Health inspection·October 24, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its own policy and procedure (P&P) titled Change of Condition Reporting dated March 2024, by not reporting to the physician that the nursing staff did not obtain urine for a urinalysis (UA- test that checks your urine for signs of health issues like infections, kidney problems, and liver disease) ordered on 9/21/2024 for one of three sampled residents (Resident 1). Residents Affected - Few This deficient had the potential for Resident 1 not being provided treatment based on the results of the UA, which could lead to a worsening infection, decreased quality of life and possibly death. Findings: During a review of Resident 1's admission Record dated indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening condition that occurs when the body's response to an infection injures its own tissues and organs), Parkinson's disease (a progressive disease of the nervous system marked by tremor [a neurological condition that includes shaking or trembling movements in one or more parts of your body], muscular rigidity, and slow, imprecise movements), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal care. A review of Resident 1's history and physical dated 9/13/2024 indicated, Resident 1 can make needs known but can not make medical decisions. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/14/2024 indicated, Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was severely impaired. Resident 1 required supervision with eating, moderate assistance with oral hygiene and personal hygiene and maximum assistance with toileting hygiene, dressing and bathing. A review of Resident 1's Physician Order dated 9/21/2024 indicated, a physician order for a UA one time be done stat (immediately). A review of Resident 1's Nursing Progress Note dated 9/25/2024, completed by Licensed Vocational Nurse (LVN) 1, indicated, station 1 charge nurse (Licensed Vocational Nurse 2 [LVN 2]) notified that a UA was not collected for lab (laboratory) on 9/21/2024. Per charge nurse (LVN 2) will attempt to collect UA if unsuccessful will endorse to oncoming nurse (a nurse who takes over resident care from another nurse at the end of their shift). Page 1 of 2 056337 056337 10/24/2024 Panorama Gardens Nursing and Rehabilitation Center 9541 Van Nuys Blvd. Panorama City, CA 91402

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/23/2024 at 1:55 p.m., LVN 1 stated that during a chart review of Resident 1's chart on 9/25/2024, stated she (LVN 1) noticed that the UA had not been collected and sent to the laboratory. LVN 1 stated that she informed LVN 2, who was working as the charge nurse of Resident 1, that the UA had not been collected. LVN 1 stated that normally when the facility receives a stat physician order to obtain a laboratory specimen, normally the physician will be notified within a one to two days if facility staff was not able to obtain the specimen. During an interview with LVN 2 on 10/23/2024 at 3:50 p.m., LVN 2 stated that she (LVN 2) was the charge nurse for Resident 1 on 9/25/2024. LVN 2 stated that she (LVN 2) was not able to obtain the urine from Resident 1 to send to the laboratory. LVN 2 stated that since the physician order was dated 9/21/2024 (to be done stat) she (LVN 2) should have notified the physician that she was unable to obtain the urine from Resident 1. During an interview with the Director of Nursing (DON) on 10/23/2024 at 4:10 p.m., the DON stated that when the physician orders a stat laboratory order it should be completed within 24 hours and if the nursing staff is not able to collect the urine for the laboratory, the nursing staff should notify the physician and complete a change of condition report on the resident. The DON stated that Resident 1's physician should have been notified that the staff was unable to obtain Resident 1's urine for the laboratory order and completed a change of condition report for Resident 1. A review of the facility P&P titled Change of Condition Reporting with a revision date of March 2024 indicated, it is the policy of this facility that all changes in resident condition will be communicated to the physician. To clearly define guidelines for timely notification of a change in resident condition. Any change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician .document resident change of condition and response in change of condition and in nursing progress notes, and update resident care plan as indicated .The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least seventy-two hours or until condition has stabled. A review of the facility P&P titled Laboratory Testing dated March 2024 indicated, it is the policy of this facility to obtain laboratory and radiology services when ordered by a physician .promptly notify the ordering entity of test results. 056337 Page 2 of 2