Health inspection·January 24, 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 interview, medical record review, and facility document review, the facility failed to ensure the head and neck support for one of five sampled residents' (Resident 1) highbacked personalized wheelchair was in the correct position when Resident 1 left the facility for an outing with her family on 12/30/23. This failure resulted in Resident 1's head being tilted to one side and incorrectly aligned in her wheelchair, causing pain, and psychological distress, which had the potential to negatively impact the resident's well-being. Residents Affected - Few Findings Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was originally admitted to the facility on [DATE],and readmitted on [DATE]. Resident 1 had a diagnosis of MS. Review of Resident 1's H&P examination dated 10/3/23, showed Resident 1 had the capacity to understand and make medical decisions. Review of Residents 1's MDS dated [DATE], showed the resident was cognitively intact. Resident 1 required substantial assistance rolling side to side and was dependent on the staff for transfers from the bed to the chair. On 1/17/24 at 1541 hours,an interview was conducted with Resident 1's Family Member (Family Member 1). Family Member 1 stated a family gathering at the mall was planned for 12/30/23, because Resident 1 wanted to see the decorations. Family member 1 stated when Resident 1 arrived at the mall, it was visibly obvious that she was not in her chair correctly. Her head was just dangling off to one side, she was sliding down in her wheelchair, and she was in pain. Family Member 1 stated it took three people to adjust and reposition Resident 1. Family Member 1 added they had a very hard time adjusting Resident 1's head. On 1/18/24 at 1045 hours,an interview was conducted with Resident 1. Resident 1 stated she had been waiting for that day for months. Resident 1 stated before she left the facility, she had told the staff that she was turned sideways and needed to be readjusted. Resident 1 stated the staff told her that they could not adjust her because the bus was already there to pick her up. Resident 1 stated the bus ride was very bumpy, which caused her head to move side to side and all around because her head was not secured in the wheelchair head rest. Resident 1 stated she slid down in the wheelchair. Resident 1 stated it was very uncomfortable and scary. Resident 1 stated her neck had continued to hurt since that day. On 1/18/24 at 1530 hours,an interview and concurrent medical record review was conducted with the Page 1 of 2 055671 055671 01/24/2024 Parkview Healthcare Center 1514 E. Lincoln Avenue Anaheim, CA 92805

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few SSD. The SSD stated Resident 1 went out on pass to the mall to visit with her family. The SSD stated shereceived a report from Resident 1's family that Resident 1 was uncomfortable in the wheelchair during their visit to the mall. The SSD stated the family also sent pictures of Resident 1 in her wheelchair while she was at the mall. Review of the photos showed Resident 1 sitting in her wheelchair and tilted on to the right side with her neck bent so far that her right her cheek was touching her right shoulder. The SSD stated Resident 1 did not have neck control and the head support on the wheelchair was not extended or it was not there at all. The SSD stated the wheelchair was not tilted backwards. The SSD stated shealways accompanied the resident to the medical appointments and made sure the wheelchair was tilted back so the resident's head restingagainst the support and the resident did not fall forward. On 1/18/24 at 1600 hours, an interview and concurrent observation of Resident 1's wheelchair was conducted with the SSD and DSD. The DSD confirmed the head rest support was flush with the top of the back of the wheelchair and not in the proper position. The DSD tried multiple ways to get the head rest support to raise up. The DSD confirmed it was difficult to reposition. On 1/24/24 at 1139 hours, a telephone interview was conducted with CNA 4. CNA 4 stated he got Resident 1 ready for the visit with her family on 12/30/23. CNA 4 stated hedid not touch Resident 1'sneck support because he did not have the tools to adjust it. CNA 4 stated Resident 1 waited for the bus ride in the front entrance of the facility. CNA 4 stated while Resident 1 was waiting to be picked up, her wheelchair was only tilted back a little bit because she liked to be able to see when the bus arrived. CNA 4 stated Resident 1 normally had her wheelchair tilted back to about 30 degrees. CNA 4 stated the longest Resident 1 could stay in her wheelchair was two hours. CNA 4 stated Resident 1 was upright when she returned to the facility that day. On 1/24/24 at 1006 hours, an interview was conducted with the DON. The DON confirmed Resident 1's wheelchair headrest was not in the proper position when Resident 1 was on pass to visit her family. The DON stated the wheelchair should have been tilted back so the weight of the resident's head was back, to allow for the head to be supported. The DON confirmed the resident was not correctly positioned in the wheelchair during her family visit. 055671 Page 2 of 2