Health inspection·August 1, 2024

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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). Residents Affected - Few * The facility failed to ensure Resident 1 was assessed and monitored by a licensed nurse regarding bruises. In addition, the facility failed to ensure the physician or Resident 1's representative was notified of the bruises. This failure had the potential for not providing necessary care and services for the resident. Findings: Review of the facility's P&P titled Change in Condition dated 3/2021 showed it is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. If there is a significant change in the resident's physical or mental condition, a thorough assessment of the resident's condition must be done by a licensed nurse. The assessment results should assist the physician in determining the course of clinical management for the resident. Review of the facility's P&P titled Abuse Reporting and Prevention dated 4/2024 showed under the section for Reporting Procedure, the Administrator or designee shall make a reasonable attempt to reach a conclusion as to the cause of the injury and to take corrective actions during an investigation to provide a safe environment for the resident(s). Closed medical record review for Resident 1 was initiated on 8/1/24. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on 6/28/24. Review of Resident 1's H&P examination dated 6/7/24, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's Initial Nursing History and assessment dated [DATE], showed Resident had right upper cheek redness skin discoloration and right forehead redness. Review of Resident 1's Order Summary Report showed a physician's order dated 6/7/24, to administer Eliquis (blood thinner) 2.5 mg tablet one tablet by mouth two times a day for atrial fibrillation (irregular and very rapid heart rhythm). Review of the facility's investigation documents related to fall and purplish bilateral lower legs Page 1 of 2 055571 055571 08/01/2024 Buena Park Nursing Center 8520 Western Avenue Buena Park, CA 90620

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 6/21/24, showed the document titled Staff Declaration/Statement dated and signed by CNA 1 on 6/25/24, showed on 6/19/24, during the 2300 hours to 0700 hours shift, CNA 1 reported bruising and discoloration found on Resident 1's legs to the charge nurse. However, review of Resident 1's Daily Skilled Nurse's notes dated 6/19-6/20/24, showed no documented evidence Resident 1's lower legs bruises were assessed after it was reported by CNA 1 to the charge nurse. In addition, review of Resident 1's MAR for June 2024 showed the resident was being monitored for both bruising and signs and symptoms of bleeding related to Resident 1's use of anticoagulant medication. However, the licensed nurses documented Resident 1 did not have any signs and symptoms of bleeding, including bruising from 6/7 to 6/27/24, despite the documentation of skin discoloration and redness on the 6/7/24 initial nursing assessment, and the documentation of purplish bilateral lower legs on the facility's investigative report including CNA 1's interview. Further review of Resident 1's medical record showed no documentation a change in condition was completed to address the bruises noted on Resident 1's lower legs on 6/19/24, and if Resident 1's physician or representative was notified. In addition, there was no skin assessment, and/or care plan developed to address the resident's bruises. On 8/1/24 at 1304 hours, an interview was conducted with CNA 1. CNA 1 stated during her shift on 6/19/24 from 2300 hours to 0700 hours, when she was the sitter for Resident 1, CNA 1 noticed bruises on Resident 1's both lower legs. CNA 1 stated she informed the AM shift charge nurse on 6/20/24, of Resident 1's lower legs bruises. On 8/1/24 at 1400 hours, an interview and concurrent closed medical record review was conducted with the DON and ADON. The DON and ADON verified there were no documentation and/or care plan developed to address the bruises on Resident 1's both lower legs reported by CNA 1 on 6/20/24. In addition, the DON and ADON verified there was no change in condition documentation to show the physician or representative was notified of the bruises. When asked if there should have been documentation in Resident 1' medical record regarding the bruises on Resident 1's lower legs, the DON stated yes, and it was the facility's policy to document. During the interview, the DON and ADON verified Resident 1 was admitted with the right cheek and forehead redness. The DON and ADON also verified Resident 1's MAR for June 2024 showed the licensed nurses documented Resident 1 did not have any signs and symptoms of bleeding, including bruising from 6/7/24 to 6/27/24. The ADON stated Resident 1's MAR should have reflected the discoloration on Resident 1's right cheek and forehead beginning 6/7/24. 055571 Page 2 of 2