Health inspection·August 16, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop new interventions to address the prevention of displacement and clogging of one of one sampled resident's (Resident 1) nasogastric tube (NGT, a tube that is inserted through the nose going down into the stomach) when Resident 1's NGT was displaced or clogged five times between January to July 2024. This deficient practice resulted in five transfers to the acute care hospital emergency department for NGT reinsertion for Resident 1. This also had the potential of making Resident 1 feel discomfort and develop infections. Findings: Review of the admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (an interruption in the flow of blood to cells in the brain), dysphagia (difficulty swallowing) and hemiplegia (paralysis that affects only one side of your body). Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/19/24 under Section C, indicated Resident 1's short- and long-term memory was impaired, and had moderately impaired decision-making capacity (decisions poor, cues/supervision required). Review of Resident 1's Physician's Orders (PO), dated 8/9/24, the PO indicated an active diet order of NPO (nothing by mouth) dated 11/25/22 and an order of Glucerna (liquid food/nutrition) at a rate of 70 milliliters (ml., a form of measurement) per hour for 16 hours a day thru NGT. Review of Resident 1's Physical Therapy Evaluation and Treatment, dated 7/23/24, indicated the Resident 1 was able to move her left upper extremity (the region of the body that includes the left arm, forearm, left wrist, and left hand). Review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, is a structured communication framework that can help teams share information about a change in the condition of a resident) notes dated 1/15/24, 1/27/24, 3/9/24 and 7/31/24, the SBAR indicated Resident 1 ' s NGT was dislodged or was pulled out. The SBAR indicated Resident 1 was sent to the hospital ' s emergency department on 1/15/24, 1/27/24, 3/9/24, and 7/31/24 for NGT reinsertion. Review of Resident 1's SBARs dated 4/18/24 and 4/22/24 indicated Resident 1 ' s NGT was clogged. SBAR indicated Resident 1 was sent to the emergency department on 4/18/24. Page 1 of 2 555398 555398 08/16/2024 Hayward Post Acute 25919 Gading Road Hayward, CA 94544

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 1's PO dated 8/9/24, the PO indicated an order to transfer Resident 1 to the emergency department for the replacement of NGT on 1/15/24, 1/27/24, 3/9/24, 4/18/24 and 7/31/24 for NGT reinsertion. During an interview with the Licensed Vocational Nurse (LVN) 1, on 8/16/24 at 1:18 p.m. , acknowledged updating and revising the care plan to add new interventions to prevent dislodgement and clogging of NGT and could have prevented some of Resident 1 ' s transfer to the emergency department for NGT reinsertion. LVN further stated staff monitored Resident 1's NGT every 2 hours but was unable to provide documentation. During a concurrent interview and review of Resident 1's nutritional care plan dated with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/8/24 at 2:17 p.m., DON and ADON were not able to find a care plan revision and new interventions to address how to prevent the clogging and dislodgement of NGT after 1/15/24. DON stated the purpose of revising the care plan was to change the interventions because the previous intervention did not work. Review of facility's policy and procedure, titled care plan comprehensive, dated August 2021 indicated, . the interdisciplinary team is responsible for evaluation and updating of care plans: a. When there has been a significant change in the residence condition . c. When the resident has been readmitted to the facility from a hospital stay and d. At least quarterly . 555398 Page 2 of 2