Health inspection·November 15, 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, medical record review, and facility P&P review, the facility failed to notify the physician of a change of condition for one of two sampled residents (Resident 1). * Resident 1 had a change of condition on 10/7/23 at 2106 hours, in which her blood pressure was measured at 196/90 mmHg and another change of condition on 10/18/23 at 1622 hours, in which her blood pressure was measured at 180/86 mmHg. The facility failed to conduct a change of condition assessment specific to Resident 1's episodes of hypertension and failed to notify Resident 1's physician in accordance with the facility's P&P. This failure posed the risk for changes in Resident 1's health condition not being identified, potentially delaying necessary care and treatment, which posed the risk for negative health outcomes to Resident 1. Findings Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the nurse will notify the resident's attending physician when there has been a significant change in the resident's physical condition. Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. Medical record review for Resident 1 was initiated on 10/26/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/2/23, showed Resident 1 had a diagnosis of hypertension. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. On 10/26/23 at 1335 hours, an interview was conducted with Resident 1. Resident 1 stated her blood pressures were often very high. Resident 1 stated when her blood pressures were very high, she had headache, felt lightheaded, and had stiffness in her legs. Resident 1 stated the staff were often very busy and did not always recheck her blood pressures timely after her blood pressures were very high. On 10/26/23 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she was assigned to care for Resident 1 on 10/7/23, from 1500 to 2300 hours. Review Page 1 of 3 055459 055459 11/15/2023 Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident 1's Weights and Vitals Summary showed on 10/7/23 at 2106 hours, Resident 1's blood pressure was 196/90 mmHg. LVN 1 verified the findings and stated on 10/7/23 at 2106 hours, as per the physician's order, LVN 1 administered the PRN clonidine 0.1 mg orally for Resident 1's systolic blood pressure being greater than 160 mmHgHgH. However, review of Resident 1's medical record failed to show documentation LVN 1 conducted a change of condition assessment (specific to Resident 1's blood pressure measuring 196/90 mmHg) and failed to notify Resident 1's physician of Resident 1's blood pressure of 196/90 mmHg. LVN 1 stated she did not consider Resident 1's blood pressure of 196/90 mmHg to be a change of condition warranting an assessment or notification to Resident 1's physician as hypertension was an ongoing issue for Resident 1. LVN 1 was asked at what point she would conduct a change of condition assessment (specific to hypertension) for Resident 1. LVN 1 stated she would conduct a change of condition assessment specific to hypertension if Resident 1's blood pressure did not decrease after an hour. LVN 1 stated a change of condition assessment specific to hypertension would consist of a neurological assessment and whether Resident 1 had complaints of chest pain, shortness of breath, and/or respiratory distress. However, review of Resident 1's Weights and Vitals Summary showed Resident 1's next blood pressure was not obtained for several hours after (approximately 4 hours) Resident 1's blood pressure was measured at 196/90 mmHg on 10/7/23 at 2106 hours. Resident 1's blood pressure was next obtained on 10/8/23 at 0115 hours, which was measured at 168/100 mmHg. LVN 1 verified the findings and stated she should have obtained Resident 1's blood pressure within 1 hour of Resident 1 having received the dose of Clonidine 0.1 mg PRN (administered when Resident 1's blood pressure was 196/90 mmHg on 10/7/23 at 2106 hours). LVN 1 verified during her shift (on 10/7/23 1500 to 2300 hours) that she had not conducted a change of condition assessment, nor had she notified Resident 1's physician regarding Resident 1's blood pressure of 196/90 mmHg at 2106 hours on 10/7/23. LVN 1 verified she was also assigned to care for Resident 1 on 10/18/23, from 1500 to 2300 hours. Review of Resident 1's Weights and Vitals Summary showed on 10/18/23 at 1622 hours, Resident 1's blood pressure was measured at 180/86 mmHg; however, Resident 1's medical record failed to show documentation a change of condition assessment was performed specific to Resident 1's hypertension and failed to show documentation Resident 1's physician was notified of Resident 1's blood pressure of 180/86 mmHg. LVN 1 verified the findings. Review of Resident 1's Health Status Note dated 10/21/23 at 2043 hours, showed Resident 1's blood pressure was measured at 211/97 mmHg. Resident 1's significant other subsequently called the paramedics as Resident 1 was not feeling good. Resident 1 was subsequently transferred to Acute Care Hospital 1 by the paramedics. Review of Resident 1's Health Status Note dated 10/22/23 at 0323 hours, showed Resident 1 was admitted to Acute Care hospital 1 with hypertensive crisis. On 10/26/23 at 1635 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 1 had a change of condition on 10/7/23 at 2106 hours, in which Resident 1's blood pressure was measured at 196/90 mmHg. The DON also verified Resident 1 also had a change of condition on 10/18/23 at 1622 hours, in which Resident 1's blood pressure was measured at 180/86 mmHg. The DON verified the facility failed to conduct a change of condition assessment specific to Resident 1's episodes of hypertension and failed to notify Resident 1's physician. The DON stated 055459 Page 2 of 3 055459 11/15/2023 Buena Vista Care Center 1440 S Euclid Avenue Anaheim, CA 92802

F 0580 Level of Harm - Minimal harm or potential for actual harm her expectation in accordance with the facility's P&P, was for the change of condition assessment be conducted for Resident 1's episodes of hypertension which should include any neurological changes, complaints of chest pain and/or palpitations, and/or complaints of shortness of breath, and having obtained Resident 1's vital signs every 15 minutes until Resident 1's blood pressure was within normal limits. Residents Affected - Few 055459 Page 3 of 3