Health inspection·January 15, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 treatment and care provided were in accordance with professional standards of practice when vital signs monitoring was not done for one (Resident 1) out of two sampled residents. Residents Affected - Few This failure resulted in unrecognized decline of Resident 1's physical and mental status that led to hospitalization. Findings: The clinical records of Patient 1 was reviewed. She was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a movement disorder of the nervous system that worsens over time) without Dyskinesia (involuntary movements), Spinal Stenosis, cervical region (spinal canal in the neck narrows, compressing the spinal cord and nerves), psychotic disorder (mental disorder characterized by disconnection from reality) with hallucinations (a perception of having seen, heard, touched, tasted or smelled someting that wasn't actally there). A review of Resident 1's Progress Notes dated 10/16/24 at 07:50 a.m. by Licensed Vocational Nurse (LVN) A indicated, Received report from pm [afternoon] shift that this resident didn't eat dinner and didn't drink anything. So monitor her the whole shift. VS [vital signs] at 0100 .able to open eyes when called. At 0300 resident not responding but with shallow breathing .Called 911 . A review of Resident 1's hospital records dated 10/16/24 and timed 12:00 a.m. by Medical Doctor (MD) B, indicated, Critical Care Consultation And ICU Admitting Note: History of Present of Present Illness: .The patient has 24 hour assistant. She is fed by staff .was brought in from nursing facility by ambulance with chief complaint concern for altered mental status. The patient is nonverbal in the ER [Emergency Room] with decreased level of consciousness .Hypotensive with blood pressure 80/50 .The patient will be admitted to ICU [Intensive Care Unit] with: 1. Septic Shock . 2. Urinary tract infection, possible cystitis [inflammation of the bladder] . During an interview on 1/15/25 at 12:51 p.m. with LVN C, LVN C stated that Resident 1 was non-verbal, needed assistance and someone had to feed her. During an interview on 1/15/25 at 1:03 p.m. with LVN D, LVN D stated that Resident 1 was totally dependent, needed to be fed and only on rare occasions would answer staff. A review of Resident 1's Vital Signs Monitoring record indicated that Blood Pressure (BP) and Heart Rate (HR) were checked six times in September 2024 (September 3rd, 7th, 14th, 21stand 28th) and Page 1 of 2 555712 555712 01/15/2025 Morgan Hill Healthcare Center 530 West Dunne Avenue & LA Selva Morgan Hill, CA 95037

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few four times in October 2024 (October 5th, 10th, 12th and 16th). BP and HR were monitored and recorded twice on September 3rd. During a concurrent interview and record review on 1/15/25 at 2:13 p.m. with the Director of Nursing (DON), the DON verified that vital signs were not consistently checked for Resident 1 for the month of October 2024. The DON verified that prior to Resident 1's transfer to the hospital on [DATE], the previous vital signs documented were dated 10/12/24, four days prior to Resident 1's change in condition on 10/16/24. The DON stated that vital signs monitoring is done according to the physician's order. The DON verified there was no physician order for Resident 1's vital signs monitoring. A review of Resident 1's physician ordered dated 5/15/23, indicated, I certify that Skilled Nursing Services are required on an inpatient basis. A review of facility's policy and procedure (P&P) titled Vital Signs implemented on 6/12/24, the P&P indicated, .3. Vital Signs shall be obtained at least in the following circumstances: c. Daily or as often as ordered by physician for a resident receiving skilled services . 555712 Page 2 of 2