Health inspection·July 6, 2023

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 inform the responsible party (RP), for one of three sampled residents (Resident 1), of the development of a blister to Resident 1's left heel. This deficient practice resulted in Resident 1's RP to not be informed of Resident 1's change of condition. Findings: During an observation on 7/6/2023 at 1:45 p.m., in the Subacute Unit, Resident 1 was observed in bed. Resident 1 had splints placed to both feet. The left heel had a bandage dressing. Resident 1 was non-verbal and unresponsive. During a concurrent interview on 7/6/2023 at 1:45 p.m., with the charge nurse (CN), the CN stated Resident 1 had a popped blister to the left heel. During a review of Resident 1's Face Sheet, the Face sheet indicated Resident 1 was admitted to the facility on [DATE] for chronic respiratory failure (when lungs cannot get enough oxygen into the blood). Resident 1's ER (Emergency) Contact Name was Responsible Party (RP). During a review of Resident 1's History and Physical (H&P), dated 4/17/2023, the H&P indicated Resident 1 was admitted to the facility in a vegetative state (brain dysfunction in which a person shows no signs of awareness), ventilator dependent (person who required a breathing machine to breathe). During a review of Resident 1's Wound Care Reassessment, dated 5/24/2023 at 6:18 p.m., the documentation indicated Resident 1 had blood filled blister to the left heel. During a review of Resident 1's Nursing Narrative Note, dated 6/26/2023 at 3:10 p.m., the Nursing Narrative Note indicated the following: Resident 1's Responsible Party (RP) visited and expressed concerns and issued .RP made aware that Resident 1's Family Member (FM) made aware ., who was visiting, was informed of the closed blister to the left heel on 5/24/2023. RP stated she (RP) does not have a good relationship with FM and they (RP and FM) do not communicate. Any changes in Resident 1's condition, RP should be notified . During an interview on 7/6/2023 at 2:16 p.m., with the Nurse Manager for Wound care (NMWC), the NMWC stated the following: Resident 1 developed a blister to the left heel on 5/24/2023 and the blister has since popped. This was considered a change of condition and the responsible party (RP) should be notified of the change of condition. Resident 1's responsible party was notified on 6/26/2023, a month later. Page 1 of 2 555638 555638 07/06/2023 Los Angeles Comm Hospital 4081 East Olympic Blvd Los Angeles, CA 90023

F 0580 Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 7/6/2023 at 3 p.m., with the Director of the Subacute Unit (DSAU), the DSAU stated the following: Resident 1 developed a blister on the left heel on 5/24/2023. Resident 1's RP found out of blister to the left heel while visiting on 6/26/2023. Another family member (FM) was informed of the blister to the left heel, while visiting on 5/23/2023. Resident 1's RP should have been informed on 5/24/2023. Residents Affected - Few During a review of the undated facility's policy and procedure (P&P) titled, Change in Resident Condition/Notification of Changes, the P&P indicated, The responsible party for making medical decisions regarding the resident will be notified that there has been a change in the resident's condition, and what steps are being taken . 555638 Page 2 of 2