East Los Angeles Doctors Hosp

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the can opener was maintained in a sanitary manner in the kitchen. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in two of two residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prescribing provider obtained informed consent for the administration of psychotropic medication (drugs that alter brain chemistry to affect mood, thoughts, perceptions, and behavior) for three of three sampled residents (Residents 4, 14, and 5), and failed to renew the psychotropic informed consents every six months for one of three sampled residents (Resident 5). These deficient practices removed Residents 4, 14, and 5's responsible parties right to make an informed decision to consent to, or continue, administration of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to elevate the head of bed (HOB) during the administration of enteral feeding ( tube feeding, liquid nutrition delivered directly into the gastrointestinal tract via a soft tube), and perform daily behavioral monitoring for residents receiving psychotropic medications (drugs that alter brain chemistry to affect mood, thoughts, perceptions, and behavior), as indicated in the care plan, for five of 12 sampled residents (Residents 9, 13, 16, 4, and 14), These deficient practices placed Residents 9, 13, and 16 at risk for aspiration (the accidental inhalation of foreign material into the airways/lungs, causing issues like pneumonia [an infection/inflammation in the lungs]) and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) was elevated for three of seven sampled residents (Residents 9, 13, and 16) during the administration of enteral feeding (liquid nutrition delivered directly into the gastrointestinal tract via a soft tube). This deficient practice placed Residents 9, 13, and 16 at risk for aspiration (the accidental inhalation of foreign material into the airways/lungs, causing issues like pneumonia [an infection/inflammation in the lungs]) and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures by not ensuring the phlebotomist (health worker trained in drawing venous blood) donned (to put on) personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to performing blood collection, and by not ensuring the phlebotomist did not place phlebotomy supplies on another resident's bedside dresser and disinfect after use for two of 12 sampled residents (Residents 4 and 6). These deficient practices placed Residents 4 and 6 at risk for cross contamination and increased the risk for spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure RNA services were performed daily for five out of six sampled residents (Resident 5, Resident 8, Resident 21, Resident 22 and Resident 23). This deficient practice had the potential to decline in functional mobility and contractures.

Inspectors wroteBased on interview and records review the facility's staff failed to: 1. Ensure one out of two sampled residents (Resident 13) rights were not violated by not explaining medications that were given. This deficient practice had the potential of the resident lower the resident self-esteem.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had a revised care plan for outside food. This deficient practice of not revising the care plan for outside food had the potential to place Resident 12 at risk for aspiration (the act of breathing in a foreign object).

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had physician orders that were not updated for the diet plan. This deficient practice of not updating physician orders for Resident 12's diet had the potential to cause a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that involves testing a sample of blood, urine, or other substance from the body) of phenobarbital level (a test that measures the amount of phenobarbital-a medicine used to treat seizure, in the blood) for the month of October 2024, was completed for one of one sampled resident (Resident 20). This deficient practice had the potential for Resident 20's to have abnormal values or drug toxicity (accumulation of an excessive amount of any medication in the bloodstream) that would result in delay of treatment and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had accurate documentation to have food from home. This deficient practice of not accurately documenting food brought in by Resident 12's family and friends which had the potential for Resident 12 to aspirate (the act of inhaling food, liquids, or other material into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete the Revised McGeer Criteria (minimum set of signs and symptoms which when met, indicate that a resident likely has an infection and that an antibiotic (a drug used to treat infections caused by bacteria) might be needed) for Infection Surveillance Checklist for two out of two sampled residents (Resident 17 and 20). This deficient practice had the potential to result in the development of multi-drug resistant organisms ([MDRO] - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) from inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food items were labeled and expired food was not stored in the kitchen accessible to be used in preparing foods for one of 22 sampled residents (Resident 17) on the Sub-Acute unit. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses.