Health inspection·June 28, 2023

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of two sampled residents (Resident 1). Residents Affected - Few * Resident 1 ' s BPs were below the set parameters with five doses of BP medications being held and the oxygen saturation levels were low on 6/19 and 6/20/23. The nursing staff failed to notify the physician and completed the change in condition assessment related to low BPs and oxygen saturation levels for Resident 1. This had the potential for a delay in providing the necessary care and services and deterioration of the resident ' s conditions. Findings: Review of the facility ' s P&P titled Policy/Procedure – Nursing Administration, under the section titled Care and Treatment, under the subject: Change of Condition Repotting showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. - Any change in a resident ' s condition manifested by a marked change in physical or mental behavior will be communicated to the physician. - Document resident change of condition and response in eInteract Change of Condition UDA and in nursing progress notes, and update resident care plan, as indicated. Review of the NIH (National Library of Medicine) showed the document titled Oxygen Saturation Last Update: November 23, 2022, showing the following: - The generally accepted standard is that a normal resting oxygen saturation of less than 95% is considered abnormal. Therefore, it remains vital to observe the patients for the clinical markers of hypoxemia (low oxygen saturation level). Review of Resident 1 ' s closed medical record wasinitiated on 6/27/23. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care hospital on 6/20/23. Review of Resident 1 ' s H&P Examination dated 6/2/23, showed the physician determined Resident 1 had the capacity to understand and make decisions. The document further showed Resident 1 was admitted with a diagnosis of high BP. Page 1 of 3 055237 055237 06/28/2023 Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1 ' s Order Summary for June 2023 showed Resident 1 had the physician ' s orders for the following medications: - losartan potassium (antihypertensive) 100 mg one tablet by mouth one time a day for HTN (high BP) and hold if SBP <110 mmHg or HR <60 beats per minute. Residents Affected - Few - metoprolol tartrate (antihypertensive) 100 mg one tablet by mouth two times a day for HTN and hold if SBP <110 mmHg or HR <60 beats per minute. On 6/28/23 at 0951 hours, a concurrent interview and closed medical record review for Resident 1 wasconducted with LVN 1. LVN 1 stated Resident 1 was wheelchair bound and had decreased alertness from admission. LVN 1 further stated at the time of transfer to the acute care hospital, Resident 1 was only alert to her name. When asked to describe the process when the resident experienced a change in condition, LVN 1 stated they would inform the physician, facility supervisor, and resident ' s family; and the CNA should make the nursing staff aware of any changes. Review of Resident 1 ' s Weights and Vitals summary from 6/15/23 – 6/20/23, showed from 6/15-6/18/23, Resident 1 ' s BPs ranged from 125-146/60-80 mmHg. Then, on 6/19 and 6/20/23, the medical record showed the following: - On 6/19/23 at 0737 hours, the BP was 100/57 mmHg and oxygen saturation level was 90% on room air. - On 6/19/23 at 1600 hours, the BP was 105/62 mmHg and oxygen saturation level was 90% on room air. - On 6/19/23 at 1626 hours, the BP was 105/62 mmHg. - On 6/20/23 at 0243 hours, the BP was 106/75 mmHg. - On 6/20/23 at 0900 hours, the BP was 103/70 mmHg. - On 6/20/23 at 1730 hours, the BP was108/66 mmHg. LVN 1 verified the above BPs and oxygen saturation levels for Resident 1. Review of the June 2023 MAR showed the following: -losartan 100 mg once a day was not administered on 6/19 and 6/20/23 at 9 AM due to BP below set parameter. - metoprolol 100 mg twice a day was not administered on 6/19/23, for the AM and PM doses, for the 6/20/23 AM dose due to BP below set parameter, and for the 6/20/23 PM dose due to refusal. LVN 1 further verified the five consecutive doses of Resident 1 ' s BP medications were held due to the resident ' s BPs being too low. When asked if the above BPs where a change for Resident 1 ' s usual BPs, LVN 1 stated yes. When asked if the above oxygen saturation levels were normal for Resident 1, LVN 1 stated no. When asked if a change in condition was completed for the low BPs on 6/19/23 or 6/20/23, LVN 1 verified they had not been completed. When asked if a change in condition had been completed for the low oxygen 055237 Page 2 of 3 055237 06/28/2023 Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few saturation level on 6/19/23, LVN 1 verified it had not been completed. When asked if a change in condition should have been completed as per the facility ' spolicy, LVN 1 stated yes. On 6/28/23 at 1140 hours, a concurrent interview and closed medical record review for Resident 1 was conducted with RN 1. RN 1 verified the above BP and oxygen saturation levels. RN 1 verified the facility failed to complete a Change of Condition form for the low BPs and oxygen saturation levels on 6/19 and 6/20/23. RN 1 further agreed these were a concern for Resident 1. RN 1 verified the physician should have been made aware but was not. On 7/3/23 at 0917 hours, a concurrent interview and closed medical record review of Resident 1 was conducted with the DON. When asked if the facility had a P&P which guided the staff on the normal range of vital signs and what to do when the resident ' s vital signs were out of range, the DON state no. When asked without that P&P, how the staff would know what the facility expected of staff, the DON stated the nurses were expected to do an assessment, recognize a change, complete a change of condition assessment, and notify the physician whenever something was outside of normal for the resident. When asked how thestaff would know when the vital signs were not normal, the DON stated a message came up and notified the staff in the electronic medical records system. When asked what happened when there was a change in condition for the resident, but the system did not flag it as abnormal, the DON state it was up to the nurses to identify if there was a change for the resident. When asked how long the staff could hold a medication without notifying a physician, the DON stated the staff did not need to notify a physician unless there was a trend for 3-5 days, which caused the medications to be held. When asked to clarify if it was 3-5 doses or 3-5 days, the DON clarified 3-5 day with multiple dosses of a medication being held in each day. When asked how the staff would know that3-5 days was the expectation of the facility, the DON stated she had no answer to the question. The DON further elaborated the staff should contact the physician in the event a resident refused the medications. When asked if an oxygen saturation level of 90% was normal for Resident 1, the DON stated she did not know. The DON verified a change of condition should have been completed for Resident 1 ' s low BPs and oxygen saturation levels on 6/19 and 6/20/23, but was not. The DON verified the physician should have been made aware of Residents 1 ' s vital signs on 6/19 and 6/20/23, but was not. Further review of the medical record showed the nurses ' progress note dated 6/20/23 at 1457 hours, showing the resident ' s family member visited and requested for the resident to be transferred to the acute care hospital due to poor intake and confusion. There was no documented evidence the physician was informed of the low BPs, holding of five doses of the BP medications, and low oxygen saturation levels on 6/19 and 6/20/23. Review of the Resident 1 ' s acute care hospital medical record showed Resident 1 arrived to the acute care hospital on 6/20/23 at 1817 hours. Resident 1 ' s vital signs were assessed as follows: temperature 97. 5 degrees F (Fahrenheit), pulse 165 beats per minute, respirations 20 breaths per minute, and B/P 87/72 mmHg (low BP). 055237 Page 3 of 3