Torrance Memorial Med Ctr SNF/Dp

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a change of condition for one of one sampled residents (Resident 35) when Resident 35's oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) decreased to 90 percent ([%] a number or ratio expressed as a fraction of 100) on room air (normal O2 sat is 92% -100%). This failure resulted in Resident 35 experiencing respiratory distress, agitation and being transferred to the General Acute Care Unit (GACH) for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent in providing one to one care ([1:1 sitter] provides constant supervision to a single patient to ensure safety) for one of one residents (Resident 38) who was diagnosed with suicidal ideations (death caused by injuring oneself with the intent to die) in the facility. This deficient practice had the potential to affect Resident 38 and all residents requiring close observation, and placed them at risk for self-harm, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:Ensure staff change gloves after picking up a dirty trashcan and before passing medications to one of three sampled residents (Resident 4). Ensure visitors followed Enhanced Barrier Precautions (EBP- infection control steps requiring staff to wear gowns and gloves during high-contact care [dressing, bathing, or changing linen] for residents with, or at risk of, germ-resistant infections) for one of three sampled residents (Resident 40). These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place all residents at risk for spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: a. opened, unlabeled and undated bag of pepperonis with freezer burns was not stored in the freezer and was discarded. b. the temperature on a High Temperature Dishwasher wash cycle was 150 degrees Fahrenheit. These failures had the potential to result in residents eating compromised quality of meat due to dryness and altered texture and had the potential to result in residents being exposed to rapid growth of bacteria that can cause foodborne illness (food poisoning).

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician on one of four sampled residents (Resident 122) by: 1. Failing to notify the physician and document a change in condition when Resident 122 had an episode of nausea and vomiting and refusal to eat. This failure had the potential to delay treatment or care for Resident 122.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for one of four sampled residents (Resident 12) by failing: 1. To ensure vital signs (measurements of the body's most basic functions such as heart rate, breathing rate, blood pressure, and temperature) were obtained before administering medications that can affect blood pressure( bp- force of blood pushing against the walls of the arteries). 2. To ensure vital signs reading taken two hours ago before administration of an anti-hypertensive medicines (medicines that are used to lower high blood pressure) was not used as a parameter(limit that affects how something is done) to administer the medicine. These failures have the potential to put Resident 12 at risk for hypotension (low blood pressure) that could lead to fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic.

Inspectors wroteBased on observation and interview the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. This deficient practice resulted in unavailable information for the number of staff and actual hours worked daily that is visible for residents, staff and visitors.

Inspectors wroteBased on observation and interview the facility failed to ensure one of one ice machines in the facility kitchen was clean. This deficient practice had the potential to result in an outbreak of food borne illness (illness caused by food contaminated with germs).

Inspectors wroteBased on interview and record review, the facility failed to address/ implement facility assessment elements when: a. The facility failed to include the Infection Prevention Nurse (IPN) dedicating mandated hours in the Transitional Care unit (TCU) for 40 of 40 residents in the facility assessment. b. The facility failed to obtain an offsite contract for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center as indicated in the facility assessment. c. The facility failed to implement Certified Nurse Assistants' (CNA) 1 hour in service education to be provided twice per month, including dementia management, abuse/neglect, and patient rights and responsibilities as indicated in the facility assessment. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (drug that affects brain activities associated with mental process and behavior) for two out of three sampled residents (Resident 119 and 67) as indicated in the facility's policy and procedure (P&P). These deficient practices resulted in the violation of residents' right to be informed in advanced by the physician of the risk and benefits of the drug and treatment alternatives.

Inspectors wroteDuring an observation, interview and record review the facility failed to store medication in a locked compartments and not left at residents' bedside for two of four sampled residents (Resident 170 and 171). This failure had the potential for medication errors, and lack of oversight for Resident 170 and 177.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of five sample residents (Resident 8) fingernails were clean. This deficient practice had the potential to result in a violation of resident's right to a dignified existence which can result in a negative psychosocial wellbeing.

Inspectors wroteDuring an interview and record review the facility failed to include resident and resident representative in Interdisciplinary ([IDT]- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) care planning and informed of any changes in care, treatment, and interventions for one of four sampled residents (Resident 166). This failure had the potential to violate Resident 166 and resident representative right to be an active participant to Resident 166's care.

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan addressing assistance for feeding for one (1) of four (4) sampled residents (Resident 63). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 63 and negatively impact the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) and person-centered care plans for two out of four sampled residents Resident 163 and 166). 1. Ensure Resident 163 who had pain on her left ankle develop specific interventions to address pain medications and interventions to alleviate (lessen) her pain. 2. Ensure Resident 163 who have an indwelling foley catheter were care planned to assess continued need of indwelling catheter. 3. [...]

Inspectors wroteDuring an observation., interview and record review Physical Therapy (PT-health specialist that treat residents to improve movement ) 1 failed to apply gait belt (assistive device which can be used to help safely transfer a resident from a bed to a wheelchair, assist with sitting and standing, and help with walking around) to one of four sampled residents ( Resident 177). This failure had the potential for increased risk of fall for Resident 177.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) was assessed for continued need and removed according to facility's policy and procedure (P&P) for one of four sampled residents (Resident 163). This failure resulted in continued discomfort to Resident 163 and had the potential for Resident 163 to have catheter associated urinary tract infection (CAUTI- a urinary tract infection [ UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra] associated with urinary catheter use).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services on one of four sample residents (Resident 63) to prevent complications during feeding by: a. Failing to obtain a physician's order for feeding assistance for Resident 63. b. Failing to create a comprehensive resident centered care plan indicating interventions to be implemented while feeding Resident 63 to prevent complications like aspiration (accidentally inhaling food or liquid through vocal cords into the airway) and choking (when person can't speak, cough, or breath because something is blocking the airway). This failure had the potential to result in Resident 63 aspirating and choking while eating.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pain management for two of two sampled residents (Resident 119 and 163) consistent with the facility's policy and procedure when: a. The facility failed to ensure Resident 119's pain was assessed before and after pain medication was administered. b. The facility failed to communicate with Resident 163'S physician regarding pain management of her left ankle pain. c. The facility failed to develop an individualized comprehensive care plan to address Resident 163 pain management. These deficient practices had the potential to result in a poor pain management that can affect physical and psychological wellness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 63) was free from significant medication errors when: a. The facility failed to ensure Resident 63's medication was not left at the bed side table; and b. The facility failed to ensure six of Resident 63's medication on 1/12/2024 were administered on time. This deficient practice of leaving medication at the bedside had the potential for other staff, visitors, or residents to access prescription medication at any time. This deficient practice of not administering six medications on time had the potential to result in untoward effects to Resident 63.

Inspectors wroteBased on observation and interview the facility failed to ensure the opened orange juice, apple juice, and vegetable salad were labeled with the residents' name, room number, and date it was opened in two out of two resident refrigerators in the Transitional Care Unit (TCU). These deficient practices had the potential to result in contamination of residents' food items which can cause food-borne illnesses (food poisoning).

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control to prevent the spread of infection when: 1. Plant Engineer exited Resident 163's room who was on contact isolation (precautions intended to prevent transmission of infectious agents) with isolation gown and gloves and failed to do hand hygiene (cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) after doffing (remove) personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards). This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents and staff at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic (drug to treat infection) Stewardship (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) program for one of three sampled residents (Resident 163). Resident 163 was prescribed Piperacillin-tazobactam (antibiotic) 3.375 gram (gm-unit of measurement) intravenous piggyback (IVPB-small bag of solution attached to a primary infusion line) every eight hours without any laboratory confirmation to screen for a Urinary Tract Infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra) and without a stop date. This deficient practice had the potential to result in the resident developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review: a. The facility failed to ensure the Infection Preventionist Nurse (IPN) implemented the antibiotic (drug to treat infection) stewardship program (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) for twenty-nine of twenty-nine sampled residents. b. The facility failed to ensure the (IPN) dedicated mandated hours to the Transitional Care Unit (TCU) as required by federal and state regulations. This deficient practice resulted in a lack of oversight in the Antibiotic (drug to treat infection) Stewardship (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) program and Infection Control and Prevention Program for 29 out of 29 sampled residents in the TCU.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 173) received education regarding the benefits and potential side effects of the pneumococcal vaccine (medication help protect against infection that can cause serious illness like pneumonia [infection of the lungs]) before the vaccine was administered on 1/12/ 2024. This deficient practice had the potential to result in misinformation that can negatively affect physical and mental wellness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person ' s capability to participate in everyday life activities) and/or physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatments based on the physician ' s order and therapy treatment plan for three of four sampled residents (Residents 1, 2, and 4). These deficient practices had the potential to delay recovery and discharge planning for Residents 1, 2, and 4.