Health inspection·March 19, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to support one resident's (Resident 1) right to access personal and medical records (all records maintained for the purposes of patient treatment, including reports, notes, orders, diagnoses, treatments, test results, photographs, medical images, and more); failed to provide Resident 1's and/or Resident 1's representative (RR, an individual who is authorized either by a patient or a State law, to make health care treatment decisions for the patient when the patient is unable to do so) access to the personal and medical records within 24 hours of a written request; failed to follow up and mail to the requestor (Resident 1's representative) a written statement explaining the delay and setting forth the date by which the facility will provide records or a response. This deficient practice had the potential to violate Resident 1's rights to obtain copies of the protected health information as per federal regulation and the facility's policy and procedure. Findings: During a review of Resident 1's History and Physical ( H&P, a through medical examination conducted upon admission to the facility), dated 4/29/2023, the H&P indicated, Resident 1 was admitted on [DATE] with past medical history (PMH, a record of information about a person's health) of hypertension (HTN, when the pressure in the blood vessels is above defined normal parameters) and traumatic brain injury (TBI) with right (R) subdural hematoma (SDH, a type of bleeding near your brain that can happen after a head injury) after a ground level fall; two craniotomies (surgical opening into the skull) and worsening mental status (unable to make decisions for self or speak); tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck intended for breathing) and percutaneous endoscopic gastrostomy (PEG, feeding tube inserted in the placement of a feeding tube through the skin and the stomach wall). During an interview on 3/20/2024 at 12:01 p.m. with Medical Records personnel (MR), MR stated, RR requested Resident 1's medical records and filled out an authorization form for medical record release in October 2023. MR further stated, since Resident 1's medical records contained a lot of information due to length of stay, the request was forwarded to the corporate office for medical record release. MR stated, there was no further follow up done by the facility's MR regarding Resident 1's medical records. During an interview on 3/20/2024, at 12:15 p.m. with the facility's Medical Record Supervisor (MRS), MRS stated, on 1/30/2024, the MRS received an email from the facility's MR regarding Resident 1's medical records. MRS further stated, the facility usually provides all medical records the same day Page 1 of 5 555380 555380 03/19/2024 Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436

F 0573 Level of Harm - Minimal harm or potential for actual harm as requested, but since RR wanted all medical records to be burned (write) on a compact disk (CD, a digital storage medium that can hold large amounts of data (information), the records were not released to the RR until 2/24/2024 due to a large amount of information that needed to be written on the CD. MRS further stated, by State regulation, medical records shall take no more than thirty days to be released to the requesting party. Residents Affected - Few During an interview on 3/20/2024 at 4:00 p.m. with Resident 1's representative (RR), the RR stated, the facility did not release Resident 1's medical records in a timely manner. RR further stated multiple requests for Resident 1's personal and medical information were attempted before the records were finally released to RR in February 2024. RR further stated, RR did not receive a written statement explaining the delay for the medical records requested. During a review of the facility's policy and procedure (P&P), titled, Medical Records, dated 2/24/2024, the P&P indicated, Patient are permitted in most circumstances to inspect and obtain copies of their protected health information. Copies and records will be provided, or a written denial made, in response to requests from patients or their representatives within 15 days of receipt of the request. If the facility is unable to produce records within the time limits, requestor shall be mailed a written statement explaining the delay and setting forth the date which the facility will provide records or a response. 555380 Page 2 of 5 555380 03/19/2024 Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make information available on how to file a grievance (an official statement of a complaint over something believed to be wrong or unfair) for one resident (Resident 1) and/or resident's representative (s) (RR). This failure resulted in violation of Resident 1's and/or Resident 1's representative to receive information on how to file a complaint in accordance with the Patient Rights and Responsibilities and the facility's policy and procedure. Findings: During a review of Resident 1's History and Physical ( H&P, a through medical examination conducted upon admission to the facility), dated 4/29/2023, the H&P indicated, Resident 1 was admitted on [DATE] with past medical history (PMH, a record of information about a person's health) of hypertension (HTN, when the pressure in the blood vessels is above defined normal parameters) and traumatic brain injury (TBI) with right (R) subdural hematoma (SDH, a type of bleeding near your brain that can happen after a head injury) after a ground level fall; two craniotomies (surgical opening into the skull) and worsening mental status (unable to make decisions for self or speak); tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck intended for breathing) and percutaneous endoscopic gastrostomy (PEG, feeding tube inserted in the placement of a feeding tube through the skin and the stomach wall). During an interview on 3/20/2024, at 11:04 a.m. with charge nurse (CN), CN stated, during the admission stay, Resident 1 developed Stage 4 pressure injury (Full thickness tissue loss with exposed bone, tendon, or muscle) to sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and suffered from chronic (persisting for a long time) diarrhea (loose, watery, and possibly more-frequent bowel movements) since April 2023. CN further stated, Resident 1's gastrointestinal (GI, pathway by which food enters the body and solid wastes are expelled) issues were a big concern for Resident 1's representative (RR) (Resident 1's medical decision maker) because of how diarrhea negatively affected Resident 1's health. CN stated, RR complained about Resident 1's diarrhea many times and the facility's medical director was aware of the complaint. During a review of Resident 1's medical record (MR), titled, Nursing Progress Note, dated 6/27/2023, the progress note indicated, Gastroenterologist (GI, a medical practitioner specializing in the diagnosis and treatment of disorders of the gastrointestinal tract) was called and made aware of consultation request for chronic diarrhea and stated GI will see Resident 1. During a concurrent interview and record review on 3/20/2024, with FM, the facilities and RR's email correspondence, dated 11/29/2023 was reviewed. The MR indicated, RR reached out to the facility's Chief Nursing Officer (CNO) stating that Resident 1 had chronic diarrhea and the attending physician ordered GI consultation, but the GI consulting physician did not come to see Resident 1. The MR further indicated, the CNO responded to RR stating the gastroenterologist was contacted and was going to see Resident 1 the following day. During a review of Resident 1's medical record (MR), titled, Gastrointestinal consultation, dated 12/1/2023, the MR indicated, first consultation by GI specialist was done on 12/1/2023. During an interview on 3/20/2024 at 12:01 p.m. with Medical Records personnel (MR), MR stated, RR 555380 Page 3 of 5 555380 03/19/2024 Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requested Resident 1's medical records and filled out an authorization form for medical record release in October 2023. MR further stated, since Resident 1's medical records contained a lot of information due to length of stay, the request was forwarded to the corporate office for medical record release. MR stated, there was no further follow up done by the facility's MR regarding the Resident 1's medical records. During an interview on 3/20/2024, at 12:15 p.m. with the facility's Medical Record Supervisor (MRS), MRS stated, on 1/30/2024, the MRS received an email from the facility's MR regarding Resident 1's medical records. MRS further stated, the facility usually provides all medical records the same day as requested, but since RR wanted all medical records to be burned (write) on a compact disk (CD, a digital storage medium that can hold large amounts of data (information), the records were not released to the RR until 2/24/2024 due to a large amount of information that needed to be written on the CD. MRS further stated, by State regulation, medical records shall take no more than thirty days to be released to the requesting party. During an interview on 3/20/2024, at 2:15 p.m., with facility's manager (FM), the FM stated, the facility does not have a specific department that handles grievances, but the facility's staff and the manager shall attempt to resolve the complaint first. The FM further stated, the chain of commands shall be activated, and the complaint should be forwarded to the Director of Nursing (DON) and the Chief Nursing Officer (CNO) for a follow-up if a prompt resolution cannot be achieved. The FM stated the information on filing complaints is not posted anywhere in the facility. FM further stated, there are no complaints filed by the Resident 1's representative (RR) regarding Resident 1's care, medical records, or anything else. During an observation on 3/20/2024 at 2:45 p.m., in the facility's hallway, Patient Rights signage was observed. The signage indicated that the space allocated for the information on how to file an internal (to the facility) complaint (information regarding resident's right to confidentially complain about the quality of care, the safety of the environment and services received) was left blank. During a concurrent observation and interview on 3/20/2024 at 2:46 p.m., with the facility's manager (FM), in the facility's hallway, an enclosed Bulletin Board was observed. The Bulletin Board contained a one page printed public notice intended to inform the facility's residents and visitors of a right to confidentially complain to the facility. The FM stated, the information regarding complaints in the facility was outdated and incorrect because the facility has a new process for filing complaints and the posted notice shall be updated. During an interview on 3/20/2024 at 4:00 p.m. with Resident 1's representative (RR), the RR stated, the facility does not have a clear channel for filing complaints. RR stated, multiple times RR made complaints regarding medical and treatment issues involving Resident 1's care. RR stated, the primary care physician never communicates a plan of Resident 1's care with RR and Resident 1 had to wait for months to obtain a gastroenterology consultation regarding chronic diarrhea, even though RR complained about it many times during to the management. RR further stated, Resident 1 has been having diarrhea for over six months before she was seen by a gastroenterologist specialist and continues to have chronic diarrhea without a definitive diagnosis. RR further stated, many other complaints and concerns such as inability to obtain Resident 1's medical records for months were also disregarded by the facility and no resolution of many complaints was ever achieved at the management level. During a review of the facility's policy and procedure (P&P), titled, The complaint/grievance process, dated 2/024, the P&P indicated, In accordance with Patient Rights and Responsibilities and the 555380 Page 4 of 5 555380 03/19/2024 Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few organization's desire to continually improve patient care services, the Facility elicits patients' complaints, concerns, and compliments and responds to significant patient complaints and concerns in a timely, and consistent manner. The CNO/Risk Manager and or designee(s) has the authority to investigate and resolve all patient complaints/grievances. Patient/family significant other complaints may be received at any level throughout organization. Staff is empowered to seek a prompt resolution of the complaint at the point closest to the problem. 555380 Page 5 of 5