Health inspection·October 22, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for. This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition. Findings: During a review of Resident 1's Medical Records (MR), MR indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: palliative care (medical care to improve the quality of life for people with a serious illness), amyotrophic lateral sclerosis (progressive, fatal disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty swallowing), dysarthria (speech disorder that makes it hard to form and pronounce words due to muscle problems) and anarthria (complete loss of speech), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), gastrostomy tube ([g-tube] a tube used to provide an alternative route for delivering nutrition, fluids, and medications directly to the stomach), muscle weakness, and need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS) (a standardized assessment tool to evaluate the health and functional abilities of residents in nursing homes), dated 10/4/2024, indicated, short term and long term memory problem, and cognitive skills for daily decision making severely impaired. Review of Resident 1's History and Physical (H&P), dated 3/1/2024, indicated, Resident 1 is able to make own decisions. During a concurrent interview and record review on 10/22/2024 at 1 p.m. with the Director of Nursing (DON), Resident 1's medical chart was reviewed. Nursing progress notes (NPN), dated 8/11/24, indicated Sent to ED for further evaluation due to g-tube (gastrostomy tube) being clogged since yesterday. The DON verbalized received a phone call from Licensed Nurse (LN 2) regarding Resident 1's g-tube being clogged and stated, We tried ourselves with milking it, warm water, soda as an acid to try to break it down and were unsuccessful and sent (Resident 1) out the next morning. Further review of the NPN indicated, no documentation of interventions to unclog Resident 1's g-tube. The DON stated, There is no documentation prior to 8/11/24 . I don't know why. During an interview on 10/22/2024 at 2:53 p.m. with the Administrator (ADMIN) and the DON, ADMIN stated, We received a phone call that night and steps were taken to unclog it, and after many attempts we proceeded to send (resdient) out. The ADMIN was unable to recall the time of the phone call. The DON verbalized there is no documentation of Resident 1's g-tube being clogged and there is no Page 1 of 2 055830 055830 10/22/2024 Villa Maria Post Acute 425 East Barcellus Avenue Santa Maria, CA 93454

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation of the phone call. The DON verbalized was not sure of the cause of Resident 1's g-tube becoming clogged. During a concurrent interview and record review on 10/22/2024 at 2:53 p.m. with the DON and the ADMIN, the facility's policy and procedures (P&P) titled, Care and treatment quality of care, change of condition reporting, revised 11/2023 and P&P titled, Charting and Documentation, revised 11/2023 were reviewed. P&P titled, Care and treatment quality of care, change of condition reporting indicated, 4. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. P&P titled, Charting and documentation indicated, Rules for charting: 2. Daily notes are required as the necessary arises . 5. Continuous nurse's notes are required on all residents as the necessary arises. The DON stated, I can ' t say, if the P&Ps were followed. The ADMIN stated, The documentation wasn't as robusk as it should have been. During a concurrent phone interview and record review on 11/4/2024 at 3:53 p.m. with the DON, Resident 1's Medication Administration Record (MAR), dated August 2024, was reviewed. The MAR indicated, an X on 8/10/2024 on the noc shift (nocturnal night shift between evening and early morning) and an X on 8/11/2024 on the day shift. The DON verbalized the X means they weren ' t able to give Resident 1 the enteral (nutrition) feeding via g-tube, and the noc shift starts at 7 p.m. 055830 Page 2 of 2