Health inspection·November 21, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not follow the physician's order for Resident 1. This failure had the potential to result in Resident 1 not receiving needed care and treatment, as ordered by the physician. Residents Affected - Few Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential hypertension (HTN-high blood pressure). Review of Resident 1's medical record review indicated KUB (kidney, ureter, and bladder) x-ray (a type of radiation that creates images of the inside of the body) for abdominal pain was performed on 9/16/24 with the impression: no bowel obstruction (blockage) or perforation (a hole), increased bowel distention (bloating and swelling) from prior exam. Review of Resident 1's progress notes, dated 9/17/24, indicated physician A was notified of the x-ray results and ordered repeat abdominal x-ray. Review of Resident 1's physician's orders indicated there was no order to repeat abdominal x-ray. Review of Resident 1's medical record review indicated there was no documentation indicating the repeat abdominal x-ray was performed. There was no result of the repeat abdominal x-ray. During a telephone interview on 11/21/24 at 12:01 p.m. with physician A, he stated he was informed about Resident 1's abdominal x-ray result of bowel distention and ordered to repeat an abdominal x-ray to follow up the prior x-ray finding of bowel distention. The physician verified the repeat abdominal x-ray result was not reported to him. During a telephone interview and record review on 11/22/24 at 9:07 a.m. with licensed vocational nurse (LVN) B, she confirmed she notified Resident 1's abdominal x-ray result of 9/16/24 to physician A and received an order to repeat an abdominal x-ray from physician A. LVN B verified there was no order to repeat the abdominal x-ray on Resident 1's physician's order. LVN B further stated she could not locate the repeat abdominal x-ray result. Review of the facility's policy and procedure titled Medication and Treatment Orders, revised Page 1 of 2 055017 055017 11/21/2024 Redwood Grove Post Acute 2990 Soquel Avenue Santa Cruz, CA 95062

F 0684 Level of Harm - Minimal harm or potential for actual harm 7/2016, the P&P indicated, Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Residents Affected - Few 055017 Page 2 of 2