Health inspection·April 16, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the code status (a legal document or instruction that outlines a patient's wishes regarding medical care, particularly if they experience a cardiac or respiratory arrest) and presence of medical device was communicated accurately to the receiving facility when the resident was transferred to the acute hospital, for one of three residents sampled (Resident A). This failure had the potential to result in Resident A not to receive the correct code status during the resident's hospital stay, and could have a delay in care and treatment when the presence of medical device was not initially communicated to the receiving facility. Findings: On [DATE], at 9:30 a.m., an unannounced visit to the facility was conducted to investigate for a complaint of resident rights and quality of care. On [DATE], at 10 a.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included respiratory failure, tracheostomy (a surgical procedure where an opening is created in the neck to insert a tube into the trachea, allowing air to enter the lungs and bypass the mouth, nose, and throat), and aphasia (a language disorder resulting from brain damage). Resident A's POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order that helps people with serious illnesses make and communicate their choices about medical treatments they do or do not want to receive during serious illness), dated [DATE], indicated, .attempt resuscitation/CPR (cardio-pulmonary resuscitation-a method used to revive the heart and lungs, to sustain life) .full treatment . Resident A's Hospital Transfer Form, dated [DATE], at 12:35 p.m., indicated .Code status .DNR (do not resuscitate) .02 at 1% . The document did not include the type and size of the tracheostomy tube. Resident A's Respiratory Therapy (RT) Notes, dated [DATE], at 1:16 p.m., indicated .O2 (oxygen) 98% . trach (tracheostomy tube) secured and intact .removed off vent (ventilator-a medical device that helps a person breathe when they are unable to do so on their own) per husband's request and placed on T-bar (a medical device, placed on a tracheostomy tube, to help with breathing and allows for the delivery of oxygen) tolerated well .husband refused for downsized trach from Shiley (a type of tracheostomy tube that is flexible) 7 cuffed (an option on a tracheostomy tube) to Shiley 6.5 cuffless Page 1 of 2 055542 055542 04/16/2025 Mission Care Center 8487 Magnolia Avenue Riverside, CA 92504

F 0622 even after husband requesting to downsize trach . Level of Harm - Minimal harm or potential for actual harm A review of Resident A's Social Service Notes, dated [DATE], at 12:10 p.m., indicated . [family member] .was able to sign the new POLST for FULL code .he wants her (Resident A) out to the acute hospital. He wants to admit her (Resident A) to the hospital and hold her there until he can take her home . Residents Affected - Few On [DATE], at 1 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated when a resident was sent out, transferred to the hospital, the facility would fill in a transfer form, which would include most of the information about the resident. The RN stated the type of trach and size of the trach should be noted on the transfer form, and the current code status should also be indicated in the transfer form. On [DATE], at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A's transfer form indicated DNR, and the tracheostomy size and type should have been indicated on the transfer form, the [family member] changed the POLST to full code the morning of Resident A ' s transfer. On [DATE], at 1:20 p.m., an interview was conducted with the Respiratory Therapist (RT). The RT stated at the time of Resident A's discharge from the facility, on [DATE], Resident A was a full code, not a DNR. A review of the facility's policy titled Transfer and Discharge, dated [DATE], indicated, .For transfer to another provider .Advanced directive information .resident status .all special instructions and/or precautions for ongoing care .treatments and devices .all other information necessary to meet the resident's needs .Anticipated transfers or discharges-resident-initiated discharges .obtain physicians' orders .the interdisciplinary team completes relevant sections of the discharge summary. The nurse caring for the resident at time of discharge is responsible for ensuring the discharge summary is complete and includes .resident's status .the comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes .supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility . 055542 Page 2 of 2