Santa Monica Rehabilitation Center
SANTA MONICA REHABILITATION CENTER in SANTA MONICA, CA — inspection on August 8, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/05/2024 at 12:47 PM with RN 1, RN 1 stated that on 8/05/2024 between 7 AM and 7:30 AM, RN 1 initially noticed bruises on Resident 4's forehead and left cheek. RN 1 stated Medical Doctor 1 (MD 1) was notified on 8/05/2024 at 11 AM.
When asked why there was a four-hour delay in reporting Resident 4's injuries to MD 1, RN 1 stated I [RN 1] got busy.
During a telephone interview on 8/05/2024 at 1:13 PM with family member 4 (FM 4), FM 4 stated that when FM 5 visited Resident 4 in the facility on either 8/01/2024 or 8/02/2024 (not sure of the date), the facility did not notify/inform FM 5 of Resident 4's bruises on the forehead and left cheek prior to FM 5's visit. FM 4 stated from 8/01 until today (8/05) facility did not inform/notify FM 3, FM 4, or FM 5 of Resident 4's bruises on the forehead and left cheek.
During an interview on 8/07/2024 at 4:20 PM with LVN 2, LVN 2 stated that on 8/04/2024 around 4:30 pm and 5 PM, CNA 3 notified LVN 2 of Resident 4's bruises on the forehead and left cheek. LVN 2 stated When I saw [Resident 4], [Resident 4] already had the bruise (on the forehead and on the left cheek). I did not witness what happened to [Resident 4]. LVN 2 stated that on 8/04/2024 around 7 PM, LVN 2 made a call to MD 1 but did not leave any messages.
When asked why the call to MD 1 was made three to four hours after initially informed by CNA 3 about Resident 4's bruises on the forehead and left cheek on 8/04/2024 around 4:30 PM and 5 PM, LVN 2 stated I was passing meds (medications), and [Resident 4] was not complaining of pain. LVN 2 stated when MD 1 was making rounds (visiting other residents) in the facility on 8/04/2024 at around 8 PM or 9 PM, LVN 2 did not notify MD 1 about Resident 4's injuries to the forehead and left cheek.
During an interview on 8/07/2024 at 5:41 PM with Administrator 1 (Admin 1), Adm 1 stated when their (facility's) own investigation concluded that Resident 4 was not allegedly abused, report to California Department of Public Health (CDPH), Ombudsman (a long-term care representative that assists residents in LTCF with issues related to day-to-day care, health, safety, and personal preferences), and law enforcement will not be made.
555808
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555808 B.
Wing 08/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404
During a concurrent observation and interview on 8/05/2024 at 12:22 PM, of Resident 4, Resident 4 was found sitting on a wheelchair just outside Resident 4 ' s room.
The surveyor observed Resident 4 with a round maroon/reddish color discoloration on the left cheek, and swelling with maroon, reddish, purple, light yellow, dark red discoloration on the forehead.
When Resident 4 was asked how Resident 4 got the maroon/reddish color discoloration on the left cheek, and swelling with maroon, reddish, purple, light yellow, dark red discoloration on the forehead, Resident 4 stated I don ' t know. Resident 4 was observed with facial grimacing.
When asked if in pain, Resident 4 pointed to her forehead, but the resident was not able to state the pain level.
A review of facility ' s undated Incident/Accident Report incident on Resident 4, RN 3 documented that Resident 4 had discoloration on the forehead and left cheek with no pain, and no bleeding.
The Report indicated, RN 3 notified FM 5 about Resident 4 ' s discoloration on the forehead and left cheek on 8/05/2024 at 11 AM.
A record review and concurrent interview on 8/05/2024 at 12:40 PM with RN 1, Resident 4 ' s entire medical chart (paper charting) was reviewed. RN 1 acknowledged and stated that Resident 4 ' s medical chart did not have/include the nursing progress notes, physician orders, physician progress notes, skin assessment, Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility), care plans, or an SBAR/COC related to Resident 4 ' s injuries to the forehead and the left cheek.
During an interview on 8/05/2024 at 12:47 PM with RN 1, RN 1 stated that MD 1 was notified about Resident 4 ' s injuries to the forehead and the left cheek on 8/05/2024 at 11 AM.
When asked why MD 1 was not immediately informed of Resident 4 ' s injuries after the injuries were identified on 8/05/2024 between 7 AM or 7:30 AM, RN 1 stated I [RN 1] got busy.
555808
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555808 B.
Wing 08/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Santa Monica Rehabilitation Center 1338 20th Street Santa Monica, CA 90404