Health inspection·March 20, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to notify the responsible party (RP, a person designated to make decisions on behalf of a resident) of resident's change of condition for one of three sampled residents (Resident 1). This failure had the potential to affect the ability of the RP to participate in the planning of resident's care and treatment plans. Residents Affected - Few Findings: Review of Resident 1's admission record, indicated Resident 1 was readmitted to the facility with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe), unspecified whether with hypoxia (low levels of oxygen in body tissues) or hypercapnia (when high levels of waste products such as carbon dioxide remain in the blood), pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), disorders of diaphragm (the muscle that separates the chest cavity from the abdomen) and unspecified diastolic heart failure (a heart condition that can lead to decreased blood flow and other complications). The record also indicated Resident 1 had a family member who was her daughter listed as a contact person. Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment, Recommendation] COC [Change of Condition] 911 Transfer, dated 10/31/2023, it indicated, Change of Condition Type: ALOC [altered level of consciousness - change in patient's state of awareness and alertness], increased lethargy [deep unresponsiveness], SOB [shortness of breath]. The record also indicated Resident 1 had increased confusion, decreased consciousness and weakness. Further review of the record indicated, Patient was found by staff laying in bed with the HOB (head of bed) at 45-degree angle. Patient was noted to be very lethargic, difficult to wake, and patient was noted with delayed verbal responses to questions from staff .Patient was responsive to painful stimuli such as sternal rub (a technique of rubbing the knuckles of a closed fist firmly and vigorously on the patient's sternum [a bone located in the middle part of the chest]). Labored shallow breaths noted upon assessment . The record indicated Resident 1 was transferred to the acute hospital through 911. It did not indicate Resident 1's daughter was notified about Resident 1's change of condition and transferred to the acute hospital During a phone interview with Resident 1's daughter on 11/20/2023 at 1:49 p.m., Resident 1's daughter stated, my mom was found unresponsive and was rushed to the emergency room. Resident 1's daughter further stated she was never been notified and she was never informed when resident was rushed to the acute hospital emergency room. During a concurrent interview and record review with nurse supervisor (NS) on 11/21/2023 at 12:45 p.m., NS confirmed the notification of the daughter was not documented. NS stated the notification of the RP or family member should have been documented in the SBAR COC form or progress notes. NS Page 1 of 2 055797 055797 03/20/2024 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further stated the daughter wanted to be notified during the hospital transfer or change of condition. NS confirmed Resident 1 preferred her daughter to be notified for any new orders, or changes in resident's condition. During an interview with the assistant director of nursing (ADON) on 01/04/2024 at 2:15 p.m., ADON stated the responsible party or emergency contact should have been notified whenever a resident needed to be transferred out to the hospital. ADON further stated notification of the RP or contact person was important for them to be aware of the resident's condition and whereabouts. During a review of the facility's policy and procedure titled, Managing Change of Condition Within PCC [Point Click Care - facility's electronic medical record], dated January 2022, indicated, Practice Standards: For emergent life-threatening events: .6. Notify the responsible party. 7. Document assessment findings and communications . Further review indicated, SBAR-Change of Condition 911 Transfer .are used to document assessments, MD (medical doctor)/RP notifications, and initial COC progress notes . 055797 Page 2 of 2