Health inspection·June 20, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to follow their own policy and procedure to ensure one of three residents (Resident 1) had an interdisciplinary (IDT)/Bioethics review process to evaluate resident ' s care needs that required informed consent who was known to have fluctuating capacity to understand and make decisions. Residents Affected - Few This deficient practice violated the residents' right to make an informed decision including the use of psychoactive medications. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a range of conditions where brain dysfunction occurs due to a systemic metabolic problem, meaning a problem with the body's overall chemical processes. This dysfunction can manifest as confusion, memory problems, changes in behavior, and even loss of consciousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and memory deficit following (a decline in a person's ability to remember things, encompassing difficulties in forming new memories, recalling past events, or both. It can range from mild forgetfulness to significant amnesia and may be a symptom of various conditions, including aging, brain injury, or neurological disorders) other cerebrovascular disease (a group of conditions that affect blood flow to the brain, potentially causing damage to brain tissue and affecting brain function). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 5/1/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline where individuals experience more pronounced difficulties with thinking, memory, and judgment than what is considered normal for their age). The same MDS indicated Resident 1 was dependent on staff for his Activities of Daily Living such as: (ADLs routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the General Acute Care Hospital progress note dated 4/29/2025 at 1:27 pm, the progress note indicated under assessment/plan Acute metabolic encephalopathy with waxing/waning mental status. Unclear etiology. Query if toxic-metabolic encephalopathy and residual effect from intentional ingestion of meds at home. and/or delirium (a state of acute mental confusion and disorientation that develops rapidly). During an interview with Certified Nursing Assistant (CNA) 1 on 6/19/2025 at 12:40 pm, CNA 1 stated Page 1 of 2 055136 055136 06/20/2025 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident 1 ' s had instances where it was difficult to have conversations with him (Resident 1) because he would get confused and refer to things that were not there such as seeing a baby in his room. During an interview with the Social Worker (SW) on 6/20/2025 at 3:34 pm, the SW stated that Resident 1 had fluctuating capacity (a person's ability to make decisions or understand information varies over time). The SW stated that capacity was important for making informed decisions but stated that she was not involved in getting any type of consent from Resident 1. During an interview with the Facility administrator (FA) on 6/20/2025 at 5:16 pm, the FA confirmed that Resident 1 had fluctuating capacity to make decisions. The FA stated that during the times that Resident 1 was unable to make decisions, the facility waited until the times when Resident 1 had a moment of clarity. The FA was unable to demonstrate or verbalize how one could prove that a document was signed while the resident had capacity. The FA stated that a resident must be able to make decisions or have capacity so that he (Resident) understands what is going on with their care. During a review of a Policy and Procedure (P&P) titled, Interdisciplinary Team Review/Bioethics – Substitute Decision-Making, revised 4/16/2025, indicated, Biomedical ethical dilemmas often occur when Long-Term Care Facility (LTCF) residents do not have the cognitive capacity to make informed choices about their health care and when they do not have an advance directive and where there is no surrogate decision-maker/resident representative. The same P&P indicated, The Facility makes a reasonable effort to reach family members and friends, and if none located, take steps to search for a representative to participate in the IDT meeting, including - Interviewing residents -Reviewing medical records -Consulting with SNF staff -Document efforts made to find a legal decision-maker and/or resident representative -If unable to identify a Resident Representative, contact The Long-Term Care Office for Patient Representatives (OPR) within 72 hours of MD determination of no capacity May contact OPR before 72 hours if unlikely that a legal decision-maker, family member, or friend will be located 1) Continue to search after contacting OPR 2) Family member or friend may replace the OPR selected Resident Representative if person becomes available to serve as the resident representative 055136 Page 2 of 2