Health inspection·September 29, 2023

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 ensure for one sampled resident (Resident 1), Resident 1's oxygen delivery via tubing was secured and maintained. Residents Affected - Few This deficient practice had the potential to result in Resident 1 suffering from hypoxemia (low level of oxygen in the blood) and may lead to the resident's deterioration of medical condition. Findings: A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 was found down by family members. Cardiopulmonary Resuscitation ([CPR] is an emergency lifesaving procedure performed when the heart stops beating) was initiated prior to Emergency Medical Services ([EMS] is a system that responds to emergencies in need of highly skilled pre-hospital clinicians) arrival. The patient was intubated (a tube has been placed inside a patient's trachea through the mouth to keep airways open in an emergency setting) for airway protection. In addition the H&P indicated Resident 1's Computed Tomography ([CT] scan is an imaging test that helps healthcare providers detect diseases and injuries) scan of the head showed a large intracranial (Within the cranium, the bony dome that houses and protects the brain) and intraventricular (within the ventricles of the brain) hemorrhage (bleeding) with developing hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain). During an interview on [DATE], at 8:24 A.M., with the Nurse Manager (NM), the NM confirmed that on [DATE], Resident 1's oxygen tubing was found disconnected by the resident's family member (FM). Resident 1's FM immediately informed Staff Nurse 1 (SN1), who was with another patient in the same room. The NM stated SN1 was not sure why oxygen tubing was disconnected. The NM added there was a similar event in the past involving Resident 1, where the oxygen tubing was found disconnected. These incidents may have been the result of how staff reposition residents. During an interview on [DATE], at 9:12 A.M., with the NM, the NM stated Resident 1 was brought back from activity room to bed by Certified Nurse Assistant 1 (CNA 1) on [DATE] between the hours of 12:30 p.m. and 1:00 p.m. CNA 1 went back around 4:30 p.m. to 5:00 p.m. to reposition Resident 1. Resident 1's FM found the oxygen tubing disconnected sometime after 5:00 p.m. In the same interview, the NM stated on investigation CNA 1 did not check if oxygen tubing was connected to Resident 1 after repositioning Resident 1. The NM stated the staff should do environmental check before leaving the patient. The NM stated CNA 1 informed her that after repositioning Resident 1, CNA 1 did not check if the oxygen tubing was connected to the patient. Page 1 of 2 555074 555074 09/29/2023 Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345

F 0684 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P), titled Standards of Care - Sub Acute indicated Licensed nurse will carry out safety procedures as outlined in the Policies and Procedures for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated. Residents Affected - Few 555074 Page 2 of 2