Health inspection·January 14, 2025

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 interview and record review, the facility failed to notify the resident ' s representative, of a transfer to the Emergency Department (ED) for further evaluation of agitation for one of three residents (Resident 1). This failure resulted in Resident 1 ' s Representative not being informed of the transfer to the ED, limiting their ability to participate in the resident's medical care decisions to the extent deemed possible. Findings: On January 9, 2025, an unannounced visit was made to the facility for a quality of care issue. A review of Resident 1 ' s, Face Sheet, undated, indicated, resident was admitted to the facility on [DATE], with an admitting diagnosis of a resistive organism fungemia (fungal infection in the blood). On January 9, 2024, at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, the document, Appointment of Personal Representative (APR), is part of the admission packet. The DON verified, this document allowed the resident to appoint a representative to be notified in case of an emergency or to make healthcare decisions on the resident's behalf if the resident is deemed confused or incapacitated. A review of Resident 1 ' s Appointment of Personal Representative, dated, December 13, 2024, untimed, indicated, . I do wish to appoint a Personal Representative . Further review of the document indicated Representative 1 was listed as resident ' s personal representative. A review of Resident 1 ' s Nursing Narrative, dated December 13, 2024, indicated, . (Resident 1) (transferred to) ED per (Doctor) . (resident) very restless/agitated . multiple attempts to crawl (Out of Bed) . Further review of Resident 1's nursing narrative revealed no documentation indicating that Resident 1's representative was notified of the transfer by RN 1. On January 9, 2025, at 5:15 p.m., a concurrent interview with the DON, and a review of Resident 1 ' s APR, Nursing Narratives, and Notification/Transfers, was conducted. The DON stated, if a resident is deemed too confused to notify their family or representative of a transfer, staff should notify the resident's appointed representative. The DON stated, the staff should document the notification in the resident ' s medical record under the Notification/Transfers section. The DON stated, Resident 1 was transferred to the ED on December 13, 2024, at 6:30 p.m., and notification of the transfer Page 1 of 2 555417 555417 01/14/2025 Desert Regional Medical Center D/P Snf 1150 North Indian Canyon Drive Palm Springs, CA 92262

F 0580 was not documented in Resident 1's medical record. Level of Harm - Minimal harm or potential for actual harm On January 13, 2025, at 1:37 p.m., an interview was conducted with RN 1. RN 1 stated, the staff should notify the resident's appointed representative when the resident is unable to notify their family or representative. RN 1 stated, he would document the notification of the resident's representative in the Nursing Narrative note. RN 1 stated, he was Resident 1 ' s assigned nurse on the day the resident was transferred to the ED (December 13, 2024 at 6:30 p.m.). RN 1 stated, prior to the transfer, Resident 1 was combative, agitated, and confused. RN 1 stated, he received orders to transfer Resident 1 to the ED for further evaluation. RN 1 stated, he forgot to notify Resident 1 ' s Representative about the transfer to the ED. Residents Affected - Few On January 14, 2024, at 10:30 a.m., an interview was conducted with the DON, who stated, RN 1 should have notified Resident 1 ' s Representative because resident was in no condition (restless & agitated) to notify their representative herself. A review of the facilities Policy & Procedure, Resident Rights, approved, April 23, 2021, indicated, . Policy: The patient has a right to . D. A patient who had not been adjudged incompetent by the state court: 1. Has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the patient ' s rights to the extent provided by state law . L. Be notified immediately on changes such as: 4. When there is a decision to transfer or discharge the patient . 7. The facility shall also contact the patient representative if the patient so chooses. If patient is deemed incompetent the representative shall be notified consistent with this or her authority . 555417 Page 2 of 2