Health inspection·August 17, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure for one of three residents (Resident 1) that: Residents Affected - Few 1. Certified nursing assistants (CNA) completed the required documentation of Resident 1's bowel movements each shift, and 2. Licensed nurses (LNs) followed up on the accuracy and completeness of CNA documentation for Resident 1's bowel movements to determine if bowel protocol (systematic interventions to prevent/address constipation) needed to be initiated. As a result, there was the potential for documentation that was incomplete and not followed up on to affect the residents' health and well-being. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility 6/16/23. A review of CNA documentation titled Documentation Survey Report v2, for Resident 1's July 2023 bowel movements indicated, CNAs were required to document each shift (AM shift 7 A.M. to 3 P.M., PM shift 3 P.M. to 11 P.M., and Night shift 11 P.M. to 7 A.M.). The CNA documentation were incomplete with blank entries on: 7/2, 7/8, 7/9, 7/10, 7/14, 7/15, 7/16, 7/19 and 7/20/23. The CNA documentation further indicated, Resident 1 did not have bowel movements for seven days (7/10 through 7/16/23). Resident 1's clinical record was reviewed. There was no documentation the LN responded to and followed up on the CNA's incomplete bowel movement documentation. There was no documentation the LN assessed if Resident 1 had required bowel protocol. There was no documentation bowel protocol had been initiated for Resident 1. On 8/15/23 at 8:50 A.M., a joint interview and record review was conducted with CNA 2. CNA 2 stated CNAs were required to document the residents' bowel activity every shift. CNA 2 reviewed Resident 1's Documentation Survey Report v2, dated July 2023, and stated the documentation that were left blank meant the CNA did not do their documentation. On 8/15/23 at 8:58 A.M., a joint interview and record review was conducted with CNA 3. CNA 3 stated documentation of the residents' activities of daily living (ADLs, self-care activities such as toileting) was mandatory and had to be completed every shift by the CNA assigned to each resident. CNA 3 Page 1 of 2 055182 055182 08/17/2023 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed Resident 1's Documentation Survey Report v2, dated July 2023, and stated, There shouldn't be blanks. CNA 3 further stated when residents did not have a recorded bowel movement in three consecutive days, the LN had to act upon it. On 8/15/23 at 9:10 A.M., a joint interview and record review was conducted with LN 2. LN 2 stated the LN was responsible to review the CNA's documentation for accuracy and completeness. LN 2 stated the LN had to follow up when a resident was documented as not having a bowel movement after three days. LN 2 stated the LN had to determine if the bowel protocol needed to be implemented. LN 2 stated bowel protocol included giving a resident magnesium hydroxide (laxative), and if still no bowel movement after the shift, then give a suppository or enema (medications to promote a bowel movement). LN 2 stated the proper implementation of bowel protocol was important to prevent constipation and other complications. LN 2 reviewed Resident 1's Documentation Survey Report v2, dated July 2023, and stated incomplete CNA documentation was not acceptable. LN 2 reviewed Resident 1's clinical record and stated there was no documentation the LN had followed up on the CNA's incomplete documentation or had determined whether or not the bowel protocol should have been initiated. LN 2 stated the LN should have followed up on this. On 8/15/23 at 11:30 A.M., a joint interview and record review was conducted with the assistant director of nursing (ADON). The ADON reviewed Resident 1's Documentation Survey Report v2, dated July 2023, and stated the CNA documentation should not have been incomplete. The ADON stated it was her expectation for the LN to follow up on the CNA documentation and verify if Resident 1 had a bowel movement or not and to determine if bowel protocol was required. The ADON stated the LN follow up should have been documented in Resident 1's clinical record. On 8/15/23 at 2:40 P.M., an interview was conducted with the director of nursing (DON). The DON stated CNAs were required to document on each resident's ADLs each shift with no blanks. The DON stated LNs providing care to Resident 1 should have followed up on the CNA documentation and if the bowel protocol was required or not. A review of the facility's undated policy titled ADL Care, indicated, . 3. Nursing staff will document ADL functions and assistance provided as indicated The facility did not have a policy to guide bowel protocol. 055182 Page 2 of 2