Health inspection·January 19, 2024

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 patient 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;

F684 § 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,

F806 Patient Allergies, Preferences and Substitutes §483.60(d) Food and drink Each patient receives and the facility provides— §483.60(d)(4) Food that accommodates patient allergies, intolerances, and preferences. On 12/5/2023, at 7:55 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an anonymous complaint allegation regarding the facility’s dietary services and death of a resident. As a result of the investigation, CDPH determined that the facility failed to provide treatments and services for Patient 1, who had a known food allergy to fish, by failing to: 1. Ensure Patient 1 was served food appropriate for Patient 1’s diet and not served fish and fish containing products because of a known fish allergy. Patient 1 was served fish on two occasions, 11/24/2023 (tuna salad sandwich) which was immediately returned to the kitchen as requested by the patient’s responsible party (Family [FM] 1) and 12/1/2023 (lemon ginger fish) which was consumed by the patient, resulting in harm. 2. Ensure Patient 1's food allergy and allergic reaction to fish were transcribed and verified in the resident's Dietary Profile and Meal Ticket, in accordance with the facility's policy and procedure on "Food Allergies and Reference Sheets," and "Diet Record Maintenance" to alert facility staff of the resident's food allergies. 3. Ensure facility staff check Patient 1’s meal tickets for accuracy, and food allergens, prior to serving food to Patient 1, as indicated in the residents' electronic medical records, in accordance with the facility's policy and procedure titled "Diet Record Maintenance." 4. Ensure Patient 1's care plan on food allergy was developed to include the type of allergic reaction manifested by the patient and implemented the care plan on food allergy (fish allergy) to ensure Patient 1 was free from allergic reaction. 5. Ensure Licensed Vocational Nurse (LVN) 3 communicated with the facility's Dietary Department by indicating Patient 1's fish allergy on the Diet Communication Slip upon Patient 1's admission to the facility on 11/20/2023, as indicated in Patient 1's Order Summary Report and in accordance with the facility's policy and procedure titled "Diet Orders." 6. Ensure the facility's Dietary Supervisor (DS) checked Patient 1's Allergy Report found in the resident's electronic records and General Acute Care Hospital (GACH) 1's History and Physical (H&P), during initial patient interviews. In addition, to check accuracy of the Dietary Communication Slip, the resident's Diet Type Report (a list of residents, their corresponding diets and other information such as allergies) and Meal Tickets, in accordance with the Dietary Supervisor's documented "Job Description." 7. Ensure the facility had a system in place for licensed nurses, certified nurse assistants, dietary supervisor, and kitchen staff to implement the facility's policy and procedure titled "Food Allergies and Reference Sheets," to ensure the ingredient list of foods was reviewed, and recipes served to Patient 1, which included fish, was followed to verify that the items and meals prepared was truly allergen free. 8. Ensure the entire care team (interdisciplinary team) was made aware of Patient 1’s food allergies to fish and its reaction, as required by the policies and procedures titled "Food Allergies and Reference Sheets." These deficient practices resulted in Patient 1 having an allergic reaction on 12/1/2023, after eating fish for lunch. Patient 1 had difficulty breathing and was observed with watery eyes and a swollen face. The facility's licensed nurses called 911 emergency medical services (EMS), EMS intubated (healthcare provider inserts a tube through person's mouth or nose down to their airway) Patient 1 and administered three doses of epinephrine (a drug used in emergencies to treat very serious allergic reactions). Patient 1 passed away on 12/1/2023, upon arrival to the General Acute Care Hospital (GACH) 2 Emergency Room (ER) due to anaphylaxis (severe allergic reaction including closure of airways). A review of Patient 1's Admission Record indicated the facility admitted the 67 year old female patient, on 11/20/2023, with diagnoses that included Type 2 diabetes mellitus (DM, a health condition when the body does not use insulin properly causing increase in blood sugar), chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), and essential hypertension (high blood pressure). A review of Patient 1's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated 11/27/2023, indicated the resident's cognition was severely impaired. The MDS indicated Patient 1 needed partial/moderate assistance (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) when eating. A review of Patient 1's physician diet order, dated 11/20/2023, indicated Patient 1's diet was No Added Salt (NAS) consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal), regular texture, thin consistency. A review of Patient 1's Order Summary Report, for December 2023, signed by Physician 1 on 11/21/2023, indicated "Allergies: fish." A review of Patient 1's GACH 1 History and Physical (H&P, details of physician examination of the resident), dated 11/10/2023, indicated that Patient 1's allergic reaction to fish was anaphylactic reaction. A review of Patient 1's Allergy Report printed by the facility with created date 11/20/2023 indicated Patient 1 had a food allergy and the allergy was "Fish." The Allergy Report severity indicated "unknown." The Allergy Report indicated blank on "Reaction Manifestation" and blank on "Reaction Note." A review of a facility document titled "Diet Communication Slip" dated 11/20/2023, and signed by LVN 3, indicated Patient 1's name, room number, regular diet, no concentrated sweets, NAS diet. The "Allergies Section" of the Diet Communication Slip was left blank. A review of Patient 1's care plan indicated that on 11/25/2023, a care plan was developed for Patient 1's food allergy, titled "Patient allergic to fish and at risk for allergic reaction" (4 days after the physician's order summary report indicating the patient was allergic to fish). The care plan indicated a goal for Patient 1 to be free of allergic reaction through the next review date. The care plan interventions included, to list all allergies in the resident's face sheet, have an allergy sticker on the chart, list allergies to medications, and treatment administration sheet. The care plan interventions also included to notify the physician for further change of condition or allergic reaction, and to administer antihistamine (a class of drugs commonly used to treat symptoms of allergies) as ordered. A review of the facility's fall menu spreadsheet dated 12/1/2023, approved by Registered Dietitian (RD) 2 on 8/17/2023 indicated, CCHO, diet included the following food item on the tray: "Lemon ginger fish 3 ounces (oz, a unit of measurement)." A review of the facility's recipe titled "Lemon-Ginger Fish" not dated, indicated "ingredients included: fish fillet, thawed (suggest tilapia, pangasius-swai, cod), ginger, jarred or ginger, ground, melted margarine, lemon juice and salt. A review of a physician's telephone order dated 12/01/2023 timed 12:30 PM, authored by the case manager (CM), indicated an order for Patient 1 to receive Epinephrine Injection kit 1 milligrams (mg/milliliter (ml) (a unit of measurement) inject 1 mg intramuscularly (under the muscle) one time only for anaphylaxis (a severe, potentially life-threatening allergic reaction). A review of Patient 1's progress notes from 11/07/2023 to 12/08/2023, with a note titled "SBAR [Situation, Background, Assessment and Recommendations] Summary for Providers" dated 12/01/2023 signed by Registered Nurse (RN) 1 timed at 12:30 PM indicated, "At 12:15 PM, Certified Nursing Assistant (CNA 1) served lunch plate to Patient 1. Around 12:25 PM, the patient called the CNA and complained of shortness of breath. CNA (CNA 1) called LVN (LVN 2), and he paged Registered Nurse 1 (RN 1) to assess Patient 1 around 12:26 PM. Patient 1 was assessed at 12:28 PM, Patient 1's Oxygen saturation (amount of oxygen circulating in the blood) was at 88% (normal oxygen saturation: 95 to 100%). RN 1 administered oxygen 2 liters via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level) and elevated the resident's head of bed. Oxygen saturation was rechecked, and it was 91%. RN 1 asked Case Manager (CM) to call Patient 1's physician around 12:30 PM. (Physician 1) ordered epinephrine 1 mg via intramuscular (under the muscle) injection and to call 911 emergency service. LVN 1 was delegated to call 911 around 12:31 PM. Around 12:32 PM, epinephrine was administered to left thigh of Patient 1 but no effect. No vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) appreciated (found or noted) around 12:35 PM. CPR (cardiopulmonary resuscitation [an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) initiated and 911 (EMS) came around 12:38 PM and took over to continue CPR and patient was taken to (GACH 2) around 1 PM." A review of Patient 1's Fire Department Patient Care Report, dated 12/1/2023, timed at 1:03 PM, indicated Emergency Medical Services (EMS) was notified at 1:03 PM, EMS was dispatched at 1:04 PM, En route at 1:05 PM, and arrived at the facility at 1:07 PM. The Report indicated under EMS Narrative "Patient 1 was found in bed pulseless (a condition where your heart stops), apneic (a temporary stop of breathing), pupils fixed/dilated (when the black circles in the colored part of the eyes [iris] gets larger, usually caused by brain damage/injury), unresponsive. The Report indicated that upon EMS arrival, they found facility staff performing CPR on Patient 1, for approximately 3 minutes. The Report indicated that according to facility staff, Patient 1 was "Seen approximately 10 minutes before being found in full cardiac arrest, conversing and being alert and oriented times 3 (patient is alert and oriented to person, place and time)." The Report indicated "Per facility staff patient (Patient 1) had eaten lunch, which was a fish meal. Unknown if patient has any allergies to fish..." A review of Patient 1's GACH 2 records dated 12/1/2023 titled "ED Provider Notes" authored by the ED Physician, indicated "(Patient 1) was brought in from the (facility) where the patient was in cardiac arrest, CPR for 18 minutes." The ED Physician wrote that according to the paramedics, 3 (three) epinephrine were given and Patient 1 lost pulses and ED Physician immediately intubated Patient 1. The ED Physician wrote Patient 1 was given another epinephrine and CPR was continued until the ultrasound (an imaging method that uses sound waves to produce images of structures within the body) showed no heart movement at 1:53 PM. At 2:06 PM, Patient 1 was defibrillated (use of electrical current to help a person's heart return to normal rhythm) in the ED and there was no change in heart movement at 2:06 PM. The ED Physician wrote "Diagnosis Death secondary to cardiac arrest with severe metabolic (a condition in which acids build up in the body) and respiratory acidosis (occurs when the blood is too acidic d