555667
12/14/2023
Garden Park Care Center
12681 Haster Street Garden Grove, CA 92840
F 0842
Level of Harm - Potential for minimal harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the accuracy of the medical record for one of the two sampled residents (Resident 1) was complete and accurate. * The facility failed to ensure Resident 1's Change in a Resident's Condition or Status was initiated. This failure had the potential for the resident's care needs to not be met as their clinical information was incomplete.
Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised January 2012 showed the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 12/12/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/7/23. Review of Resident 1's Physician's Order Summary Report for November 2023 showed to transfer Resident 1 to an acute care hospital. Review of the Resident's 1 nurses' progress note dated on 11/22/23 at 1350 hours, showed Resident 1 was transferred to the acute care hospital. Further review of the nurses' progress note dated 11/22/23 at 1800 hours, showed Resident 1 returned to the facility with the right eyebrow laceration and was placed on high risk for falls. On 12/12/23 at 1349 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 2. LVN 2 verified Resident 1 had an unwitnessed fall on 11/22/23. Resident 1 was sent out to the acute care hospital on [DATE]. LVN 2 confirmed there was no change of condition initiated to show Resident 1 had sustained a fall on 11/22/23. LVN 2 further stated the change of condition must be initiated for any changes that may have occurred to any residents like falls. On 12/12/23 at 1422 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated a change in condition must be completed for every change in the residents such as falls. The DON verified Resident 1 sustained an unwitnessed fall on 11/22/23, the DON further verified no change of condition was documented to show Resident 1 had sustained a fall on 11/22/23.
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555667
555667
12/14/2023
Garden Park Care Center
12681 Haster Street Garden Grove, CA 92840
F 0842
Level of Harm - Potential for minimal harm
Residents Affected - Some
On 12/13/23 at 1450 hours, an interview was conducted with the DSD. The DSD stated the change of condition documentation had to be completed for falls. The DSD defined falls were when the resident was found on the floor whether witnessed or unwitnessed.
Based on interview and medical record review, the facility failed to ensure the accuracy of the medical record for one of the two sampled residents (Resident 1) was complete and accurate. * The facility failed to ensure Resident 1's Change in a Resident's Condition or Status was initiated. This failure had the potential for the resident's care needs to not be met as their clinical information was incomplete.
Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised January 2012 showed the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 12/12/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/7/23. Review of Resident 1's Physician's Order Summary Report for November 2023 showed to transfer Resident 1 to an acute care hospital. Review of the Resident's 1 nurses' progress note dated on 11/22/23 at 1350 hours,showed Resident 1 was transferred to the acute care hospital. Further review of the nurses' progress note dated 11/22/23 at 1800 hours, showed Resident 1 returned to the facility with the right eyebrow laceration and was placed on high risk for falls. On 12/12/23 at 1349 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 2. LVN 2 verified Resident 1 had an unwitnessed fall on 11/22/23. Resident 1 was sent out to the acute care hospital on [DATE]. LVN 2 confirmed there was no change of condition initiated to show Resident 1 had sustained a fall on 11/22/23. LVN 2 further stated thechange of condition must be initiated for any changes that may have occurred to any residents like falls. On 12/12/23 at 1422 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated a change in condition must be completed for every change in the residents such as falls. The DON verified Resident 1 sustained an unwitnessed fall on 11/22/23, the DON further verified no change of condition was documented to show Resident 1 had sustained a fall on 11/22/23. On 12/13/23 at 1450 hours, an interview was conducted with the DSD. The DSD stated the change of condition documentation had to be completed for falls. The DSD defined falls were when the resident was found on the floor whether witnessed or unwitnessed.
555667
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