Health inspection·November 27, 2024

F695 Respiratory/Tracheostomy care and Suctioning §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident 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 residents’ goals and preferences, and 483.65 of this subpart.

F755 Pharmacy Svcs/Procedures/Pharmacist /Records §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. An unannounced visit was conducted by the California Department of Public Health (CDPH) on 10/17/2024 at 7:30 AM to investigate a complaint received on 10/16/2024 regarding a patient’s death. The facility failed to provide prescribed respiratory care and treatment to Patient 1 who was diagnosed with chronic respiratory failure (a long term condition that makes it difficult to breathe because the lungs cannot exchange air properly), chronic obstructive pulmonary disease (COPD; a common lung disease that makes it hard to breathe) and asthma (a chronic lung disease that causes the airways in the lungs to narrow and swell making it difficult to breathe), and who was on continuous oxygen therapy (treatment that provides oxygen to people who have breathing problems or lung disease). Patient 1 was transferred from the Long-Term Acute Care Hospital (LTACH, a facility that specializes in treating patients who require a longer period of closely monitored healthcare) on 9/26/2024 to the facility. Upon admission to the facility, facility staff failed to: 1. Obtain an order for Patient 1’s continuous oxygen therapy by (via) nasal cannula (NC; a medical device that provides supplemental oxygen to patients through their nose) at five (5) liters per minute (LPM; a unit of measurement for flow rate) in accordance with the LTACH’s transfer packet (document/s that summarizes a patient’s hospital care and provides instructions for their post- hospital care for continuity of care). 2. Obtain an order to administer Patient 1’s bilevel positive airway pressure (BIPAP; a medical device that helps people breathe by delivering pressurized air into the airways) at night and as needed (PRN) in accordance with the LTACH’s transfer packet. 3. Administer Patient 1’s respiratory treatments of albuterol sulfate (medication for breathing) 1.25 milligram (mg, unit of measurement) inhalation via nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) every 6 hours and budesonide (medication for breathing) 0.5 mg inhalation via nebulizer twice a day from 9/26/2024 at 11:17 PM until Patient 1 was found unresponsive on 9/27/2024 before 3:20 PM (approximately 16 hours from admission) in accordance with the LTACH’s transfer packet and as indicated on the physician’s order. 4. Have a system in place to receive medications that have been delivered by the pharmacy to ensure timely administration to the patients and implement that system to ensure timely administration of prescribed medication to Patient 1. 5. Ensure Licensed Vocational Nurse (LVN) 3 followed up with Pharmacy on the delivery of medication and checked the STAT safe (emergency medication kit to secure medication system ensuring that critical medications, including respiratory treatments, were readily available for immediate use) for availability and timely administration of Patient 1’s respiratory medications (albuterol sulfate and budesonide). 6. Train LVN (3) on the necessity and importance of following up with Pharmacy on the delivery of medication and checking the STAT safe for medication availability and timely administration, resulting in a failure to timely provide Patient 1 with prescribed respiratory medications. As a result of these deficient practices, Patient 1 was found unresponsive by facility staff on 9/27/2024 (time not specified). Facility staff started Cardiopulmonary resuscitation (CPR; an emergency procedure that is used to restart a person’s breathing and heartbeat when they’ve stopped) and called 911 for emergency medical care. Paramedics (persons trained to give emergency medical care) arrived at the facility at 3:30 PM, took over administration of CPR to Patient 1, then pronounced Patient 1 dead at 4:28 PM. A review of Patient 1’s LTACH transfer packet dated 9/20/2024, the LTACH transfer packet indicated the following under “Discharge (DC) Plan”: * Oxygen at 5 LPM via NC or oxymizer (a nasal cannula that delivers oxygen during inhalation and exhalation and is designed to increase oxygenation) * BIPAP: 18/8 (BIPAP inspiratory pressure [breathing in air into the lungs] and expiratory [breathing out air from the lungs] pressure setting) FIO2 (fraction [percentage of air the person inhales into the lungs] of inspired oxygen; BIPAP setting) 45%” at night and as needed. A review of Patient 1’s Reconciled and Needing Reconciliation Report from LTACH dated 9/26/2024 at 4:29 PM, the Reconciled and Needing Reconciliation Report indicated Patient 1’s medications included: * Albuterol sulfate, 1.25 mg, inhalation, medical nebulizer (med neb), solution, every 6 hours (q6h) with Patient 1’s last dose being given on 9/26/2024 at 12:38 PM. * Budesonide, 0.5 mg, inhalation, med neb, suspension (susp; a liquid with small pieces of drug), twice a day (bid) with Patient 1’s last dose being on 9/26/2024 at 7:52 AM. A review of Patient 1’s Admission Record, indicated the patient is a 75-year-old female patient who was admitted to the facility on 9/26/2024 with diagnoses of chronic respiratory failure, COPD, asthma, sleep apnea (a common sleep disorder that causes breathing to repeatedly stop or become very shallow during sleep) and shortness of breath (SOB). A review of Patient 1’s Progress Notes, dated 9/26/2024, indicated Patient 1 was admitted to the facility on 9/26/2024 at 11:17 PM. The Progress Notes indicated Patient 1 was receiving oxygen via NC at 2 LPM and the oxygen saturation was at 93% (oxygen saturation is a measurement of the amount of oxygen in a person's blood, which is a key indicator of how well the lungs are working, and a healthy level is between 95 percent [%] and 100%). During further review of Patient 1’s Progress Notes upon the patient’s admission, it did not indicate that any order was placed to administer oxygen to the patient. A review of Patient 1’s Baseline Care Plan Summary dated 9/26/2024, the Baseline Care Plan Summary indicated under therapy and nursing services that Patient 1 needed oxygen. During further review of the Baseline Care Plan Summary did not indicate that Patient 1 received any oxygen therapy. A review of Patient 1’s Physician’s Order, dated 9/27/2024, transcribed at 1:04 AM (approximately 1 hour and 45 minutes from admission) by Registered Nurse 2 (RN 2), indicated an order to give albuterol sulfate 1.25 mg by nebulizer every six (6) hours. A review of Patient 1’s Physician’s Order, dated 9/27/2024, transcribed at 1:27 AM (approximately 2 hours and 10 minutes from admission on 9/26/2024) by RN 2, it indicated an order to give budesonide 0.5 mg orally two times a day (BID). A review of Patient 1’s Pharmacy Fax Form (PFF) dated, 9/27/2024, indicated the facility faxed the following orders to the pharmacy and were concurrently received by the pharmacy on 9/27/2024 at 4:34 AM (Approximately 3 hours after RN 2 transcribed the physician’s orders [9/27/2024 at 1:04 AM]): a. Albuterol 1.25 mg every 6 hours for wheezing (a high-pitched whistling sound that occurs when the airways in the lungs are narrowed or blocked) and SOB. b. Budesonide 0.5 mg BID for wheezing and SOB. A review of the Pharmacy Packing Slip Proof of Delivery (POD), dated 9/27/2024, indicated Patient 1’s medications including albuterol and budesonide were delivered at the facility and received by RN 1 on 9/27/2024 at 10:15 AM. The POD indicated RN 1 signed receipt of the medications from the POD. A review of Patient 1’s Progress Notes dated 9/27/2024 at 3:20 PM entered by LVN 3, indicated LVN 3 was notified by a staff member (unidentified) that Patient 1 was found unresponsive (specific time not indicated), CPR was initiated immediately with backboard (a device that is flat and with firm surface used during CPR to ensure effectivity of CPR) to the patient’s back and 911 was called. The Progress Notes also indicated paramedics arrived at 3:30 PM (on 9/27/2024) and attempted to revive the patient. A review of Patient 1’s Progress Notes dated 9/27/2024 at 5:20 PM entered by the DON, indicated the primary physician (MD) was made aware of the patient’s condition (did not indicate specific condition) and paramedics pronounced Patient 1’s time of death at 4:28 PM (on 9/27/2024). A review of Patient 1's Paramedic Record dated 9/27/2024, indicated when the paramedics arrived on scene (at the facility), Patient 1 was lying supine (lying on the back with face up) in bed and found pulseless and apneic (when one stops breathing). The report also indicated, paramedics immediately began CPR with advanced life support (ALS; a set of life-saving skills and protocols that extend beyond basic life support) interventions and continued treatment for 40 minutes. Patient 1 had no improvement throughout treatment and CPR was discontinued. The report indicated Patient 1’s time of death was at 4:28 PM. During a concurrent interview and record review on 10/17/2024 at 10:40 AM with Registered Nurse (RN) 2, Patient 1’s Order Summary Report and Medication Administration Record (MAR) dated September 2024 was reviewed. Patient 1’s Orders Summary Report and MAR did not indicate an order to administer oxygen therapy. RN 2 stated the Order Summary Report and MAR for Patient 1 did not have documented evidence that the oxygen therapy was ordered to administer oxygen of 5 LPM to the patient. RN 2 also stated, upon a patient’s admission to the facility, the facility’s policy and procedure is for licensed staff to notify the patient’s MD to obtain medication and treatment orders and review discharge orders from the acute hospital to ensure continuity of care. RN 2 stated the patient’s admitting nurse needs to review the transfer orders from where the patient was admitted from and ensure the MD orders were carried out (complete the MD order). Also notify the MD if the patient needed oxygen therapy, so they can obtain the order for the oxygen therapy and administer it to the patient. RN 2 further stated if a patient that needs oxygen, does not receive it, the patient could have a medical emergency and be sent to the hospital or die. During a concurrent review and interview with Licensed Vocational Nurse 3 (LVN 3) on 10/17/24 at 11:19 AM, Patient 1’s Medication Administration Record (MAR), for the month of 9/2024 was reviewed. LVN 3 stated, the MAR indicated “9” in the MAR box (area which is initialed by the licensed nurse to indicate the medication was administered), which meant to check the documentation in the progress notes for the following medications: a. Budesonide 0.5 mg on 9/27/2024 at 9 AM b. Albuterol sulfate 1.25 mg on 9/27/2024 at 12 PM During the same concurrent review and interview with LVN 3 on 10/17/2024 at 11:19 AM, Patient 1’s Progress Notes dated 9/27/2024 timed at 9:41 AM were reviewed. The progress notes indicated, awaiting pharmacy to deliver budesonide. LVN 3 verified budesonide was not administered to Patient 1. LVN 3 stated Patient 1’s progress notes dated 9/27/2024 timed at 12:58 PM indicated, awaiting pharmacy to deliver albuterol sulfate. LVN 3 also verified albuterol sulfate was not administered to Patient 1. LVN 3 stated he did not check the STAT safe for the availability of Patient 1’s respiratory medications and he also did not call the pharmacy to follow up on the delivery of medications.  LVN 3 stated he did not call the doctor to notify the doctor of the medications (albuterol and budesonide) that were not administered to Patient 1.  During an interview on 10/17/2024 at 12:47 PM, RN 1 stated she signed the Pharmacy Packing Slip POD and confirmed Patient 1’s medications which included albuterol sulfate and budesonide were delivered on 9/27/24 at 10:15 AM.  During an interview on 10/17/2024 at 3:07 PM, RN 3 stated if the medication was not available at administration time, the nurse should have called the pharmacy to follow up on the delivery of the medication and obtain the medication if available from the STAT safe so it can be administered to the patient timely.  During an interview on 10/17/2024 at 4:01 PM, LVN 1 stated he was the nurse in charge during Patient 1’s admission to the facility on the night of 9/26/2024. LVN 1 also stated when Patient 1 was admitted to the facility, he called the patient’s family member and texted the MD stating the patient had arrived and admitted to the facility. LVN 1 further stated he endorsed the patient’s admission to LVN 2 (night shift nurse on 9/26/2024). During an interview on 10/18/2024 at 1:28 PM, LVN 2 stated on the night of 9/26/2024, she worked the 11 PM – 7 AM shift and that Patient 1 was admitted by LVN 1 during the 3 PM – 11 PM shift. LVN 2 stated she did not call or text the MD on her shift to verify the patient’s admission orders and that LVN 1 should have been the one to contact the MD regarding Patient 1’s admission. LVN 2 also stated, once a patient is admitted to the facility, the admitting licensed nurse notify the MD to verify and obtain the patient’s medications and orders to see what to continue, change or discontinue and that ideally it is best to get MD verification and orders right away within an hour or two hours. LVN