Health inspection·July 11, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a skin discoloration to a resident's physician and failed to complete a Situation, Background, Assessment, Recommendation form (SBAR, communication between members of the health care team about a patient's condition, usually done when there is a sudden change in condition) for one of four sampled residents (Resident 1). Resident 1 was observed by licensed nursing staff with left inner thigh skin discoloration. This had the potential for Resident 1 to have a delay in care and services and potential complications. Findings: A review of Resident 1's Face Sheet (admission Record) indicated the facility admitted the resident on 8/26/2020 and re-admitted on [DATE] with a diagnoses that included atrial fibrillation (irregular rapid heart rate) and polyosteoarthritis (in which at least five joints have arthritis [inflammation and stiffness of the joints]). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/14/2023, indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 required two-person, extensive assistance (resident involved in activity, staff provide weight-bearing support) with walking and toilet use. A review of Resident 1's Physician's Orders indicated the following: 1. Apixaban (an anticoagulant or blood thinner, also known as Eliquis), tablet 2.5 milligrams (mg, a unit of measure), give one tablet by mouth every 12 hours for atrial fibrillation, dated 10/23/2022. A review of Resident 1's SBAR dated 6/20/2023, indicated resident complained of increased low back pain and had a decline in activities of daily living and ambulation. The SBAR indicated Resident 1's physician was notified, a pelvis (bones that form a bowl-shaped structure in the area below waist at the top of the legs) x-ray was ordered, and family was notified. There was no documentation of any left inner thigh skin discoloration. A review of Resident 1's Transfer Record (assessment of a resident before being discharged from the facility to a general acute care center (GACH, or simply hospital), dated 6/21/2023 indicated Page 1 of 2 055360 055360 07/11/2023 Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042

F 0580 Resident 1 had left inner thigh massive skin discoloration and left hip skin discoloration. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/29/2023 at 4:04 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she observed Resident 1 have left inner thigh skin discoloration on 6/18/2023 or 6/19/2023, unsure of exact date, but stated she did not report to the physician or complete an SBAR because the family wanted to keep Resident 1 on anticoagulants. Residents Affected - Few During a concurrent interview and record review on 7/10/2023 at 12:08 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 1's medical record and Resident 1's Transfer Record, dated 6/21/2023. LVN 2 stated she started documenting on the Transfer Record form on 6/20/2023 because they were anticipating Resident 1 to be sent out to the GACH. LVN 2 stated she documented Resident 1 had left inner thigh massive skin discoloration. LVN 2 stated an SBAR was not completed for Resident 1's left inner thigh discoloration. When asked why there was no SBAR completed for this event or added to the existing SBAR for increased low back pain on 6/20/2023, she stated she should have either added to the exiting SBAR or created a new one. During a concurrent interview and record review on 7/11/2023 at 9:24 a.m., with the Director of Nurses (DON), the DON stated LVN 2 should have completed an SBAR for the left inner thigh discoloration or added to the existing SBAR. The DON stated licensed nursing staff should document any discoloration or bruising observed. The DON stated RN 1 should have completed an SBAR and reported the discoloration she observed on 6/18/2023 or 6/19/2023 to Resident 1's physician since the discoloration could get larger indicating there was bleeding occurring which could result in a drop in blood pressure, oxygen saturation (amount of oxygen you have circulating in your blood), and increased pain. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, reviewed 10/26/2023, indicated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision to the care plan. The policy indicated the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition. A review of the facility's policy and procedure titled, Skin Tears - Care of Abrasions and Minor Breaks, reviewed 10/26/2023, indicted to obtain a physician's order as needed and to document physician notification in the medical record. A review of the facility's Treatment Nurse Job Description, reviewed 10/26/2023, indicated licensed nurses are to initiate the nurse's skin and wound progress report upon identification of any skin problem. The document indicated to notify the attending physician promptly when any skin condition is identified and ensure that all skin conditions have corresponding treatment orders. 055360 Page 2 of 2