (occurs when the heart's left ventricle [one of the four chambers of the heart that pumps blood full of oxygen out to the body] causing the heart to be weak and cannot contract (squeeze) normally to deliver blood to the rest of the body), severe aortic stenosis (a narrowing of the aortic valve (valve in the large artery in the heart that restricts blood flow from the left ventricle to the aorta, end stage renal disease (final, permanent stage of kidney disease) on dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), dyspnea (shortness of breath), and hypoxia. The GACH Pulmonology Progress Notes indicated Patient 1 felt weak and tired and was receiving 4 liters of oxygen via nasal cannula. The progress note indicated Patient 1’s chest x-ray results indicated small bilateral pleural effusions (buildup of excess fluid between the layers of the pleura [part of the respiratory tract that cushions the lung and reduces any friction that may develop between the lung, rib cage, chest cavity] outside the lungs). A review of GACH Cardiology Progress Notes, dated 4/7/2024 timed at 8:21 AM, indicated Patient 1 was receiving 4 liters per minute of oxygen therapy and Patient 1 reported her breathing was stable at this level of oxygen. A review of Patient 1’s Admission Record indicated the facility originally admitted the patient on 1/8/2024, and was readmitted back to the facility on 4/14/2024, with diagnoses that included acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and COPD. A review of Patient 1's Clinical Admission record, dated 4/14/2024 timed at 3:18 PM, indicated Patient 1 was receiving oxygen at 3 liters per minute. The Clinical Admission indicated Patient 1's pulse oximetry (pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen [measures the percentage of oxygen in the blood] in a person's blood) reading during admission to the facility was at 95% (normal range at 90-100%) using oxygen administered via nasal cannula (a long plastic hose used to deliver oxygen into the nares). The Clinical Admission indicated Patient 1's discharge goal was to return home. A review of Patient 1's Medication Administration from 4/1/24 to 4/30/2024 indicated an order to administer Ipratropium-albuterol (made up of two different bronchodilators (a drug that relaxes and opens the airways, used to treat COPD) inhalation solution 0.5 - 2.5 milligrams (mg) / 3 milliliters (ml). Inhale 3 ml orally, every 6 hours as needed for shortness of breath. The MAR indicated "X" marks from 4/14/24 to 4/18/24, indicating no inhalation solution was administered to Patient 1. A review of the POLST signed by Patient 1 on 4/14/2024, indicated Patient 1 requested if found without pulse and/or not breathing, under "Cardiopulmonary Resuscitation indicated to "Attempt/Resuscitation/CPR." The POLST indicated under "Medical Interventions" the facility was to provide "Full Treatment (primary goal of prolonging life by all medically effective means)." A review of Patient 1's History and Physical (H&P) dated 4/15/2024, indicated the patient had the capacity to understand and make decisions. The H&P indicated one of Patient 1's diagnosis included "Pneumonia (severe lung infection) treated." A review of Patient 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of 4/17/2024, indicated the patient had moderate cognitive (thought process) impairment. The MDS indicated Patient 1 required partial/moderate assistance (helper does less than half the effort) in walking up to 10 feet and was not attempted to be assessed if she could walk 50 feet or more. The MDS indicated Patient 1 required supervision (helper provides verbal cues) on task such as oral hygiene, upper body dressing, sit to stand and bed mobility. The MDS indicated Patient 1 required partial/moderate assistance with toileting, shower, and lower body dressing. A review of Patient 1’s physician’s order, dated 4/17/2024 (three days after date of admission) authored by LVN 2, indicated to administer oxygen via NC at 3 liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 92% every shift for shortness of breath. A review of Patient 1's care plan dated 4/17/24, indicated the patient had pneumonia. The care plan interventions included to auscultate (listening to the sounds of the body during a physical examination) lung sounds, listen for crackles and diminished breath sounds due to atelectasis (the collapse of part or all of a lung, which is caused by a blockage of the air passages). During the review of Patient 1's Progress Notes dated 4/18/2024 timed at 5:30 AM, authored by Licensed Vocational Nurse (LVN) 1 indicated Patient 1 approached LVN 1 at the Nursing Station asking for another oxygen tank. The Progress Notes indicated LVN 1 advised Patient 1 that she still has "half a tank (oxygen) left" in the tank and will change (the oxygen tank) when it was "lower." The Progress Notes indicated Patient 1 "understood and just waited outside Nursing Station until staff finished with rounds." During the same review of Patient 1's Progress Notes dated 4/18/2024 timed at 5:30 AM, the Notes indicated "Noted Patient 1's oxygen tank outside Nursing Station." The Progress Notes indicated LVN 1 went inside Patient 1's room to ask if Patient 1 still wanted her oxygen tank. The Progress Notes indicated Patient 1 was found "unresponsive in bed with eyes slightly open, no pulse, no rise of chest (an indication that the patient was not breathing). [Patient 1] was still warm, blood sugar 301, unable to get blood pressure." The Progress Notes indicated "911 [paramedics] was called while staff (unknown) did CPR" The Progress Notes indicated Patient 1 was transferred to the GACH on 4/18/2024 at 6:25 AM, and family and Physician 1 was notified on 4/18/2024 at 6:42 AM. A review of Patient 1's Change of Condition (COC) note dated 4/18/2024 timed at 6:23 AM, indicated "Found [Patient 1] unresponsive lying in bed with eyes slightly open. Called Code Blue (code to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest) and started CPR. 911 was called and noted patient (Patient 1) was full code, did CPR for 10 minutes before paramedics arrived and took over patient care. No pulse, after 25 minutes of CPR patient was transferred to GACH." The COC indicated Physician 1 was notified on 4/18/2024 at 6:42 AM and with the vital signs (measurement of the heart rate, breathing and blood pressure) as follows: a. Blood pressure- 00/00 (no blood pressure) (normal ranges between 120/80 to 100/60) b. Respirations- 0 (no breathing) (number of breaths per minute normal range is between 12 to 20) c. Pulse-0 (no pulse) (heart rate per minute, normal range is 60 to 100) d. Apical pulse 0 (a pulse point on your chest at the bottom tip (apex) of your heart often heard using a stethoscope [medical instrument for listening to the action of someone's heart or breathing]) e. Temperature-97.5 F (Fahrenheit, a unit of measuring temperature [normal range 97 F to 99 F]) f. Oxygen Saturation 65% (critically low oxygen level in the blood-normal range 90-100%) g. Blood sugar- 301 mg/dL (high level-milligrams per deciliter- normal range 70-100 mg/dL) A review of Patient 1's Emergency Department (ED) Report from GACH, dated 4/18/2024, indicated the paramedics was called by the facility staff on 4/18/2024 at approximately 5:52 AM. The report indicated Patient 1 died on 4/18/2024 at 6:50 AM. A review of Patient 1's GACH Emergency Department Reports dated 4/18/2024 timed at 7:14 PM, indicated Patient 1 was brought in ED by ambulance from the facility where Patient 1 was found pulseless and not responsive. The GACH ED report indicated the paramedics were called by the facility at approximately on 4/18/2024 at 5:52 AM and Patient 1 was last seen in her usual state of health 10 minutes prior. The GACH ED repo