Health inspection·May 24, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy when staff did not notify the physician and alternative physician promptly for a change of condition for one of four sampled residents (Resident 1). This failure had the potential to result in a delay of treatment for redness, swelling and tender to touch of the left foot of Resident 1. Findings: During a review of Resident 1 ' s admission Record (general demographics) on May 22, 2024, the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnosis that included type 2 diabetes mellitus (a condition of that occurs when the sugar in the blood is too high), osteoporosis ( a condition that causes bones to become weak and more likely to break), hypertension, rheumatoid arthritis (a condition of joint swelling and pain), contracture of muscle left lower leg (a condition that occurs when the muscles, tendons, joints and tissues tighten or shorten). During a review on May 22, 2024, at 10:00 am, of Resident 1 ' s document, COC (Change of Condition)/INTERACT ASSESSMENT FORM (SBAR) (Situation Background Assessment Recommendation) v1.4 dated, May 14, 2024, at 11:47 am, the document indicated, .0900 alerted by cna (Certified Nursing Assistant) that pt is complaining of L. (left foot) pain. 0915 resident assessed. All vitals WNL (within normal limit) redness and swelling noted to L. foot tender to touch .0920 dr (Doctor) [Name of physician] notified, picture attached. No response . 1435 dr [Name of physician] updated, no response this shift. endorsing to next shift. daughter contacted and no response, message left . A review on May 22, 2024, at 10:00 am, of Resident 1 ' s Progress Notes, dated, May 14, 2024, at 9:47 pm, indicated, MD made aware of resident noted with edema and discoloration to left ankle and foot. MD order for CBC (complete blood count) AND XRAY TO LEFT FOOT AND ankle. Resident made aware . A review on May 22, 2024, at 10:00 am of Resident 1 ' s Progress Notes, dated, May 15, 2024, at 2:28 am, indicated, RECEIVED NEW ORDER FROM DR. [Name of physician]. MAY TRANSFER RESIDENT TO ACUTE HOSPITAL TO RULE OUT DVT (deep vein thrombosis) due to left leg swelling discoloration . During an interview on May 22, 2024, at 1:48 PM, with the Registered Nurse Supervisor (RNS), the RNS was asked about a change of condition of Resident 1. The RNS stated, Usually, we call to report to the physician immediately any change of condition and follow new orders if any. The RNS further stated, Usually, another call is made shortly to follow up with the physician if there is not an Page 1 of 2 056429 056429 05/24/2024 Laurel Convalescent Hospital 7509 N. Laurel Ave Fontana, CA 92336

F 0580 immediate response. Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy and procedure (P&P), titled, Change of Condition dated, March14, 2024, indicated, Purpose: TO ENSURE PROPER ASSESSMENT AND FOLLOW-THROUGH FOR ANY RESIDENT WITH A CHANGE OF CONDITION . CONTENT: A. ALL CHANGES OF CONDITION IN A RESIDENT SHALL BE HANDLED PROMPTLY . C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions . b. PHYSICIAN SHALL BE CALLED PROMPTLY. If for some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity . Residents Affected - Few During a concurrent interview and record review on May 22, 2024, at 1:55 PM, with the Administrator (Admin), the P & P titled, Change of Condition dated, March14, 2024, was reviewed. The Admin. acknowledged that nursing staff did not follow facility policy for promptly notifying the physician of a change in condition of Resident 1. The Admin. further stated, The staff should have called and notified an alternative physician or the Medical Director. 056429 Page 2 of 2