Health inspection·November 26, 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 observation, interview, and record review, the facility failed to adhere to its policy titled Change in Resident Condition by not reporting a bruise sustained on the left leg for one of two sampled patients (Resident 1) to the physician and Resident 1's next of kin (daughter) This failure to escalate and address the bruise in a timely manner potentially compromised the quality and safety of care provided to Resident 1. Findings: During a review of Resident 1's Face Sheet (document containing the resident's demographic and clinical data), the Face Sheet indicated Resident 1 was admitted on [DATE] for chronic respiratory failure with hypoxia (condition where the patient does not have enough oxygen in the blood). During a concurrent observation and interview on 11/26/2024 at 2:30 p.m. with License Vocational Nurse (LVN, an entry-level health care provider who is responsible for rendering basic nursing care) in Resident 1's room, Resident 1 had yellow and light purple discoloration (bruise) on the left lower leg, approximately 5 centimeters (cm, a unit of measurement) by 5 centimeters. The LVN stated, The bruise was discovered last week, but we don't know how it happened. During a concurrent interview and record review on 11/26/2024 at 3 p.m. with the Chief Nursing Officer (CNO) and the Director of Quality and Risk Management (DQRM), Resident 1's wound photos of the left lower leg bruise dated 11/19/2024 and 11/20/2024 were reviewed. Both photos show a purple discoloration approximately 5 cm by 5 cm. DQRM stated the bruise was discovered on 11/19/2024. However, the physician was not notified by nursing until 11/21/2024, two days later. DQRM stated that upon discovery of bruising, the physician must be notified, and the resident's family should be informed. During a review of Resident 1's Wound Care, notes dated 11/21/2024, the note indicated, Patient's daughter arrived when we were seeing patient at the bedside, upset with regards to a bruise to her mother's left anterior lower leg. During a review of Resident 1's History of Present Illness (HPI, a description of the development of the Resident 1's present illness), dated 11/22/2024, the HPI indicated, Resident 1 is a resident at the skilled nursing facility (is a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services to patients) who developed the sudden onset of choking and turned pale and unconscious for an unknown period of time. The HPI further indicated Resident 1 later suffered a cardiac arrest (when the heart stop beating), which resulted in Resident 1 being Page 1 of 2 555237 555237 11/26/2024 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0580 Level of Harm - Minimal harm or potential for actual harm intubated (inserting a tube into the airway). The HPI indicated, She was placed on a ventilator (a machine that helps with breathing) .Patient has been comatose (unconscious and unresponsive) in the subacute unit (care area for medically complex patients needing long-term care) for about 9-10 years .Called by nurse to evaluate newly discovered bruise on the left shin. No history of trauma reported, no swelling no redness. No pin on palpation. Not on blood thinner. Lab ordered yesterday. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Change in Resident Condition, dated April 2022, the P&P indicated, It is the policy of this facility that all changes of conditions will be communicated to the physician and family or legal representative. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to the physician with a request for physician visit promptly and or acute care evaluation. The licensed nurse in charge will notify the physician AT ONCE . The responsible party for making medical decisions regarding the resident will be notified that this has been a change in the resident's condition, and what steps are being taken. (The resident may be the responsible party). All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met . All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that not life threatening, and weight loss or gain. The nurse in charge is responsible for notification of physician and family or legal representative prior to end of assigned shift when a change in a resident's condition is noted. Accident With Injury: Any injury that occurs, as the result of an accident will be communicated to the physician and the family or legal representative promptly. A request for a physician visit promptly and or acute care evaluation will be made by the licensed nurse in charge. 555237 Page 2 of 2