Los Angeles Comm Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control and Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) protocols for two of six residents (Resident 23 and Resident 2), by not wearing the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during suctioning and not maintaining proper infection control practices during wound care. These deficient practices placed Residents 23 and 2 and other residents at increased risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of eight sampled residents (Resident 13 and Resident 24) had informed consent prior to the placement of hand and wrist restraints. This deficient practice resulted in Resident 13 and Resident 24 being placed in restraints without consent from their responsible party.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) orders for lorazepam (Ativan, a medication to treat anxiety [feeling of unease]), did not exceed a 14-day administration period for two of 12 sampled residents (Resident 2 and Resident 19). This deficient practice had the potential to result in prolonged administration of lorazepam placing the resident at risk for serious complications such as dependence on the medication, sedation, and withdrawal from prolonged use (the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for three of 12 sampled residents (Resident 2, Resident 7, and Resident 14). This deficient practice placed Residents 2, 7, and 14 at risk of not receiving resident-centered interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff documented and properly assessed bilateral hand edema (swelling caused by an abnormal accumulation of excess fluid trapped in the body's tissues) and documented the scab above a resident's lip for two resident of eight sampled residents (Resident 7 and 14). These deficient practices delayed care for Resident 7 and 14 and placed the residents at risk for complications due to not receiving the necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Foley catheter (a flexible indwelling tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) drained properly into the collection bag preventing the backflow of urine (when urine flows backward from the bladder to one or both ureters and sometimes to the kidneys) for one of two residents (Resident 20). This deficient practice placed Resident 20 at an increased risk for potential infection, discomfort, obstruction, and decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pulse oximetry (device called placed on a finger or earlobe used to measure the oxygen level of the blood) was applied in order to effectively monitor the oxygen saturation level ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage) for one of eight sampled residents (Resident 24) receiving respiratory services (treatment, management and care of the patient's breathing). This deficient practice placed Resident 24 at high risk of failing to detect hypoxemia (low blood oxygen), and delayed treatment that can rapidly progress to life-threatening complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders for hydrocodone-acetaminophen 5-325 (brand name Norco, an opioid medication used to reduce moderate to severe pain) did not exceed seven (7) days for one of twelve sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications related to administration of opioid medications, such as constipation, nausea, vomiting, sedation, dizziness, respiratory depression, physical dependence, addiction, and overdose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in one room with multiple residents. This deficient practice had the potential to compromise resident privacy and could potentially affect residents' health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure Resident 19's peripheral line (a small flexible tube inserted into a vein near the skin surface to administer fluids and medications) to his right forearm dressing was changed every 72 hours (three days) per policy and procedure. 2. Ensure Resident 17's peripheral line to his right-hand dressing was changed every 72 hours per policy and procedure. 3. Ensure the Medication Cart (Cart 1) was cleaned after a sticky liquid medication had spilled onto other medications. These deficient practices of not changing the peripheral lines dressing placed Resident 19 and 17 at risk for infection at the insertion site. In addition, the sticky liquid medication spill had the potential to result in cross-contamination with other medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Post the report of complaint investigation results by California Department of Public Health ([CDPH] state licensing and certification agency) during the three preceding years in the areas of the facility that are prominent and accessible to the residents, visitors, family members, or resident representative. This deficient practice placed the residents, visitors, family members, or resident representative at risk of not knowing the status of the facility non-compliance outcome results and past performance history.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 8) by failing to: 1. Ensure Resident 8's Psychiatric/Mood Disorder under section I (Active Diagnoses) diagnosis of Psychotic Disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was encoded correctly. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect Resident 8's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASRR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 8) who had a new diagnosis of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) to the appropriate state-designated authority for PASRR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 8 not receiving specialized services for mental illness. Cross Reference F641.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of six sampled residents (Resident 25) had a revised care plan for interventions on the non-behavioral restraint (a device or method used to restrict a patient's movement preventing them from removing medical tubes or lines) flow sheet. This deficient practice of not having a revised care plan for the Non-Behavioral Restraint Flow Sheet had the potential to increase Resident 25's discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out six sampled residents (Resident 11) hair was shampooed twice a week. The deficient practice had the potential for Resident feeling unkept and not clean.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the corrugated (a flexible tube that delivers oxygen to a patient from an oxygen source, such as a tank or concentrator) oxygen (air) was labeled with a date of change for one of five sampled residents (Resident 183). This deficient practice had the potential to cause respiratory infection for Resident 183.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to review and provide justification for restarting of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of out of five sampled residents (Resident 8) was acknowledged and acted upon. This deficient practice for failing to respond to recommendation from the pharmacy consultant placed Resident 8 at risk for unnecessary medication administration. Cross Reference F758.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure there were consistent indication and behavior was specifically identified and non-pharmacological interventions were attempted to support the use of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of five sampled residents (Resident 8). This deficient practice had the potential to develop an undesired effect due to unnecessary psychotropic drug use for Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the medication error rate was less than 5%. This deficient practice resulted in medication errors.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure an intravenous (fluids given directly into the blood stream) medication, Amikacin (an antibiotic used to treat serious infections that are caused by bacteria), was refrigerated as labeled. This deficient practice had the potential to result in administering an ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet a minimum of 80 square feet (sq. ft.) per resident in one room (room [ROOM NUMBER]). This failure to provide adequate space created the potential for adversely affecting the quality of life, safety, health, and the provision of care of residents who may had occupied room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review the facility failed to remove expired insulin (medication used to regulates the amount of glucose in the blood) vials for three of six residents (Residents 25, 27, and 30) receiving insulin. This deficient practice placed the residents at risk for not receiving the proper strength of insulin doses.

Inspectors wroteBased on interview and record review the facility failed to communicate with one of six sampled residents' (Resident 12) representative that Resident 12 was transferred to General Acute Care Hospital (GACH) intensive care unit (residents who are dangerously ill are kept under constant observation) due to labored breathing. This failure had the potential to result in Resident 12's representative being unaware of the residents' medical condition and status.

Inspectors wroteBased on observation, interview, and record review the facility failed to clarify the physician order for the administration route of Pioglitazone (medication to treat high blood sugar levels) for one of seven sampled residents (Resident 27). This failure placed Resident 27 at risk for aspiration due to inability to swallow medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 performed hand hygiene during a wound dressing change for one of four Residents (Resident 19). This deficient practice placed Resident 19 at increased risk of contamination of the sacral (near the lower back and spine) wound during a dressing change.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident rooms (Rooms # 16) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.