Health inspection·November 14, 2023

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a representative (ensures residents wishes are respected) was in place for two of three sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had impaired decision making abilities and did not have a representative in place to give consent for medical decisions. Residents Affected - Few This failure resulted in two clinically compromised residents making medical decisions in which resident 1 and resident 2 were unable to understand or comprehend based on their History and Physical. Findings: An abbreviated survey was conducted on October 23, 2023, at 3:55 PM, to investigate a complaint related to Resident Rights. 1.A review of Resident 1's, face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included: schizoaffective disorder (affects your thoughts, mood, and behavior), bipolar disorder (feelings of extreme happiness and sadness), psychosis (not in touch with reality), depression, and anxiety, A review of Resident 1's, History and Physical (physicians' exam) dated August 26, 2023, indicated Resident 1 cannot make medical decisions. A review of Resident 1's, Informed Consent for Medical Treatment (permission granted in the knowledge of the possible consequences) dated August 25, 2023, indicated a representative for Resident 1 had not given consent for medical treatment. A further review of the Informed Consent indicated The resident and responsible party hereby consent to the facility providing such routine nursing care as may be directed by said attending physician. Resident 1's Informed Consent for medical treatment was not signed by Resident 1's representative, a facility representative or the attending Physician. A review of the Resident 1's record titled Physicians Orders for Life Sustaining Treatment (POLST- presents a person's wishes for care in the event of incapacity or inability to communicate), dated August 28, 2023, indicated Resident 1 declined to complete the POLST. The POLST was not signed by a representative of Resident 1. 2.A review of Resident 2's face sheet (contains demographic information) indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included: Depression, and Anxiety. A review of Resident 2's History and Physical dated August 3, 2023, indicated Resident 2 cannot Page 1 of 2 555521 555521 11/14/2023 Rancho Mesa Care Center 9333 LA Mesa Dr Alta Loma, CA 91701

F 0551 make medical decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 2's record titled Physician Orders for Life-Sustaining Treatment (POLST), dated August 2, 2023, indicated Resident 2 signed this medical document as a legally recognized decision maker. A responsible party for Resident 2 did not sign this document. Residents Affected - Few A review of Resident 2's Informed Consent to (give a) Psychotropic Drug undated, indicated I have obtained informed consent from the resident and/or responsible party for the use of Olanzapine (medication used to treat schizophrenia). I have obtained informed consent from Resident 2. This document was signed by a staff member. This form did not indicate Resident 2's representative gave consent for this medication. During an observation and concurrent interview of Resident 2 on October 23, 2023, at 4:08 PM, Resident 2 stated, I am supposed to be leaving in November. They (facility staff) are supposed to find me a place. I make all the decisions here. If I can't make my decisions, then I don't know who will make my decisions. During an interview and concurrent record review with the Director of Nursing (DON), on October 23, 2023, at 4:58 PM, DON stated, Resident 1 and Resident 2 do not have a responsible person. I didn't find any notes from the Social Services Director or Interdisciplinary Team about finding a responsible person or informing the ombudsman about Resident 1 and Resident 2 receiving representation. DON stated further, the documentation does not state that the SSD tried to contact anyone regarding a responsible person for Resident 1 and Resident 2. After the DON reviewed resident 1's consents, in which resident 1 either refused to sign or there were no signatures, the DON stated for the ' Consent for Medical Treatment' which was unsigned, the doctor should have signed it and the Ombudsman should have been contacted at the start of Resident 1's stay for representation. The DON then reviewed the H&P for resident 2 and stated, Resident 2, is not supposed to sign or give consent. It is a medical decision. During an interview and concurrent record review on October 23, 2023, at 5:44 PM, the Administrator, stated, To find out if the resident can make decisions we go by the H&P. After reviewing Resident 1 and Resident 2's H&P, the Administrator stated, There should be documentation to indicate we notified the ombudsman and attempted to find representation. They should have had representation. The facility could not provide documentation that indicated they informed the ombudsman or attempted to locate a responsible party or a family member for medical consents for Resident 1 and Resident 2. During a review of the facility's Policy and Procedure titled Informed Consent undated indicated To facilitate the Attending physician informed consent procedure and to meet the requirements of section 772528(a)(b) of Title 22 of the California Code of Regulations, California Health, and Safety Code Section 1418.8 and the State Operations Manual. It is the policy of this Facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic days, physical restraints and medical devices which may lead to the inability to regain use of a body function and prolonged use. Procedure A. The facility informs Attending Physicians of the informed consent process and their responsibilities according to the regulations. B. The Attending Physician determines the capacity of the resident to make decisions and give informed consent on his/her History and Physical. If the resident is determined to not have the capacity to make informed decisions, a surrogate decision maker is identified G. If the resident is not capable of making decisions and there is no surrogate, the Interdisciplinary Team may give consent on behalf of the resident. 555521 Page 2 of 2