Health inspection·October 15, 2021

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) with a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) had documentation of provision of ordered nursing care related to the GT. This failure resulted in impaired communication across shifts and had the potential to result in inaccurate assessments of needed care, and unnecessary duplication of care. Findings: A review of Resident 10's face sheet indicated Resident 10 admitted to the facility with a diagnosis of dysphagia (difficulty or discomfort in swallowing). A review of Resident 10 ' s Medication Administration Record (MAR) dated 9/2021, indicated the following physician orders were not signed/initialed to indicate task completion by the night shift (the shift starting at 11 p.m. and ending 7:30 a.m. the following morning) nurse on 9/17/21, 9/18/21, 9/24/21, 9/28/21: every shift, check stomach contents before beginning a tube feeding, and delay feeding for one hour if the contents were more than 100 milliliters; elevate the head of the bed 30-45 degrees during feedings; flush the GT with 30ml of water before and after each medication. During a review of Resident 10 ' s Treatment Administration Record (TAR) dated 9/21, indicated the following physician orders were not signed/initialed to indicated task completion by the night shift nurse on 9/17/21, 9/24/21, 9/28/21, and 9/30/21: change the syringe that contained the tube feeding every night shift; monitor GT site for any redness or discharge every shift. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/13/21 at 12:50 p.m., with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated she had been the assigned nurse on the night shifts of 9/17/21, 9/24/21, 9/28/21, and 9/30/21. LVN 1 stated she had forgotten to document completion of the tasks on those dates. LVN 1 stated if the tasks were not documented, the assumption was the tasks were not performed. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/12/21, at 11:13 a.m., with the Director of Nursing (DON), the DON stated the ordered tasks without initials on the MAR and TAR indicated those tasks had not been completed. The DON stated nurses should document completion of all resident care tasks. A review of the facility policy and procedure, Center's Nursing Policies revised 6/1/21, indicated, Documentation includes information about the patient's status, nursing assessment and interventions Page 1 of 2 056121 056121 10/15/2021 Washington Center 14766 Washington Avenue San Leandro, CA 94578

F 0842 . Timely entry of documentation must occur as soon as possible after the provision of care . All patient information will be documented . Level of Harm - Potential for minimal harm Residents Affected - Some 056121 Page 2 of 2