Hancock Park Rehabiliation and Nursing Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose diagnoses included Congestive Heart Failure (CHF) with Physician's Orders in place for management of that condition, the Facility failed to ensure they maintained a completed and accurate medical record when there was no documentation to support nursing obtained his/her weights daily or monitored signs and symptoms associated with CHF.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #48, who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), a bacterium that is resistant to several antibiotics, to ensure staff implemented precautions after entering and exiting a room identified as being on contact precautions, and2. To implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.

Inspectors wroteBased on observations and interviews, the facility failed to maintain comfortable and safe temperature levels on the third floor of the East Dining Room. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for one Resident (#121) out of a total of 28 sampled Residents. Specifically, the facility failed to ensure Resident #121's call light was within reach and accessible per his/her fall care plan.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one Resident (#15), out of a total sample of 28 residents. Specifically, for Resident #15, the facility failed to provide assistance and/or supervision with meals as per the plan of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#43) with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM, out of a total of 28 sampled residents. Specifically, the facility failed to implement the discharge plan of care made by rehab services for daily ROM with care and the use of a carrot (a device utilized to position the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture injuries while helping to prevent bacteria build up and protect against increased spasticity).

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain accurate medical records for two Residents (#45, #43), out of a total of 28 sampled residents. Specifically, the facility failed:1. For Resident #45, to accurately document the presence of three new skin areas during weekly skin evaluations; and 2. For Resident #43, to accurately document the onset of a contracture.

Inspectors wroteBased on records reviewed and interviews for one of three sample residents (Resident #1), whose Hospital Discharge Summary included treatment orders related to his/her surgical incision staple removal, the Facility failed to ensure nursing provided care and services that met professional standards of practice, when nursing removed his/her staples two weeks prematurely, Resident #1 wound dehisced (partially or completely reopened along the incision line) and he/she was transferred to the Hospital Emergency Department for evaluation of the wound.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#102), out of a total sample of 24 residents. Specifically, the facility failed to provide diabetic foot care treatments and skin checks as ordered by the physician.

Inspectors wroteBased on interviews and review of facility menus, the facility failed to ensure a repetitive menu was not provided to the residents resulting in complaints about the lack of variety in food options. Specifically, the facility failed to offer a variety of the main meal to residents on a renal diet (a diet that limits sodium, potassium, phosphorus, and sometimes protein to help people with kidney disease or limited kidney function).

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain a safe and clean ice machine on three out of three floors.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure the proper care and treatment of a peripherally inserted intravenous (IV) line device (a thin flexible tube that allows for the administration of fluids, medications, and blood product directly into a vein) and to ensure proper care and treatment of an internal jugular (IJ) venous access site after IJ line removal was provided in accordance with professional standards of practice for one Resident (#102), out of a total sample of 24 residents. Specifically, the facility failed to ensure: a. for the peripheral IV site: the dressing was changed, the line was replaced/site rotated after 96 hours, an order was obtained for an extended dwell time (greater than 96 hours but a seven-day maximum), and the line was not used after the maximum dwell time of seven days; b. for the IJ site: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#47 and #32), out of 24 sampled residents. Specifically, the facility failed: 1. For Resident #47, to notify the physician and obtain orders post-left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) revision and document the Resident's condition on return to the facility post-surgery; and 2. For Resident #32, to remove the pressure dressing applied by the dialysis center to the fistula in the left arm, as ordered by the physician, as recommended by the dialysis center and to provide proper monitoring of the site.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for one Resident (#74), out of a total sample of 24 residents, to ensure Albuterol Inhalation Aerosol Solution (a bronchodilator used to relax airway muscles) was not left unsecured and unattended in the Resident's room.

Inspectors wroteBased on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#23), out of a total sample of 24 residents, hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to ensure collaboration between the facility, Hospice, and the family, regarding the Hospice Aide schedule and the decrease in services for the weekly Hospice Aide to ensure the continuity of care for the Resident.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a physician's order dated 9/27/23, for nursing to obtain a urine sample for a suspected urinary tract infection (UTI), the Facility failed to ensure nursing staff promptly notified his/her physician when they were unable to obtain his/her urine sample in a timely manner. Resident #1's urine sample was not obtained by nursing until 10/05/23 (more than a week later), which resulted in a delay in treatment.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a physician's order dated 9/27/23, for nursing to obtain a urine sample for a suspected urinary tract infection (UTI), the Facility failed to ensure he/she received care and services consistent with professional standards of practice, when his/her urine sample was not obtained by nursing until 10/05/23 (more than a week later), which resulted in a delay in treatment of Resident #1's UTI.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement treatment interventions for a deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin), for one Resident (#58), out of a total of 27 sampled residents. Subsequently, the wound deteriorated.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure dignity was maintained for residents on the Four East Unit, out of a total of six nursing care units.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure an injury of unknown source was reported to facility administration and the State Agency for one Resident (#16), out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice were maintained for three Residents (#16, #31, and #328), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Residents #16 and #31, to ensure nursing staff accurately assessed skin changes; and 2. For Resident #328, to provide wound dressing treatment to skin tears as ordered by the physician.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide appropriate treatment and services related to hearing for three Residents (#115, #5, and #1), out of a total of 27 sampled residents.

Inspectors wroteBased on observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of four nurses observed made three errors in 27 opportunities on two of three units resulting in a medication error rate of 11.11%. These errors impacted three Residents (#87, #5 and #58), out of seven residents observed.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure medications with shortened expiration dates were labeled and dated after being opened for 2 out of 3 medication carts.