Health inspection·September 30, 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 prevent for one of three sampled residents Resident 1, two pressure injuries from reopening and an physician order placed a Computed tomography (CT) to right foot, instead of left foot. Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk and could have delayed treatment. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: contracture right knee (stiffness), vascular dementia (brain damage by multiple strokes, causing memory loss), flaccid neuropathic bladder (bladder doesn ' t contract, lead to urine retention). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. SKIN PROGRESS REPORT: July 12, 2024, Coccyx Stage 4, measuring 3.5cmx4.6cmx0.1cm . Reopened sacrococcyx wound. 2. Skilled Nursing Facility (SNF) Wound Care Note dated July 12, 2024, Left hip reopened stage 3 measuring, 0.7x0.7x0.1, post debridement measurements 0.7x0.7x0.2. 3. Interdisciplinary Team (IDT) Note dated August 02, 2024, ' Meeting with daughter to discuss plan of care. Notified doctor family has concerns of foul smell and we are referring to osteomyelitis . 4. Order dated August 02, 2024, at 1457: May have Computed tomography (CT) (computerized X-ray imaging to Right heel to rule out osteomyelitis. (ORDER FOR THE WRONG FOOT, Right heel resolved June 03, 2024, per notes). During an interview on September 05, 2024, with the Treatment Nurse (TXT), the TXT nurse states, Resident 1 had right and left heel wounds, the right one was resolved. We were just treating his Left heel, I ' m not sure who put in the order for the Right Foot CT scan, that nurse is no longer here anymore. The wound specialist did not see signs of infection, we did notice a slight smell .she wound debride every time she came, there was slough to it. The daughter told me around the time he was sent out, it does not look well. Page 1 of 2 056429 056429 09/30/2024 Laurel Convalescent Hospital 7509 N. Laurel Ave Fontana, CA 92336

F 0684 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on September 05, 2024, with the Assistant Director of Nursing (ADON), the ADON states, On August 02, 2024, we had meeting with family, the concerns were the foot infection. We called the doctor and got an order for (CT) right heel for osteomyelitis. The family wanted to send him out, so we did not get a chance to do the CT on the foot. Acknowledge after record review, order was written for the wrong foot. Residents Affected - Few During an interview with the Director of Nursing (DON), DON states, Resident 1 wounds did reopen here, he does have medical history that can attribute. Acknowledge after record review, order was written for the wrong foot. During a review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries revised March 2023, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific factors .Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .reposition all residents with or at risk for pressure injuries on an individualized schedule, as determined by the interdisciplinary team .evaluate, report and document potential changes in the skin, review the interventions and strategies for effective ness on an ongoing basis. During a review of the facility ' s policy and procedure titled, Wound Care 2021, the policy and procedure indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 056429 Page 2 of 2