Health inspection·February 5, 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 provide needed care or services based on professional standards of practice to one of three sampled residents (Resident 1) when: Residents Affected - Few 1. Resident 1 did not receive a Magnetic Resonance Imaging (MRI-scanner that uses magnetic and radio waves to generate images of the organs in the body) and physician was not notified regarding refusal of Resident 1; and 2. There was no documented evidence the physician was notified regarding the refusal of the MRI for Resident 1. These failures had the potential to negatively affect Residents 1 ' s health, due to the potential of an undiagnosed injury. Findings: During an interview on 12/19/23, at 1:11 p.m., with Resident 1, she was unable to answer simple questions. During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS- tool used to screen and identify the cognitive condition of residents), dated 10/7/23, the BIMS indicated, a score of 11 (indicating moderate cognitive impairment: confusion or memory loss that is happening more often or is getting worse during the past 12 months.) During a review of Resident 1 ' s Trauma Critical Care Prog Note dated 6/25/23, Progress Note indicated, Resident 1 was admitted to Trauma Critical Care unit on 6/25/23. During a review of Resident 1 ' s Diagnosis, Assessment & Plan from the acute care hospital dated, 6/25/23, indicated, Problem List 1. Vertigo. 2.fracture of nasal bone. 3. Pneumothorax [collapsed lung] 4. Multiple rib fractures 5. Chest wall hematoma [a solid swelling of clotted blood within the tissues] 6. Thoracic [part of middle spine] compression fracture. 7. Fracture of distal fibula [lower leg bone]. During a review of Resident 1 ' s MD Progress Noted dated 8/23/23, the Progress Note indicated, [Resident 1] who was sent to ED after a MVC[motor vehicle collision] LOC [loss of consciousness] 2-3mins. Found pneumothorax, multiple ribs fracture, [left] ankle and wrist fracture. CT[computed tomography: medical imaging technique used to obtain detailed internal images of the body] head noted [left] frontal scalp hematoma and [right] nasal bone [fracture]. [Resident 1] was confused after accident. Page 1 of 2 056037 056037 02/05/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Facesheet (undated), Facesheet indicated, Resident 1 was admitted to facility on 6/29/23. During a review of Resident 1 ' s Physician Order dated 9/19/23, Order indicated, Neurology consult, MRI of head Dx[diagnosis]: Residents Affected - Few Decreased cognitive function after car accident. During a review of Resident 1 ' s Order Details, dated 10/17/23, Order details indicated, facility ordered a MRI due to cognitive function. During a review of Resident 1 ' ' s Progress Note dated 11/21/23, Progress note indicated, Resident refused to go to MRI @ 11:30 AM. During a concurrent interview and Record Review, on 12/19/23, at 4:17 p.m., with Director of Nursing (DON), Resident 1 ' s Progress notes dated 6/29/23-12/19/23 was reviewed. The Progress notes indicated, no documentation Resident 1 ' s doctor was notified of her refusal for the MRI. DON stated, There should be a progress note regarding the refusal of Resident 1. There is no way to confirm MD was aware. During a review of the facility ' s policy & procedure (P&P) titled, Refusal of Treatment, dated 2014, the P&P indicated, 2. Notify the Physician of the resident ' s refusal of treatment and document notification. 056037 Page 2 of 2