Health inspection·March 20, 2025

F 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to arrange and confirm transportation to a doctor's appointment for one of three sample residents, (Resident 1). Residents Affected - Few This deficient practice caused Resident 1's appointment to be changed unnecessarily. Findings: A review of the admission record indicated the facility originally admitted Resident 1 on 11/16/2023 and was readmitted [DATE] with diagnoses including presence of right artificial knee joint, diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipemia (high fat in the blood), dementia (a progressive state of decline in mental abilities), abnormality of gait (not walking normal), obesity (overweight), vitamin D deficiency (low in vitamin D), overactive bladder (unable to control sudden urges to urinate) and obstructive sleep apnea (a sleeping disorder). A review of Resident 1's history and physical (H&P- the doctor's physical assessment and plan of care) dated 3/4/2025 indicated Resident 1 had a surrogate decision maker. and that Resident 1 had an appointment scheduled to see the orthopedic (bone) doctor on 3/7/2025. A review of Resident 1's minimum data set (MDS-a resident assessment) dated 3/8/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene and bathing. Resident 1 required maximal assistance (helper does more than half the effort) with toileting and transfers (moving between surfaces) from bed to chair. Lastly, Resident 1 required moderate assistance (helper does less than half the effort) with ambulating 10-50 feet using walker. On 3/19/2025 the California Department of Public Health (CDPH) received a complaint alleging the facility cancelled a doctor's appointment for Resident 1 without notifying the resident representative. During a concurrent interview and record review on 3/20/2025 at 10:05 a.m. with the social service assistant (SSA), Resident 1's nursing progress note dated 3/7/2025 was reviewed. The nursing progress noted indicated Resident 1 had an appointment with a orthopedic doctor on 3/18/2025. The SSA stated, I documented this appointment when Resident 1 returned from the initial appointment on 3/7/2025. On 3/18/2025 the certified nursing assistant (CNA) came to my office at about 10:50a.m. stating [Resident 1] had an appointment that morning at 10:45a.m. My mistake was I did not have the appointment in my folder, that is how I keep track of them, then I would set up transportation a few days before Page 1 of 3 055711 055711 03/20/2025 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the appointment, but I did not do that this time. I guess the family was already here to take Resident 1 to the appointment when the CNA told me about the appointment, but I did not know they were here already . I thought Resident 1 had missed the appointment so I called the orthopedic doctor's office and asked if they could push back the appointment to 1:00p.m. and they agreed . SSA stated, After that I contacted our driver to arrange transportation, and the driver agreed to take Resident 1 to the appointment at 1:00 p.m. After this the resident representative (RR) was already standing in front of my office yelling WHY DID YOU CANCEL THE APPOINTMENT YOU ARE NOT FAMILY and seemed very upset not allowing me to tell her that I did not cancel I just rescheduled then went and complained to the Administrator (Adm). After all of the confusion the RR was still able to take Resident 1 to the appointment at 11:30am and they returned approximately one hour later. The SSA stated, I do think this could have been avoided if I had kept track of the appointment and called the family a few days prior like I normally do to confirm the appointment and transportation . During an interview on 3/20/2025 at 11:50 a.m. with the director of nursing (DON), the DON stated on 3/18/2025 Resident 1 had a doctor's appointment and transportation had not been set up so the SSA rescheduled the appointment from 10:45 a.m. to 1:00p.m. I think the family thought we cancelled the appointment but when they spoke to the Administrator, they found out it was not cancelled just rescheduled I did not witness the interaction. I am not sure why transportation was not already arranged I did not look into it, I assumed it was resolved because [Resident 1] still went to the appointment . During an interview on 3/20/2025 at 12:50 p.m. with the resident representative (RR) stated on 3/8/2025 the RR arrived at the facility at 10:30am to take Resident 1 to the ortho appointment scheduled for 10:45 a.m. The RR stated, we scheduled the appointment at that time because it fits my schedule so we would be able to take Resident 1 to the appointment. The RR stated, the SSA was aware of this follow up appointment because we provided them with the appointment date and time when we returned from Resident 1's first appointment on 3/7/2025. The RR stated while they were in the facility on 3/18/2025 waiting to take Resident 1 to the appointment; they got a call from the ortho doctor's office informing them the appointment had been cancelled. The RR then called the Ortho doctor's office and was told the facility cancelled the appointment. The RR stated, That made me upset because we schedule all Resident 1's appointments and no one from the facility communicated with us about cancelling or rescheduling Resident 1's appointment and we were there in the facility. The facility does not know our relationship with the Ortho doctor, we have been late before, and they would still see Resident 1. The RR stated, The facility should not be cancelling and rescheduling appointments without speaking to the responsible party first. During an interview on 3/20/2025 at 3:30 p.m. the CNA stated, On 3/18/2025 between 10:15a.m. and 10:20 a.m. I had just taken [Resident 1] to the bathroom and put her back into bed when I was notified by the unidentified charge nurse (CN) that [Resident 1] had an appointment at 10:45 a.m. Usually when a Resident has an appointment it is listed n the assignment sheet, but I did not see her appointment on the assignment sheet that morning. After the (CN) told me about the appointment I went to check the appointment book, and I did not see it there, so I went to the [SSA] office to confirm the appointment with the [SSA]. I did see the family arrive to the room around 10:40 a.m. A review of the facility job description for social service assistant (no date [n.d.]) indicated the social service assistant job duties include: Arranges residents' appointments including transportation when necessary. 055711 Page 2 of 3 055711 03/20/2025 Brentwood Health Care Center 1321 Franklin Street Santa Monica, CA 90404

F 0774 A review of the facility policy and procedures titled Transportation dated 2/2025, indicated, Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to assist residents in accessing transportation according to their needs. Residents Affected - Few RATIONALE: Residents may have appointments outside the facility. While the facility is not obligated to provide this transportation, the facility is expected to help residents evaluate options and access public or private transportation according to their means and abilities to travel safely in the community. PROCEDURE: Social Service staff works with other members of the Interdisciplinary Team to determine a resident's need for transportation. A resident may also request assistance with transportation. 055711 Page 3 of 3