Heritage Rehabilitation Center
HERITAGE REHABILITATION CENTER in TORRANCE, CA — inspection on June 13, 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 a concurrent observation, interview, and record review on 6/11/2024 at 11:43a.m., with Assistant Director of Nursing (ADON) in the medication storage room at the nursing station A, there was an Emergency Kit ([EKIT] an emergency drug supply) logbook.
Reviewed the logbook and the Emergency Drug Supply Log Sheet with the ADON, the ADON stated licensed nurses document medication taken from the EKIT and the Cubex on the Emergency Drug Supply Log Sheet.
During a review of the Cubex pharmacy transactions on 5/30/2024 indicated, there was a tablet of alprazolam (used to treat anxiety) 0.25 milligrams ([mg] a unit to measure mass) issued for Resident 5 on 5/30/2024 at 3:59 p.m.
During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m. for alprazolam 0.25 mg, give 1 tablet by mouth every eight (8) hours as needed for anxiety.
During an interview on 6/11/2024 at 11:45 p.m., ADON stated this issuance of alprazolam was not recorded in the Emergency Drug Supply Log Sheet.
During a review of the facility's policy and procedures (P&P), (undated), indicated .
Cubex .Emergency STAT orders may be retrieved pursuant to the order of a prescriber for emergency or immediate administration to a resident of the facility .
The CUBEX System keeps a complete and accurate record of all users accessing the cabinet .
056308
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 056308 B.
Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
The facility failed to:
1.
Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided.
2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline).
3.
Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol.
4.
Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment on 4/29/2024.
5.
Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on [DATE] and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P.
These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness.
Findings:
056308
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 056308 B.
Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502