Health inspection·November 15, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident (Resident 3) who had a designated Advocate (AD 1) was invited to participate in the Interdisciplinary Team Meeting ([IDT] a team of health care professionals from different disciplines who work together to provide care for a resident) to discuss and participate in the revision of the care plan (a document that summarizes a resident ' s health conditions, care needs, current treatments, goals, and action plan) for one out of three sampled residents (Resident 3). This deficient practice resulted in Resident 1 ' s AD 1 not attending the IDT meeting and had the potential to result in a care plan that was not person-centered (designed specifically around the individual needs, preferences and goals of the resident receiving care) and would not meet Resident 3 ' s needs. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, abnormalities with gait (a person ' s manner of walking) and mobility (the ability to move freely or lack thereof), and Charcot ' s arthropathy (a rare disorder that causes the bones and joints in the foot and ankle to become unstable and deformed). During a review of Resident 3 ' s History and Physical (H&P) dated 1/15/2024, the H&P indicated Resident 3 had the capacity to understand and make medical decisions. During a review of Resident 3 ' s Interdisciplinary Team Conference Record dated 11/6/2024, the IDT Conference Record indicated an IDT meeting occurred on 11/6/2024 with Resident 3 in the presence of the Director of Nursing (DON) and Social Worker Representative (SWR) 1. The record indicated the care plan was reviewed with Resident 3 discussing medications, diet, and treatment. The record indicated AD 1 was not in attendance nor was there documentation indicating AD 1 was notified of the conference. During an interview on 11/15/2024 at 10:05 a.m. with Resident 3, Resident 3 stated several months ago she informed someone from the facility (does not remember who) she wanted AD 1 to be invited to and involved in all IDT meetings because she was forgetful. Resident 3 stated AD 1 was helping her handle her inaccurate care plan and other medical affairs. Resident 3 stated on 11/6/2024, the Social Worker Representative and the Director of Nursing had an unplanned rushed meeting with her regarding Page 1 of 2 555114 555114 11/15/2024 Driftwood Healthcare Center 4109 Emerald St Torrance, CA 90503

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her care plan and did not include AD 1. Resident 3 stated on the IDT meeting held on 11/6/2024, she was unable to understand what the DON was asking her and refused to sign a paper because she did not understand what she was signing. Resident 3 stated she consulted with AD 1 to verify if it was safe to sign documents. During an interview on 11/15/2024 at 2:53 p.m., with the DON, the DON stated she was not aware AD 1 was a care conference person on the face sheet and thought it was okay to have an IDT meeting without AD 1 because Resident 3 was her own decision maker. The DON stated if Resident 3 preferred an advocate at the IDT meetings AD 1 should have been invited because it was Resident 3 ' s right to have AD 1 invited and participate in IDT meetings. During an interview on 11/15/2024 at 2:59 p.m., with SWR, SWR stated the Medical Records Director (MRD) added AD 1 as the care conference person on Resident 3 ' s face sheet but she did not know when this was added. During an interview on 11/15/2024 at 3:23 p.m., with the MRD, the MRD stated months ago (exact date unknown) AD 1 and Resident 3 had informed him AD 1 was to be involved in all IDT meetings. The MRD stated although he did not remember a specific conversation the IDT meeting members were aware that AD 1 was supposed to be involved in all IDT meetings. During a review of the facility ' s policy and procedure titled Resident Rights, dated 1/1/2012, the P&P indicated the purpose of the P&P was to promote and protect the rights of all residents at the Facility. The P&P indicated state and federal laws guarantee basic rights to all residents of the Facility including the right to participate in decisions and care planning. During a review of the facility ' s P&P titled Comprehensive Person-Centered Care Planning, dated 8/24/2024, the P&P indicated the IDT may include the resident and the resident representative to the extent practicable, and an explanation must be included in the resident ' s medical record if participation of the resident and their representative is determined not practicable for the development of the resident ' s care plan. 555114 Page 2 of 2