Health inspection·September 26, 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 Based on interview and record review, the facility failed to implement their policy on acute (sudden onset) condition changes by failing to monitor a resident with hematuria (blood in the urine) for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to result in confusion in the care and services for Resident 1, which could have placed the resident at risk for not receiving appropriate care due to incomplete resident medical care information. Findings: During a review of Resident 1's admission Record, the document indicated the facility admitted the resident on 2/27/2023 with diagnoses that included metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), hereditary (passing of genetic information from parent to child) deficiency of other clotting factors, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a condition in which the heart doesn't pump blood as well as it should). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/3/2023, the document indicated Resident 1 had clear speech, was able to make herself understood, and had the ability to understand others. The MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Order Summary Report, the document indicated the following orders: - Xarelto (a blood thinner medication used to treat and prevent blood clots [gel-like clumps of blood]) oral tablet, give 20 milligram (mg- unit of measurement) by mouth in the evening for paroxysmal atrial fibrillation, ordered 2/28/2023 with a start date of 3/1/2023. - Monitor for signs and symptoms of bleeding every shift, ordered 2/27/2024. During a concurrent interview and record review on 9/20/2024 at 11:29 a.m., with the MDS Nurse (MDSN), reviewed Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a verbal or written communication tool that helps provide essential, concise information about a resident's condition) Communication Form dated 3/9/2023 and Resident 1's nursing progress notes from 3/9/2023 to 3/13/2023. The MDSN stated that after a change in condition, facility staff are to monitor the resident Page 1 of 2 055906 055906 09/26/2024 Rinaldi Convalescent Hospital 16553 Rinaldi St Granada Hills, CA 91344

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few based on the change of condition every shift for 72 hours. The MDSN stated that on 3/9/2023, Resident 1 had a change of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) and was assessed to have blood in her urine. Resident 1's physician was made aware with a new order to hold (do not administer) Resident 1's Xarelto for three (3) days. The MDSN reviewed Resident 1's nursing progress notes from 3/9/2023-3/13/2024 and stated there was no specific note monitoring hematuria on the following dates and shifts, 3/10/2024: 11 p.m. -7 a.m. shift, 7 a.m. -3 p.m. shift, 3 p.m. -11 p.m. shift; 3/11/2024: 11 p.m. -7 shift a.m., 7 a.m. -3 p.m. shift, 3 p.m. -11 p.m. shift. When asked what the importance of monitoring after a COC was, the MDSN stated that monitoring a resident after a COC is important so that staff can identify any other changes related to the specific COC. The MDSN stated if additional changes arise, staff will be able to inform the resident's physician to obtain further orders and provide additional interventions. During a review of the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, reviewed 9/20/2024, the policy indicated direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes of the nurse. Under monitoring and follow-up: The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident/patient with recent acute change of condition until the problem or condition has resolved or stabilized. During a review of the facility's policy and procedure titled, Charting and Documentation, reviewed 9/20/20024, the policy indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 055906 Page 2 of 2