Health inspection·January 31, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some 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 observation, interview, and medical record review, the facility failed to notify the resident's representative regarding the change of condition for one of two sampled residents (Resident 1). This failure posed the risk of violating Resident 1's rights. Findings: Review of the facility's P&P titled Significant Change of Condition, Response dated 12/2023 showed the resident's representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Medical record review for Resident 1 was initiated on 1/29/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 1/3/24, showed Resident 1 did not have the capacity to understand and make medical decisions. Review of Resident 1's eInteract Change in Condition Evaluation dated 1/20/24, showed the resident was noted to have pulled out his indwelling urinary catheter with moderate clotted blood noted in the diaper. The name of family or health care agent notified section showed the resident representative's name and a note showing to endorse to notify in the morning. Review of Resident 1's progress notes of a change of condition notes dated 1/21/24 at 1130 hours, showed while doing the nursing rounds at around 1100 hours, the resident was noted with his catheter in his hand. Upon the assessment, the resident had pulled out his indwelling urinary catheter with slight bleeding noted around the urethral opening. On 1/29/24 at 1115 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 was asked when the family should be notified about the change of condition. RN 1 stated they should be notified immediately, and it should be documented. If they were not able to reach the family, they should endorse and document it. On 1/29/24 at 1330 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 was asked if he had notified the family regarding Resident 1 pulling out the indwelling urinary catheter on 1/21/24. LVN 3 stated he did not notify the resident's family right away but spoke with them when they came to the facility. LVN 3 also stated the family was upset because they were not notified about the resident pulling out the catheter on the previous day. LVN 3 was asked if he Page 1 of 2 055570 055570 01/31/2024 St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some could provide any documentation showing he had notified the family and stated he did not document it. LVN 3 verified the finding. On 1/30/24 at 1240 hours, an interview was conducted with LVN 4. LVN 4 was asked if she had notified the family when there was a change of condition for Resident 1 on 1/20/24 at 2000 hours. LVN 4 stated she was busy during her shift and did not call the family to notify them of Resident 1's change in condition. When asked why she wrote she would endorse to notify in the morning, LVN 4 stated it was an error and should be endorsed to the next shift. LVN 4 verified she should have notified Resident 1's family of the change in condition. On 1/31/24 at 0850 hours, an interview was conducted with LVN 7. LVN 7 was asked if LVN 4 had endorsed to call the family regarding Resident 1 pulling out the catheter. LVN 7 stated he did not recall and did not call the family. 055570 Page 2 of 2