Health inspection·September 4, 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 interview and record review, the facility failed to ensure the family member or contact person of one of three sampled residents (Resident 1), was notified appropriately and in a timely manner, of the resident's significant change in condition requiring an emergency room transfer. This failure had the potential to result in physical and emotional trauma to both resident and family member. Findings: During a review of Resident 1's, admission Record (AR), dated 6/21/23, the AR indicated in part, Resident 1 was a [AGE] year-old male resident, who was admitted to the facility on [DATE] and discharged [DATE]. The AR also indicated, Resident 1 as the primary contact person but has named (name and telephone number) as a second contact person. During a review of Resident 1's, Minimum Data Set (MDS) Assessment (a health status screening and assessment tool used for all residents of long term care facilities), dated 6/28/23, Section C - Cognitive Patterns of the assessment indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a 15-point screening measure that evaluates memory and orientation with the score interpretations as follows: 13-15 = cognitively intact, 8-12 = moderately impaired, 0-7 = severely impaired) Score of 15. During a review of Resident 1's, Change of Condition (COC) Evaluation, dated 6/26/23, the COC evaluation indicated in part, Resident 1 complained of severe right hip pain, rated at a level eight out of ten (8/10) on the numeric ratings scale (pain scale: 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, 10 = very severe pain). On further review of the COC evaluation, the section under, Name of family/resident representative notified, failed to indicate that a second contact person was notified of Resident 1's change of condition. During a review of Resident 1's, Transfer Form V5, dated 6/27/23, the form indicated in part, Additional relevant information: Resident (1) complained of constant pain on his right hip . MD notified. Send resident (1) to ER (emergency room) for further evaluation per MD. Further review of the form, the section under, Key Contacts failed to indicate a second contact person was notified of Resident 1's unplanned transfer to the ER. During a concurrent interview and record review, on 7/17/23 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's, COC Evaluation, dated 6/26/23, and Transfer Form, dated 6/27/23, were Page 1 of 2 555876 555876 09/04/2023 Alta Healthcare Center of Camarillo 6000 Santa Rosa Road Camarillo, CA 93012

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed. DON could not confirm nor deny whether or not nursing staff notified Resident 1's family member or the second contact person on file, of the resident's change of condition and unplanned transfer to the ER. During a review of the facility's, policy and procedures (P&P), titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated in part, . 4) Unless otherwise instructed by the resident, a nurse will notify a resident's representative when: .b) There is a significant change in a resident's physical, mental, or psychosocial status, . e) It is necessary to transfer the resident to a hospital/treatment center. 555876 Page 2 of 2