Health inspection·April 21, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor the decision to refuse treatment for one of three sampled residents (Resident 1) when Resident 1 was given an enema (an injection of liquid into the intestine) against the wishes of Resident 1 and Resident 1 ' s responsible party (RP). This failure resulted in Resident 1 and RP feeling helpless in the ability to control healthcare decision-making and caused pain and suffering for Resident 1. Findings: A review of Resident 1 ' s admission Record, undated, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, muscle weakness and epilepsy. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool to guide care), dated 6/14/21, indicated Resident 1 had a score of eleven on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident ' s orientation to time and capacity to remember. A BIMS score of eight to twelve is an indication of moderate impairment). During an interview on 7/12/22, at 12:34 p.m., with the Social Services Director (SSD), SSD stated Resident 1 could speak and make her wishes known, and Resident 1 ' s RP was the decision maker for Resident 1. A review of Resident 1 ' s Acute Care Hospital (ACH) Emergency Department (ED) Record, dated 7/10/21, at 4:46 p.m., indicated Resident 1 arrived at the ACH ED from the facility with a chief complaint of rectal (area of the intestine where a person holds solid waste before it exits the body) bleeding, and was diagnosed with a perirectal abscess (a painful, pus-filled cavity in the rectum). A review of Resident 1 ' s ACH Surgical Service Clinical Notes, dated 7/10/21, at 10:40 p.m., indicated Resident 1 underwent a surgical procedure to open and drain Resident 1 ' s perirectal abscess. A review of Resident 1 ' s Progress Notes, dated 7/12/21, at 4:40 p.m., indicated Resident 1 was readmitted to the facility, alert and oriented. A review of Resident 1 ' s Order Summary Report, dated 7/15/21, indicated, Warm water enema x1 now one time only for constipation (solid waste which becomes hard and dry in the rectum and difficult to pass through the digestive system). Page 1 of 2 056392 056392 04/21/2023 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0578 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s Progress Notes, dated 7/15/21, at 3:35 p.m., by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 complained of constipation, but Resident 1 refused warm water enema. During an interview on 7/12/22, at 1:10 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had strongly refused to have the enema. Residents Affected - Few During an interview on 7/12/22, at 2:00 p.m., with Charge Nurse 1 (CN 1), CN 1 stated residents have the right to refuse a treatment or procedure, and the resident may not be treated against his or her wishes. During an interview on 6/2/22, at 10:51 a.m., with RP, RP stated she was Resident 1 ' s medical decision maker. RP stated she spoke by phone with CN 1 on 7/15/21, at 1:59 p.m., and when asked by CN 1 about administering an enema to Resident 1, RP stated she responded no because Resident 1 had a surgical wound, and that area was still too sore, sensitive, and delicate. A review of Resident 1 ' s Progress Notes, dated 7/16/21, at 4:09 p.m., by LVN 1, indicated, Lidocaine 25%/Prilocaine 25% ointment applied to rectal area prior to enema administration at 12:15 p.m. Ointment applied at 2:45 p.m. and enema administered thereafter. During an interview on 7/12/22, at 3:00 p.m., with LVN 2, LVN 2 stated Resident 1 had severe rectal pain following the enema, and LVN 2 administered Norco (a medication used to relieve moderate to severe pain) to Resident 1. During an interview on 6/2/22, at 10:51 a.m., with RP, RP stated she had clearly told staff, No enemas or suppositories for Resident 1. RP stated when she observed Resident 1 on 7/17/21 following the enema, Resident 1 was emotionally shut down, and was refusing food, medication and a diaper change. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights Guidelines for all Nursing Procedures, dated 7/1/21, indicated, Resident has right of refusal (medications and treatments) .Ask permission to implement the procedure. If the resident refuses, notify your supervisor. 056392 Page 2 of 2