Panorama City Conv & Rehab Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor medical devices to prevent pressure related injuries for 2 of 4 residents (Residents 3 and 7) when reviewed for pressure injuries. Resident 3 experienced harm when they developed avoidable pressure ulcers to both heels and their left calf, related to lack of monitoring of a medical device (E-Z boot - plastic splint designed to stabilize the foot and ankle, preventing rotation and contracture with a soft, fleece-lined interior, non-skid base, and hook-and-loop velcro closure - also called a podus Boot). This failure placed residents at further risk for avoidable pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dishwasher was cleaning dishes at required temperatures for 1 of 1 kitchen dishwashers reviewed under kitchen task. This failure created the potential to expose residents to unsanitary conditions and increased risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 3 residents (Residents 3, 5 and 130) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) were regularly monitored and documented on and gradual dose reduction (GRD, psychotropic medication decrease) had adequate indication for noncompletion for 2 of 5 sampled residents (Resident 40 & 85) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards for 1 of 6 residents (Resident 49) when reviewed for bowel management. This failure placed the residents at risk for medical complications, poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse and injuries of unknown origin timely to the State Agency for 2 of 3 residents (Resident 1 & 2) reviewed for abuse and injuries of unknown origin. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or injuries of unknown origin for 2 of 3 residents (1 & 3) reviewed for abuse or injuries of unknown origin. Failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect, poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the two staff person assistance and use of a gait belt for transfers as required according to the plan of care for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell and sustained a head laceration when staff transferred them without a second staff person to assist and properly support resident with a gait belt. This failure placed residents at risk for falls with injury, pain and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments accurately reflected their health status and/or care needs for 1 of 7 sampled residents (Residents 1) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to accurately assess residents with a pressure ulcer (PU, a wound which develops due to prolonged pressure to the body) placed residents at risk for pain and discomfort, diminished quality of life and unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include resident specific information for 1 of 7 sampled residents (Residents 1) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure person centered side effect and target behavior monitoring was identified for psychotropic medications (drug taken to exert an effect on the chemical makeup of the brain and nervous system) for 4 of 5 sampled residents (Resident 74, 46, 42 & 3) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for receiving unnecessary medications, adverse side effects, falls, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food products were labeled with a prepared or use by date, staff performed hand hygiene and glove changes during meal preparation and service, and that the high temperature (Hi-temp.) dishwasher washer met the minimum wash and rinse temperatures required for proper cleaning and sanitization of resident dishware and utensils. This failure placed residents at risk for food borne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to ensure services provided met professional standards of practice when physician orders were not followed and the provider was not notified when medications were held for 1 of 5 sampled residents (Resident 40) reviewed for unnecessary medications. This failure placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice when IV orders did not include routine monitoring of IV insertion sites, weekly changes of IV dressings and needleless injection caps and an initial and then weekly measurements of IV catheters external length and the resident's arm circumferences for 1 of 1 sampled residents (Resident 74) reviewed for IV therapy. This failure placed residents at risk for loss of vascular access, infection, and other potential negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate hand hygiene was used during dining tray pass for 1 of 3 sampled rooms (room [ROOM NUMBER]) reviewed for dining and 1 of 2 sampled residents (Resident 74) reviewed for transmission based precautions. This failure placed residents at risk for facility acquired or healthcare associated infections and related complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow the resident's individualized care plan fpr safe transfers and the resident sustained a fracture requiring hospitalization. This failure placed residents at risk for injury and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to follow professional standards of practice during medication administration for 3 of 6 residents (Residents 5, 6 & 7) reviewed for medication administration. This failure to ensure services provided met professional standards of practice placed residents at risk for diversion of medication, medication errors and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 unit refrigerators (A, E, & F-Wing Snack Rooms) reviewed for food service. This failure placed residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 8 & 19) reviewed for hospice services. The facility's failure: to designate a member of their inter-disciplinary team (IDT) to be responsible for communication and collaboration with hospice staff; to obtain and maintain a current copy of residents' hospice plans of care; to identify and communicate what services/disciplines (registered nurse, chaplain, certified nursing assistant, massage therapist etc.) hospice would provide each resident and at what frequency; and to obtain hospice staffs' visit notes, detracted from the effective coordination of care and placed residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 1 of 1 sampled residents (Resident 18) reviewed for environment. This failure placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to issue the required liability notice for 1 of 3 residents (Resident 65) reviewed for liability and appeal notices. This failure placed residents at risk of not being informed of their appeal rights prior to the end of Medicare covered services and did not uphold the right to make informed choices about further treatment or services as required by the Medicare Program.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 5 sampled residents (Resident 8) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental healthcare needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were revised and accurately reflected resident care needs for 2 of 21 residents (Resident 19 and 8) reviewed for care plans. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the bowel care they were assessed to require for 3 of 7 residents (Residents 8, 48 and 5) reviewed for bowel management. The failure to administer bowel medications in accordance with physician orders (POs) and facility bowel protocol, placed residents at risk for pain/discomfort, nausea, decreased appetite, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Residents 8) reviewed for unnecessary medications, was free from unnecessary psychotropic drugs (drug taken to exert an effect on the chemical makeup of the brain and nervous system). The failure to identify the target behaviors each psychotropic medication was intended to treat, to ensure behavior monitoring accurately reflected residents' identified target behaviors, and to perform gradual dose reductions when indicated, placed residents at risk for receiving unnecessary medications and associated adverse side effects, falls, injury and a diminished quality of life.