**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of three closed record sampled residents (Resident 98) diagnosed of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease exacerbation (worsened COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition characterized by high blood pressure (BP, the measurement of the pressure or force of blood inside the blood vessels) in the arteries of the lungs which makes the heart work harder to pump blood through the narrowed or damaged blood vessels in the lungs that causes shortness of breath and difficulty breathing] by failing to: 1. Monitor Resident 98 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident's care plan for COPD and physician orders, when Certified Nurse Assistant (CNA) 1 found Resident 98 with weakness, labored breathing, and an oxygen saturation (blood oxygen level) of 88% (normal range 90-100%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 LPM [Liters (unit of volume) Per Minute (unit of time)] and reported his findings to Licensed Vocational Nurse (LVN) 1. 2. Follow physician orders to titrate (adjust) Resident 98's oxygen therapy to 10-15 LPM via mask to maintain oxygen blood levels of 94% and above, when Resident 98's oxygen saturation decreased to 70% on [DATE] at 5:50 AM, while receiving 2 LPM of oxygen via NC. 3. Ensure LVN 1 monitored and documented Resident 98's vital signs (measurements of the body's most basic functions, including temperature, pulse rate, breathing rate, and BP, used to assess a person's overall health), treatments rendered, and reported to the physician, in accordance with the physician orders. 4. Ensure LVN 1 immediately notified the physician and called 911 (an emergency number) emergency services, when CNA 1 reported to LVN 1 that Resident 98 was experiencing labored breathing with his oxygen saturation decreased to 88% on [DATE] at around 5:30 AM, and when LVN 1 assessed Resident 98 with findings of weakness and oxygen saturation continued to decrease to 70% on [DATE] at 5:50 AM. 5. Ensure LVN 1 implemented Resident 98's Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident's preferences. These deficient practices resulted in the delay in diagnosis, care, and respiratory services for Resident 98's change in respiratory condition. Resident 98 expired at the facility on [DATE] with the cause of death as cardiac dysrhythmia (abnormal or irregular heartbeat), acute respiratory distress and pulmonary hypertension. On [DATE] at 3:09 PM, while onsite at the facility, the California Department of Public Health (CDPH) an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was identified and called regarding the facility's failure to notify the physician regarding significant changes in Resident 98's respiratory conditions and provide the necessary respiratory care and monitoring. On [DATE] at 7:52 PM, the IJ was removed in the presence of the Administrator (ADM) and the Director of Nurses (DON) after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], the Director of Nursing (DON) and Registered Nurse (RN) supervisor evaluated current residents with oxygen order (12 residents) and/or with diagnosis of COPD (32 residents) for appropriate assessment and interventions. 2. On [DATE], the Regional Nurse Consultant (RNC) provided one on one education to DON and Director Staffing Development (DSD) related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference. 3. On [DATE], the Regional Nurse Consultant (RNC) conducted an interview with LVN 1 and CNA 1 regarding the death incident of Resident 98. The RNC investigated for the licensed nurse documentation, monitoring of change of condition and the reason for not calling 911 and for the possible root cause. 4. On [DATE], the RNC provided one on one education to LVN 1 related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician including skills competency, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference. 5. On [DATE], the DON or designee conducted re-education for licensed nursing staff on the following topics: documentation, oxygen administration, compliance with individualized interventions in each resident's care plan, implementation of POLST and notification of the physician and following physician orders. 6. On [DATE], the DON or designee started auditing residents with COPD and or Oxygen order 3 times weekly (Monday - Wednesday- Friday) for 4 weeks to ensure physician's orders were carried out, resident specific care plans were implemented, and necessary respiratory equipment/supplies were in place, and monitor if change of condition occurred. Upon identification, the DON or designee would immediately address concerns and remedy any audit deficiencies with the licensed nursing staff immediately. 7. On [DATE], A Quality Assurance and Performance Improvement (QAPI, a data-driven approach to improve the quality of care and services in healthcare settings) Plan was implemented to track and report on above audit findings. The findings will be presented on the last Wednesday of the month for the monthly Quality Assessment and Assurance (QAA, an integrated system of management activities involving planning, implementation, assessment, reporting, and quality improvement to ensure that a process, or service is of the type and quality needed and expected) meeting for a minimum of three months. After the initial three months, the QAA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance. 8. On [DATE] the RNC discussed regarding Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension with post-test to LVN 1 to ensure understanding of the medical condition. 9. On [DATE], the DON or designee provided education to licensed nurses regarding COPD and pulmonary hypertension with post-test to ensure understanding of the medical condition. Cross reference to F580 and F867. Findings: During a review of Resident 98's admission Record (AR), the AR indicated the facility admitted Resident 98 on [DATE] with diagnoses that included acute respiratory failure with hypoxia, COPD with exacerbation (worsened symptoms), pulmonary hypertension, type 2 diabetes mellitus with hyperglycemia (DM, a chronic condition that happens when the body has persistently high blood sugar levels), and atrial fibrillation (afib a common type of irregular heartbeat). During a review of Resident 98's Order Summary Report (OSR), indicated on [DATE], Resident 98 had a physician order to monitor temperature and oxygen saturation every shift for suspected/confirmed Covid-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus), and to call the physician if oxygen saturation is newly below 91%, or if the resident's usual oxygen saturation is lower or is 3% or more lower than their baseline. During a review of Resident 98's Care plan (CP), dated [DATE], indicated Resident 98 had COPD exacerbation. The goal was that the Resident 98 would display optimal breathing patterns (a respiratory rate of 12 to 20 breaths per minute with regular, rhythmic inhalations and exhalations) daily with the interventions that included monitoring for signs and symptoms of acute respiratory insufficiency such as shortness of breath at rest, cyanosis (a bluish or purplish discoloration of the skin, typically caused by a lack of oxygen in the blood), and somnolence (lethargy, weakness, and difficulty thinking), and to administer oxygen via NC at 2-3 LPM continuously, may titrate oxygen to 10-15 LPM via mask to maintain oxygen saturation greater or equal to 94%. During a review of Resident 98's CP, dated [DATE], indicated Resident 98 was at risk for Covid-19 related to diagnosis of COPD exacerbation, DM, and afib. The interventions included to follow Resident 98's POLST, monitor temperature and pulse oximetry (a test used to measure oxygen levels of the blood) per physician's order and report abnormal findings to the physician. During a review of Resident 98's CP, dated [DATE], indicated Resident 98 had altered cardiovascular (related to heart and blood vessels) status related to afib, hypertension (high BP), and hyperlipidemia (high level of fats in the bloodstream). The interventions included to monitor Resident 98's vital signs and notify the physician of significant abnormalities, monitor/document/report to the physician for changes in capillary refill (a quick test to assess blood flow to tissues by observing how quickly color returns to the nail bed after pressure is applied) and color/warmth of extremities. During a review of Resident 98's History and Physical, dated [DATE], indicated Resident 98 had the capacity to understand and make decision. During a review of Resident 98's OSR, indicated on [DATE], for Resident 98 to receive oxygen via NC at 2-3 LPM continuously, may titrate oxygen to 10-15 LPM via mask to maintain oxygen saturation greater or equal to 94%. During a review of Resident 98's OSR, indicated on [DATE], the physician ordered to follow the instructions in Resident 98's POLST. During a review of Resident 98's POLST, dated [DATE], indicated if Resident 98 was found with a pulse and/or is breathing, the healthcare provider may, in addition oxygen treatment, use a non-invasive positive airway pressure (a method of breathing support that delivers pressurized air or oxygen through a mask without inserting a tube into the windpipe) which included continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open), bi-level positive airway pressure (BiPAP, a type of device that helps with breathing), and bag valve mask (a handheld device used to provide emergency breaths to someone who is not breathing or not breathing adequately) assisted respirations. During a review of Resident 98's Minimal Data Set (MDS-a federally mandated resident assessment), dated [DATE], indicated Resident 98's cognition (ability to think, remember, and reason) was moderately impaired and needed moderate assistance (helper does less than half the effort) in eating and oral hygiene. During a review of Resident 98's Weights and Vitals Summary, indicated Resident 98's last vital signs was taken on [DATE] at 1:09 AM with the resident's BP at 128/85 mmHg (millimeters of mercury, a unit of measurement for pressure), oxygen saturation of 93% while the resident was on room air, heart rate at 100 beats per minute, and temperature of 98.7 degrees Fahrenheit (a scale for measuring temperature). There was also no documented evidence that Resident 98 was monitored for vital signs on [DATE] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, and had slow breathing. During a review of Resident 98's Progress Notes, dated [DATE], indicated at 5:50 AM during CNA morning care, Resident 98 responded only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC until the resident passed away. There was no documented evidence in the report that Resident 98 was provided with increased oxygen level to increase oxygen saturation to 94% as ordered by the physician. There was also no documented evidence that Resident 98 was monitored for vital signs, provided with 10-15 LPM oxygen via mask per physician's order on [DATE] at 5:50 AM when Resident 98 responded to touch only by opening his eyes, had slow breathing, and oxygen saturation at 70 % while on 3 LPM oxygen via NC. During a review of Resident 98's SBAR Communication Form (a structured approach to healthcare communication, standing for Situation, Background, Assessment, and Recommendation to ensure clear and concise information exchange, especially in critical situations) and clinical records on [DATE], indicated that there was no documented evidence that the physician was notified when Resident 98's condition changed by responding only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC on [DATE] at 5:50 AM until the resident expired on [DATE] at 5:59 AM. During a review of Resident 98's Record of Death, dated [DATE], indicated Resident 98 expired on [DATE] at 5:59 AM with the final diagnosis that included COPD, hypoxia and respiratory failure. During a review of Resident 98's Physician's Discharge Summary, dated [DATE], indicated Resident 98 was admitted on [DATE] and was discharged from the facility due to resident expired on [DATE] at 5:59 AM. During a review of Resident 98's Death Certificate dated [DATE], indicated Resident 98 expired on [DATE] with the primary cause of death as cardiac dysrhythmia and secondary cause of death that included acute respiratory distress and pulmonary hypertension. During an interview on [DATE] at 6:38 AM with CNA 1, CNA 1 stated, he took care of Resident 98 from 11 PM on [DATE] until the resident expired on the morning of [DATE]. CNA 1 stated, when he was caring for Resident 98 at the beginning of his shift, Resident 98 was alert and oriented, with the vital signs including BP and oxygen saturation was within normal limits, though he could not recall the results of the vital signs and time they were taken. CNA 1 stated, around 5-5:30 AM during his rounds in the facility, he noticed that Resident 98 did not respond when he called Resident 98's name, and breathing very slow but his skin was warm when touched and the resident was very weak with his oxygen level at around 88%. CNA 1 stated, he immediately reported to LVN 1 that Resident 98's oxygen blood level was low and then LVN 1 went to assess Resident 98. CNA 1 stated, they (LVN 1 and CNA 1) checked Resident 98's vital signs about four times, but he could not recall the results and time the vital signs were taken. CNA 1 stated, he could only recall that Resident 98's oxygen level was at 88% when he first found the resident around 5-5:30 AM and notified LVN 1. CNA 1 then stated Resident 98 slowly died in about 1 hour while receiving oxygen via NC. During a concurrent record review and interview on [DATE] at 6:52 AM with LVN 1, Resident 98's Weights and Vitals Summary, SBAR Communication Form, and clinical records on [DATE] and [DATE] were reviewed. LVN 1 stated, there was no records indicating Resident 98 was assessed and monitored for vital signs, Resident 98's physician was notified, or interventions were provided related to Resident 98's slow breathing with oxygen saturation at 70% on [DATE] at 5:50 AM. During an interview on [DATE] at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 98 from 11 PM on [DATE] until the resident expired on [DATE] at 5:59 AM. LVN 1 stated, Resident 98 was alert, oriented and responsive at the beginning of his shift on [DATE], with oxygen saturation above 90% while receiving oxygen supplement at 3 LPM. LVN 1 stated, Resident 98 was able to make his needs known. LVN 1 stated, when LVN 1 provided Resident 98 with his scheduled breathing treatment (treatment to prevent difficulty breathing and shortness of breath) at 4 AM, Resident 98's oxygen saturation was about 93% and Resident 98 was placed back on 2-3 LPM oxygen via NC after the breathing treatment. LVN 1 stated around 5:30 AM, CNA 1 told him Resident 98 had a change in condition and breathing very slow and was very weak. LVN 1 stated he went to Resident 98's room, and Resident 98 opened his eyes but was very weak. LVN 1 stated he checked Resident 98's vital signs a few times but could not recall the results of the VS and he did not document the vital signs in Resident 98's clinical record. LVN 1 stated, he did not report Resident 98's change of condition to the Registered Nurse (RN) who was working during his shift on [DATE]. LVN 1 stated, he did not increase Resident 98's oxygen level as per physician's order because the resident had diagnosis of COPD. LVN 1 stated, he did not inform the physician when Resident 98's condition changed with oxygen saturation down to 88% and 70%. LVN 1 stated he informed Resident 98's physician after the resident passed away on [DATE]. LVN 1 stated, he supposed to notify Resident 98's physician, call for help or call 911 when CNA 1 reported to him that Resident 98 was weak with slow breathing and a decrease in the resident's oxygen saturation. LVN 1 stated, Resident 98 expired less than one hour after he was notified by CNA 1 for Resident 98's weakness and slow breathing. During a review of LVN 1's statement provided by the facility, dated [DATE] not timed, indicated on [DATE] at 11 PM, Resident 98 was laying comfortably in bed with oxygen via delivered via NC at 3 LPM with no sign and symptoms of respiratory distress. The statement indicated on [DATE] at 4 AM, LVN 1 administered the routine breathing treatment, Resident 98 was sleepy in bed, then at 5:50 AM, CNA 1 called LVN 1's attention and informed him that Resident 98 was only responding by opening his eyes. The statement indicated LVN 1 checked Resident 98's oxygen saturation that was 70 %. While Resident 98 was receiving oxygen supplement at 3 LPM. The statement indicated, LVN 1 elevated the Resident 98's head of the bed then suddenly Resident 98 became weak and unresponsive, like the resident last breath. During a review of CNA 1's statement provided by the facility, dated [DATE] not timed, indicated on [DATE] at 5:30 AM, CNA 1 came to change Resident 98's diaper and noticed a change in his condition and immediately reported his findings to LVN 1. The statement indicated, Resident 98's oxygen saturation was at 89%, then went down to 88%, and suddenly dropped down to 70%. LVN 1 and CNA 1 checked Resident 98's BP which was lower than the limit, then CNA 1 and LVN 1 elevated Resident 98's head of the bed higher and the resident became unresponsive. The statement indicated, Resident 98's breathing was slowing down until his last breath. During an interview on [DATE] at 9:40 AM with the DON, the DON stated when CNA 1 reported to LVN 1 that Resident 98's oxygen saturation was trending down and the resident was weak, LVN 1 should have immediately assessed, monitored and documented Resident 98's vital signs in the resident's clinical record. The DON stated, when LVN 1 found Resident 98's oxygen saturation of 70%, LVN 1 should have immediately called for help or Code Blue (an emergency code indicating a patient is experiencing a life-threatening medical emergency, typically a cardiac or respiratory arrest, requiring immediate medical attention and resuscitation efforts). followed the physician order to titrate Resident 98's oxygen therapy, followed Resident 98's POLST, called 911, and notified the physician to prevent a delay in treatments and interventions. During an interview on [DATE] at 1:02 PM with Resident 98's Primary Physician (PP) 1, PP 1 stated when Resident 98's oxygen saturation of 93-94% went down to 88%, it was a sudden drop of oxygen saturation or a sudden change in condition, PP 1 stated LVN 1 was supposed to follow the physician's orders and notified him (PP1) right away, followed Resident 98's POLST, called 911 and notified the physician again. PP 1 stated, he was not notified of Resident 98's significant change in respiratory status on [DATE]. PP 1 stated, he was notified only after Resident 98 already expired on [DATE]. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised [DATE], indicated the following: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. - The equipment needed for oxygen administration will depend on the type of delivery system ordered. Type of delivery systems include nasal cannula, non-rebreather mask, CPAP mask, BiPAP mask. - Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. During a review of the facility's P&P tiled, Notification of Changes, revised [DATE], indicated the facility consult with the resident's physician when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, which may include life-threatening conditions. During a review of the facility's P&P titled, Medical Emergency Response, revised [DATE], indicated the following: - The employee who first witnesses or is first on the site of a medical emergency will initiate immediate action, basic first aid and summon for assistance. - A nurse will assess the situation and determine the severity of the emergency, designate a staff member to announce a Code Blue (a medical emergency alert, usually indicating a person has experienced cardiac or respiratory arrest requiring immediate resuscitation efforts) if necessary, notify the physician and call 911 as needed. - All available staff will respond to the emergency accordingly. - The RN Supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed.