Magnolia Gardens Convalescent Hospital
17922 San Fernando Mission Blvd Granada Hills CA 91344
Citation Number: 920001270
Citation Date: 04/09/2015
Violation Date: 1/21/2012
Class: AA
Penalty: $60,000

CFR 483.10(b)(11)(i)(B)(11)notification of Changes A facility must immediately inform the resident consult with the resident's physician and if known, notify the resident's legal representative or an interested family member when there is -
(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a
deterioration in health, mental, or psychosocial status in either life threatening conditions
or clinical complications);
CFR 483.20(k)(3) Comprehensive Care Plans: The services provided or arranged by
the facility must- (i) Meet professional standards of quality; and (ii) Be provided by
qualified persons in accordance with each resident's written plan of care.
CFR 483.25 Quality of Care: Each resident must receive and the facility must provide
the necessary care and services to attain or maintain the highest practicable physical,
mental, and psychosocial well-being, in accordance with the comprehensive
assessment and plan of care.
CFR 483.25(k) Special Needs The facility must ensure that residents receive proper
treatment and care for the following special services
CFR 483.25(k)(5) Standard: Tracheal Suctioning

CFR 483.25(k)(6) Standard: Respiratory Care
The Department received a complaint on March 23, 2012, alleging a resident (Resident
1) was extremely congested and struggling to breathe on January 21, 2012, and the
facility's nursing staff were informed but did nothing. Resident 1 went into cardiac arrest
and died two hours later. On April 2, 2012 at 2:35 p.m., an unannounced visit was
made to the facility to investigate the complaint.
The facility's staff fa iled to provide the necessary care and services to Resident 1,
including but not limited to, failure to:
1. Follow the physician's orders, including orders to suction the resident every two hours,
and administer breathing treatments every four hours and as needed to maintain an
open airway in accordance with the plan of care;

2. Notify the physician when the resident was having difficulty breathing with sings of congestion and restlessness and
3. Implement the facility policy and procedure for cardiopulmonary resuscitation (CPR)
and follow Resident 1's advance directive for CPR.
These failures resulted in Resident 1's change in condition for over six hours with
excessive secretions, difficulty in breathing, and restlessness. She was found
unresponsive, pale in color with dilated pupils, and was pronounced dead at 10:08 p.m.
on January 21, 2012.
A review of Resident 1's Admission Record indicated the resident was a 77 year- old
female, who was admitted to the facility on January 10, 2012. Her diagnoses included a
right hip fracture, status-post right hip open reduction internal fixation (a surgical method
of repairing a fractured bone, using plates and screws or a rod to stabilize the bone)
done on January 5, 2012, leukocytosis (an elevated number of white blood cells), a
gastrostomy tube (GT - a feeding tube placed directly through the skin to the stomach
when a resident cannot eat or swallow safely) and Clostridium Difficile (C-diff - bacteria
that cause symptoms ranging from diarrhea to life-threatening inflammation of the
There was an "Advance Directive Acknowledgment" form dated and signed January 19,

2012, by the resident's agent for health care decisions, physician, and social service
designee, for a preferred intensity of care. The form indicated the resident wanted to
have CPR, intravenous fluids, hospitalization, tube feeding, and no restriction of any
medications or treatments.
A review of a License Nurse Record dated January 10, 2012, and timed at 6 p.m.,
indicated upon admission the resident was non-verbal, had an indwelling urinary
catheter (a flexible plastic tube used to drain urine from the bladder), was incontinent
(unable to control) of bowel, was receiving feedings via a GT, and receiving antibiotics
for C-diff for seven days. The breathing section documentation indicated the resident
had no secretions, did not require suctioning and had a pulse oximetry (non-invasive
method for monitoring oxygen in the blood) applied that read 96 percent (%) on room air
(normal value is greater than 96%). According to the "Record" the resident was placed
in isolation (private room) for C-diff precautions.
The Physician's Order dated January 10, 2012, indicated the nursing staff should
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(cough syrup) five milliliter (ml) via GT every six hours as needed (PRN) for coughing.
Another physician's order dated January 12, 2012, indicated the staff should administer
the breathing treatments of Albuteroi/Atrovent (bronchodilator that relaxes muscles in the
airways and increases air flow to the lungs) every four hours as needed (PRN) for
shortness of breath. On January 14, 2012, the physician ordered oxygen at two liters
per minute by nasal cannula (N/C) as needed for labored breathing and to monitor the
resident's oxygen saturation every shift.
A review of the Medication Administration Record (MAR) for the month of January 2012,
indicated Robitussin was not administered to the resident from January 10, 2012,
through January 21, 2012. The Atrovent!Aibuterol breathing treatments were
administered only once on January 14, 2012, since admission January 10 through 21,
There was no record of oxygen administration or oxygen saturation readings every shift
as prescribed by the physician to assess the resident's breathing status. A review of
the nurse's notes indicated the resident's oxygen saturation was not recorded on the
following days: January 12, 13, 15, 16, 17, and 21, 2012, as directed in the physician's
orders to be done every shift. On January 14, 2012, according to the Licensed Nurse

Record, Resident 1's oxygen saturation was 98%. However, it was recorded as 89% on
the Multidisciplinary Progress Record. The physician was notified and a chest x-ray was
ordered on January 14, 2012. The results of the chest x-ray indicated the resident had
slight right lower lobe atelectasis (a collapse of lung tissue affecting part or all of one
lung. This condition prevents normal oxygen absorption to healthy tissues), but no
infiltration (a density in the lungs that is not normal and usually refers to a focus of
infection). The resident's lung sounds changed from being clear to having rales and
crackles (can be associated with severe airway obstruction). On January 18, 2012, the
resident's oxygen saturation dropped again to 94%.
A review of a plan of care, dated January 11 , 2012, indicated the staff would provide
medication and breathing treatments as ordered and notify the physician of signs and
symptoms of congestion, shortness of breath, and labored breathing. There was no
documented evidence the resident's physician was notified of the resident's change of
conditions on January 21, 2012, when the resident was having difficulty breathing.
A review of the facility's policy 'Oral-Nasal indicat4ed when a resident cannot voluntarily expectorate to cough up and spit out to prevent aspiration of secretions the resident should be suctioned from the mouth.

On April 2, 2012, at 2: 30 p.m., during an interview, the director of nurses (DON) stated
she remembered Resident 1 very well, because she admitted the resident on January
10, 2012. The DON stated on admission the resident had a productive cough, so
cough medication and breathing treatments were ordered. However, a review of a
Licensed Nurse Record, with an assessment done upon admission, dated January 10,
2012, indicated the resident's lung sounds were clear and had no secretions, and did
not require suctioning.
On April 2, 2012, at 3:10p.m., during an interview, licensed vocational nurse 1 (LVN 1)
stated that Resident 1 was awake, alert, and non-verbal, but responded to tactile
(touching) stimuli, upon admission. LVN 1 stated there was pooling of secretions at the
back of the resident's mouth, which required suctioning every two hours or more. LVN 1
indicated the resident was congested and required breathing treatments and cough
medicines frequently. She stated the certified nursing assistant (CNA 1) called her into
the resident's room on January 21, 2012, at 9:45 p.m., to check the resident because
she looked pale. L VN 1 stated she found the resident unresponsive and attempted to
check her vital signs, but there was no pulse (heartbeat) or blood pressure (the pumping
action of the heart). LVN 1 stated she called the registered nurse supervisor (RN 1) into

the room and RN 1 re-assessed the resident at 9:47p.m., but there was no pulse.
When L VN 1 was asked about CPR being performed, she stated neither she nor RN 1
suctioned the resident. LVN 1 stated, "We did something, but I cannot remember if we
gave her oxygen or did CPR." LVN 1 could not provide written documentation of CPR
being performed on Resident 1 upon the initial assessment by L VN 1 or RN 1, or while
waiting for the paramedics to arrive.
On April 2, 2012, at 4 p.m., during a telephone interview, RN 1 stated that sometime
after 7 p.m., on January 21 , 2012, CNA 1 reported to LVN 1 that Resident 1 "was gone."
L VN 1 went into the room and observed that the resident was cyanotic (bluish
discoloration of the skin and mucous membranes due to not enough oxygen in the
blood) and cool to touch. LVN 1 called a Code Blue (a medical emergency in which a
team of medical personnel work to revive an individual whose heart has stopped) and all
the staff rushed into the room. LVN 1 checked the resident's vital signs, but the resident
had no pulse or blood pressure. RN 1 stated she was not sure if the resident was a Full
resident was in bed." [According to the American Heart Association (AHA), a twohand
procedure should be used to press hard on the resident's center chest, by placing
the heel of one hand over the center of the chest and place the other hand on top and
interlace your fingers]. When RN 1 was questioned about the accurate procedure to
perform chest compression she stated, "Cardiac compression can be done in two ways
either by using a cardiac board or placing the resident on the floor." However, according
to RN 1, she did not use either method, or follow the AHA CPR guidelines. RN 1 stated
she did not use an Ambu Bag (a resuscitator bag used to maintain ventilation) on the
resident. She stated she did not sucti.on the resident in an attempt to open the
resident's airway, or turn the oxygen on.
On August 6, 2012, at 6:10p.m., during an interview, CNA 2 stated that on January 21,
2012, the resident was having difficulty breathing and became very restless. CNA 2
stated LVN 1 suctioned the resident at 3 p.m., but the resident was very agitated and
did not want to lie down in bed, because she could not breathe while in a lying position.
CNA 2 stated the resident wanted to either sit up or stand up (orthopneic - a body
position that enables a person to breathe easier).
According to the National Institutes of Health (NIH), acute upper airway obstruction is a

blockage of the airway, which can be in the trachea (a tube that connects the nose and
mouth to the lungs), laryngeal (voice box) , pharyngeal (throat) areas, which can be
caused by foreign bodies; and common symptoms to all types of airway blockage
include agitation or fidgeting, difficulty breathing, gasping for air, and cyanosis (a bluish
color to the skin). According to the American Heart Association (AHA), 2005 edition,
Adult Basic Life Support, CPR is an emergency medical procedure for card iac arrest;
consisting of artificial blood circulation and artificial respiration (chest compression and
lung ventilation). AHA indicates CPR must be started at once when a person is in
cardiac arrest and placed on a hard, flat surface.
A review of a Multidisciplinary Progress Record, dated January 21, 2012, and timed at
8 p.m., indicated the resident's family was at the bedside and the resident had no
shortness of breath or distress noted. The note also ind icated the resident was
suctioned. However, on February 10, 2012, at 10:20 a.m., during a telephone interview
and a review of a written declaration, the resident's family care giver, stated she did visit
the resident the evening of January 21, 2012. She stated once she arrived at the facility
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with fast labored breaths. She stated she notified the nurses and they stated the resident
receives breathing treatments and they would come in and check on her, but they did not
come, so she went to remind them. She stated they promised they would go and
check on her while she left the facility. The family care giver stated she left the facility
after being reassured they would check on the resident and as soon as she got home,
within two hours, the facility called her and stated the res ident had a cardiac arrest and
A review of the facility's undated policy titled "CPR" indicated the staff would provide life
support to an individual who needs to be resuscitated. The policy also indicated once
CPR is initiated, it shall be continued until effective circulation and breathing are
restored in the resident and or if the resident is transferred to the care of emergency
medical services. A review of Resident 1 's Advance Directive dated and signed
January 19, 2012, indicated CPR was selected as a preferred intensity of care
authorized by the resident.
A review of the Multidisciplinary Progress Record, dated January 21 , 2012, and timed at
9:45p.m., indicated the resident had no pulse or blood pressure.

According to the Licensed Nurse Note dated January 21 , 2012, at 9:55p.m., RN 1
called 911 , and at 10 p.m., the paramedics arrived and pronounced the resident dead at
10:08 p.m.
According to the Multidisciplinary Progress Record, dated January 21, 2012, the
paramedics arrived at 10 p.m., and at 10:08 p.m., they pronounced the resident dead.
At 10:18 p.m., the family was notified of the resident's death. At 10:29 p.m., two police
officers arrived at the facility and the physician was notified of the resident's death.
The facil ity's staff failed to provide the necessary care and services to Resident 1,
including but not limited to, failure to:
1. Follow the physician's orders, including orders to suction the resident every two hours,
and administer breathing treatments every four hours and as needed to maintain an
open airway in accordance with the plan of care;
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3. Implement the facility policy and procedure for cardiopulmonary resuscitation (CPR)
and follow Resident 1 's advance directive for CPR.
The above violations either jointly, separately, or in any combination presented either an
imminent danger that death or serious harm would result or a substantial probability that
death or serious physical harm would result and was a direct proximate cause of death
of Resident 1.