Health inspection·October 2, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 nursing professional standards were provided for two of three sampled residents (Resident 1 and Resident 3), when: Residents Affected - Few 1. No documentation of an assessment (to evaluate a resident ' s health) was found in Resident 1 ' s electronic health record (EHR – a digital version of a resident ' s medical history) when Resident 1 had heart rate of 106 beats per minute (bpm – the normal range is between 60 to 100 bpm, an elevated heart rate is greater than 100 bpm and may indicate many problems such as pain, infection, or anxiety). This failure resulted in Resident 1 ' s elevated heart rate not being addressed for more than three hours from 8:19 p.m. to 11:38 p.m. 2. Resident 3 ' s range of motion services (ROM – activity aimed to improving movement of a specific joint) on 9/29/24 and 10/1/24 were not indicated as given in Resident 3 ' s EHR. This failure had the potential for Resident 3 to develop contractures (permanent tightening of muscles, tendons, ligaments, or skin that prevents normal movement of a body part). Findings: 1. During an observation on 10/02/24 at 12:10 p.m., in Resident 1 ' s room, Resident 1 was lying in bed, eyes closed, enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) being provided through a gastronomy tube (G-tube – a tube that is placed directly into the stomach through the abdominal wall incision for administration of food, fluids, and medications), and had a tracheostomy stoma (a surgically created opening in the neck that allows the person to breathe). During a review of Resident 1 ' s undated face sheet (a document that summarizes a resident ' s personal and medical information), the face sheet indicated Resident 1 was admitted on [DATE] with an admitting diagnosis of respiratory failure (a condition where the lungs cannot get enough oxygen into or remove enough carbon dioxide from the blood). During a review of Resident 1 ' s History and Physical (H&P), dated 6/4/24, the H&P indicated Resident 1 was bed bound, had a tracheostomy, G-tube, and contractures. During a review of Resident 1 ' s Consultation Report (CR), dated 6/12/24, the CR indicated Review of Systems: Unable to be obtained because of altered mental status [change in level of awareness, cognition, attention, or consciousness]. The CR further indicated Resident 1 was unable to respond to verbal stimulation. Page 1 of 3 555874 555874 10/02/2024 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s care plan (a document that outlines the care and support a person needs, including the actions, interventions, and goals of their care), revised date on 9/5/24, the care plan indicated, The resident has .a communication problem r/t [related to] Respiratory impairment . Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. During an interview on 10/2/24 at 12:18 p.m. with Registered Nurse (RN) 1, RN 1 stated facility procedure for residents with vital signs (objective measurement of the body ' s basic function such as blood pressure, heart rate, oxygen level, body temperature, and respiration rate) out of normal range would be addressed right away, and facility practice is to reassess the resident ' s vital sign, then administer any as needed physician standing (PRN - instructions already in place) orders for the abnormal vital sign. RN 1 further stated the attending physician would be notified of the abnormal vital sign if there were no standing orders, then the nurse will carry out the physician ' s orders. During an interview on 10/2/24 at 12:35 with Registered Nurse (RN) 2, RN 2 stated facility practice for residents with abnormal vital signs (vital signs outside of acceptable range) was to first assess the resident, then provide any PRN orders for the abnormal vital sign. RN 2 then stated the resident ' s attending physician would be notified if no PRN orders were available, the nurse would then carry out the new orders and reassess the resident after the intervention was given. During a concurrent interview and record review on 10/2/24 at 2:23 p.m. with the Risk Management Specialist (RMS), Resident 1 ' s vital signs EHR dated 9/20/2024 was review. The EHR indicated Resident 1 ' s heart rate was 106 bpm at 8:19 p.m. and the following heart rate documented was at 11:38 p.m. The RMS verified no vital sign was documented after 8:19 p.m. and before 11:38 p.m. During an interview on 10/2/24 at 4:12 p.m. with the Director of Quality and Risk Management (DQRM), the DQRM stated an assessment of the heart rate should be rechecked and documented after the nurse received notification of an abnormal heart rate and prior to administration of PRN orders. During a review of the facility ' s policy and procedure (P&P) titled Documentation, dated September 2022, the P&P indicated, Continuous reassessment of the patient is a nursing expectation, with documentation expected as changes occur. 2. During a review of Resident 3 ' s face sheet, (undated), the face sheet indicated Resident 3 was admitted on [DATE] with an admitting diagnosis of chronic respiratory failure (a long-term condition that makes it difficult to breathe). During a review of Resident 3 ' s Consultation Report (CR), dated 8/3/24, the CR indicated, . patient is in persistent vegetative state (a chronic condition where the patient is unable to respond to visual, auditory, tactile, or painful stimuli), chronic respiratory failure, manifests flaccid quadriplegia (a type of paralysis that causes the muscle in the limbs to become limp). During a review of Resident 3 ' s care plan (a document that outlines the care and support a person needs, including the actions, interventions, and goals of their care), undated, the Care Plan indicated, The resident is .Ventilator dependent r/t [related to] Respiratory Failure . Maintain muscle strength with active/active assistive/passive ROM and prevent contractures with use of splints [a medical device that stabilizes and immobilizes a body part]. 555874 Page 2 of 3 555874 10/02/2024 Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/2/24 at 12:35 p.m., with RN 2, RN 2 stated ROM services was provided by the resident ' s assigned licensed nursing staff and documentation of services rendered was completed in the resident ' s EMR. During a concurrent interview and record review on 10/2/24 at p.m., with the Assistant Chief Nursing Officer (ACNO), Resident 3 ' s EHR of nursing tasks was review. The EHR indicated a nursing task of passive (movement of the body or limbs without the resident ' s effort) ROM to be provided every week on Sunday, Tuesday, and Friday at 1 p.m. The EMR was found blank on the dates of Friday 9/29/24 and Tuesday 10/1/24 for the passive ROM nursing task. The ACNO stated there was no documentation on Resident 3 ' s EHR on 9/29/24 and 10/1/24 that indicated Resident 3 received the ROM service. During a review of the facility ' s P&P titled Documentation, revised date September 2022, the P&P indicated, Physiologic monitoring data, treatments, procedures and other repetitive activities in the care of the patient are documented in the patient ' s medical record following the occurrence . 555874 Page 3 of 3