Health inspection·August 5, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation Principles, to have complete documentation for one of three sampled residents (Resident 1). This deficient practice had the potential to not provide full information regarding a diagnostic service that Resident 1 received and could result in inconsistencies in providing the necessary care and treatment to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 on 9/12/2022, with diagnosis that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), pneumonia (an infection and fluid in the lungs caused by bacteria, virus, or fungi), and dysphagia (difficulty swallowing) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated, Resident 1 was rarely/never understood by others and rarely/never had the ability to understand others. During a review of Resident 1's Physician Order (PO), dated 7/5/2024, timed at 10:41 am, the PO indicated, Resident 1 had a scheduled appointment for video swallow (a study using X-ray to evaluate frequent choking, coughing, recurrent pneumonia, and problems swallowing, which may be associated with stroke or surgery) on 7/11/2024 at 11 am at General Acute Care Hospital 1 (GACH 1). During a review of Resident 1's Nurses Notes (NN), dated 7/11/2024, timed at 12:30 pm, the NN indicated, Resident 1 left the facility for Resident 1's video swallow appointment. During a review of Resident 1's NN, dated 7/24/2024, timed at 2 pm, the NN indicated, Resident 1's Family Member (FM) 1 contacted the facility to follow up on the status of a gastrostomy tube (a tube surgically placed through the abdomen into the stomach to provide access for feeding and medications) placement for Resident 1. The NN indicated, staff explained to FM 1 that facility would order copy of the video swallow test and discuss with Resident 1's physician for new order. During a review of Resident 1's NN dated 7/11/2024 to 7/24/2024, the NN indicated, no other documented follow-up notes regarding Resident 1's video swallow test result completed at GACH 1. Page 1 of 2 555903 555903 08/05/2024 The Gardens of El Monte 5044 Buffington Rd El Monte, CA 91732

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/5/2024 at 4:47 pm with the Director of Nursing (DON), the DON stated it was important to follow up on a swallow study result to prevent complications and to make sure for a resident with aspiration (food or liquid goes into the airway instead of the stomach) precautions that the facility follow through with the result. During a follow up interview on 8/15/2024 at 10:49 am with the DON, the DON stated the Assistant Director of Nursing (ADON) followed up with GACH 1's radiology (branch of medicine that uses imaging technology such as X-rays to diagnose and treat disease) department on 7/12/2024 to inquire about Resident 1's video swallow result (completed on 7/11/2024) and GACH 1 informed the ADON that the result was not ready. The DON stated the follow up made by the ADON was not documented in Resident 1's chart. The DON stated it was important to document the facility's follow-up regarding Resident 1's video swallow result in the resident's chart for communication. During a review of the facility's P&P titled, Laboratory, Radiology, and Other Diagnostic Services, revised in January 2017, the P&P indicated, if the laboratory, radiology, or other diagnostic service reports were not received within 48 hours, contact the service, and immediately request a copy of the report. During a review of the facility's P&P titled, Documentation Principles, revised in February 2018, the P&P indicated, it was the policy of the facility that resident's clinical records be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. 555903 Page 2 of 2