Other·February 2, 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 resident’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...

F842 Patient Records ? Identifiable Information §483.20(f)(5) Resident-identifiable information. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each patient that are— (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(5) The medical record must contain— (i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (v) Physician, nurse, and other licensed professionals progress notes; On 12/15/2023, at 5 PM, an unannounced visit was made, to conduct the facility’s Annual Health Recertification Survey. During the survey, the California Department of Public Health (CDPH) conducted a closed record review regarding the quality of life and death of a patient (Patient 1). As a result of the investigation, CDPH determined that the facility 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), and call 911 emergency services for Patient 1, who had a full code status (the patient or his/her representative wished for all lifesaving procedures to be provided to keep the patient alive) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 started CPR on 10/29/2023 at "around" 11 AM when LVN 1 found Patient 1 unresponsive, in accordance with the facility's policies titled, "Physician Orders For Life Sustaining Treatment (POLST, a written medical order that indicated a patient/patient lifesaving treatment wishes)," "Medical Emergencies- Code Blue (an announcement used to indicate a patient/patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a cardiac arrest [the heart stopped beathing/pumping blood) or respiratory arrest [the lungs stopped working/breathing])," and "Emergency Care - General." 2. Ensure Registered Nurse (RN) 1 started CPR immediately, provided full CPR with rescue breathing, and sent LVN 1 to call 911 after RN 1 entered Patient 1's room on 10/29/2023 at 11:02 AM, and found Patient 1 unresponsive, in accordance with the facility's policies titled, "Physician Orders For Life Sustaining Treatment," "Medical Emergencies- Code Blue," and "Emergency Care - General." As a result, on 10/29/2023, Patient 1 did not receive immediate and full CPR with rescue breathing in accordance with Patient 1's POLST indicating the patient wishes to be resuscitated. Patient 1’s medical records indicated RN 1 “pronounced [Patient 1] expired (dead)” on 10/29/2023 at 11:02 AM and informed Patient 1's attending physician (Physician 1) on 10/29/2023 at 11:06 AM that Patient 1 had expired. A review of Patient 1's Face Sheet (admission record) indicated the facility admitted Patient 1, a 77 year old female patient, on 9/24/2014, with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one side of the body) with an onset date of 9/24/2014, hemiparesis (one-sided muscle weakness) following a cerebral infarction (a type of stroke that occurs, when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) affected the left non-dominant side with an onset date of 9/24/2014, and cancer (a group of more than 100 diseases characterized by the uncontrolled growth of abnormal cells in the body) of the left breast with an onset date of 9/24/2014. A review of a document titled, "Family Medicine Office/Clinic Note," dated 8/10/2023, indicated Patient 1 was alert and oriented to self, time, place, and situation. The note indicated Patient 1 was able to make daily decisions. The Note indicated Patient 1 was "doing well." A review of Patient 1's POLST dated 8/10/2023, and signed by Patient 1, indicated under "Cardiopulmonary Resuscitation (If patient has no pulse and not breathing," showed a handwritten check mark on "Attempt/Resuscitation/CPR." The POLST indicated under "Medical Interventions" showed a check mark on "Full Treatment (primary goal of prolonging life by all medically effective means)." A review of Patient 1's Progress Notes dated 10/29/2023 timed at 12:53 PM, authored by RN 1 indicated the following events: - At 7 AM, Patient 1 was "alert and able to make needs known." The progress note indicated "The resident's RR (respiratory rate) was even and unlabored (produced without difficulty or exertion). No SOB (shortness of breath) noted at this time. The patient denied pain. There is no distress noted at this time. The patient is resting comfortably in bed. The resident's VS (vital signs): 98/60 (blood pressure), 61 (pulse rate), 97.8 (temperature), 19 (respiratory rate), PS (pain status): 0/10 (0 equal no pain, 10 equal the worst pain). The resident's oxygen saturation (oxygen level in the blood; 95% to 100% are generally considered normal) was 96%." - At 9 AM, Patient 1 was "alert and able to make needs known". The note indicated "There is no distress noted at this time." - At 10 AM, "Patient 1 was "alert and able to make needs known. The resident's RR was even and unlabored. No SOB noted at this time." The note indicated "the patient is resting comfortably on the bed at this time." - At 11:02 AM, Patient 1 "was noted to look pale. The RN could not detect the resident's pulse and blood pressure. The RN pronounced the patient expired at 11:02 AM." - At 11:06 AM, RN 1 "notified the resident's primary doctor." The note indicated RN 1 received new order "to endorse the resident's body to the mortuary service (as) requested by the family." During an interview with RN 1 and a concurrent review of Patient 1's Progress Notes dated 10/29/2023, timed at 11:02 AM, on 12/17/2023, at 2:49 PM, RN 1 stated on 10/29/2023, when RN 1 entered Patient 1's room, RN 1 checked Patient 1's pulse and blood pressure. RN 1 stated Patient 1 had "no vital signs" on 10/29/2023 (at 11:02 AM). RN 1 stated Patient 1 looked pale, not responsive, but Patient 1's body was warm to touch. RN 1 stated RN 1 attempted CPR but RN 1 did not call 911 because Patient 1 had "expired." RN 1 stated when the vital signs were not detected in a patient (in general), RN 1 would not call 911. RN 1 stated RN 1 attempted to perform CPR on Patient 1, but he did not document that he attempted the CPR on Patient 1 in Patient 1's Nurses Notes. During a continued interview with RN 1 on 12/17/2023 at 3:03 PM, RN 1 stated that on 10/29/2023 (11:02 AM), RN 1 was alone when RN 1 went into Patient 1's room. RN 1 stated RN 1 did not see Patient 1's chest rise, and Patient 1 looked pale. RN 1 stated he tried to get Patient 1's vital signs, on 10/29/2023 but RN 1 could not get any vital signs. RN 1 stated he left Patient 1's room to check on Patient 1's POLST and immediately went back to Patient 1's room and started to perform CPR by himself. RN 1 stated at the time, Patient 1's skin color looked gray. RN 1 stated, he performed chest compressions for five minutes. RN 1 stated "There was no pulse or vitals; the patient's (Patient 1) vital signs were gone." During a telephone interview with LVN 1 on 12/17/2023 at 3:05 PM, LVN 1 stated on 10/29/2023 (did not remember exact time) about 30 minutes prior to finding Patient 1 unresponsive, Patient 1 was alert and awake. LVN 1 stated LVN 1 found Patient 1 unresponsive and LVN 1 notified RN 1. LVN 1 stated they (RN 1 and LVN 1) assessed Patient 1 and the patient had "no pulse, no blood pressure, nothing." LVN 1 stated Patient 1 was a full code, and they (RN 1 and LVN 1) did not perform CPR on Patient 1. LVN 1 stated LVN 1 did not see RN 1 perform CPR on Patient 1 and they (LVN 1 and RN 1) did not call 911. LVN 1 did not give an answer when asked why LVN 1 did not perform CPR for Patient 1, knowing Patient 1 was a full code. During an interview with the DON on 12/17/2023, at 3:07 PM, the DON stated when a patient is a full code status, facility staff (in general) are supposed to "attempt CPR," and "call 911." The DON stated it was important to call 911 so that the paramedics (medical professionals who specializes in emergency treatment) may be able to revive Patient 1. The DON stated, "Full code means you call 911 and at least you try to save the patient (resident)." During another interview with RN 1 on 12/17/2023 at 3:28 PM, RN 1 stated on 10/29/2023 (did not state the time) before RN 1 attempted CPR on Patient 1, RN 1 called "a code blue but there was nobody (no staff available)." RN 1 stated LVN 1 was in Patient 1's room and helped RN 1 with "putting the papers." RN 1 stated "LVN 1 helped immediately," but RN 1 could not recall exactly what LVN 1 did during that time. RN 1 stated after 5 minutes of performing CPR on Patient 1, RN 1 notified Physician 1 that Patient 1 had expired. During an interview with Certified Nursing Assistant (CNA) 1 on 12/17/2023 at 3:28 PM, CNA 1 stated she was assigned to Patient 1 and was on lunch break on 10/29/2023 (did not remember the time) when RN 1 found Patient 1 unresponsive. CNA 1 stated when she returned from lunch break, Patient 1 had already expired. CNA 1 stated she did not recall any code blue being called on 10/29/2023. During a telephone interview with CNA 2 on 12/17/2023 at 4:22 PM, CNA 2 stated she worked on 10/29/2023 (with CNA 1) during the 7 AM to 3 PM shift. CNA 2 recalled that on 10/29/2023 (did not remember exact time), during the morning shift, Patient 1 was alert and awake. CNA 2 stated on 10/29/2023, none of the facility's staff called a "Code Blue." During a telephone interview with Patient 1's family member (Family) 1 on 12/17/2023 at 4:25 PM, Family 1 stated Patient 1 changed Patient 1's POLST "around a month" before Patient 1 passed away to a Full Code status. Family 1 stated Patient 1 wished to receive full medical treatment including CPR. During a concurrent review of Patient 1's Progress Notes, dated 10/29/2023, timed 11:02 AM, and interview with the DON on 12/17/2023 at 5:03 PM, the DON stated a physician (in general) needed to pronounce Patient 1 expired and not RN 1. The DON stated RN 1 should have called 911 and 911 paramedics would be responsible for determining and pronouncing Patient 1 expired. The DON stated the paramedics needed to check if there was no more life or if they (the paramedics) can provide Advance Life Support (ALS, referred to as Advanced Cardiac Life Support [ACLS], was a set of life-saving protocols and skills that extend beyond BLS) to revive Patient 1, especially Patient 1 had a full code status. During another interview with RN 1 on 12/17/2023 at 5:12 PM, RN 1 stated "he needed to call 911 and perform CPR until the physician (in general) pronounce the resident's death." RN 1 stated he could not recall how many chest compressions he performed, and RN 1 stated he did not use a bag valve mask (a device used to provide respiratory support to patients) to provide rescue breathing to Patient 1, RN 1 stated "I just try to pump her heart." During a telephone interview on 12/18/2023 at 5:24 PM with Physician 1, who was also the facility's Medical Director, stated that the expectation for the licensed nurses during emergency situations was to perform CPR for full code patients and someone is delegated to call the attending physician or 911. Physician 1 stated it was acceptable for licensed nurses to call 911 first before calling the physician if the patient was not breathing. Physician 1 stated "they (licensed nurses) do have the ability to call 911 ... for a full code patient." During a concurrent interview and record review on 12/17/2023 at 6:01 PM of the facility's policy and procedure titled, "Emergency Care," dated 8/1/2014 (the current policy and procedure provided by the facility), the DON stated the policy indicated for staff to immediately call 911 for medical emergency assistance during an emergency. The DON stated 911 emergency services needed to be called when Patient 1 was not breathing, pulseless, and/or unresponsive, to get help from the paramedics and preserve Patient 1's life. A review of Patient 1’s Certificate of Death timestamped 1/18/2024, indicated Patient 1’s date of death was on 10/29/2023. The Certificate of Death indicated Patient 1’s immediate cause of death (final disease or condition resulting in death) was cardiac arrest (an electrical problem that occurs when the heart malfunctions and suddenly stops beating. This can cause a person to collapse and lose consciousness. Immediate CPR and defibrillation [the use of an electrical current to help your heart return to a normal rhythm for a potentially fat