Consulate Health Care of Melbourne 6/10/2015 Inspection Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:1/5/2018
CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

OMB NO. 0938-0391
STATEMENT OF (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
DEFICIENCIES / CLIA A. BUILDING ______ COMPLETED
AND PLAN OF IDENNTIFICATION B. WING _____ 06/10/2015
CORRECTION NUMBER
105861
NAME OF PROVIDER OF SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CONSULATE HEALTH CARE OF MELBOURNE 3033 SARNO RD
MELBOURNE, FL 32934
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0224 Write and use policies that forbid mistreatment, neglect and abuse of residents and theft
of residents' property.
Level of harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
jeopardy Based on observation, interview, record review and policy review, the facility neglected to provide services necessary to
avoid harm. They failed to follow facility policy for head injury, failed to provide accurate assessments, and failed to
Residents Affected - Few provide nursing care to prevent neglect. The result of the facility's neglect resulted in Immediate Jeopardy for 1 of 16
sampled residents who had a fall and change in condition, resulting in a transfer to a higher level of care (#1). The
facility failed to ensure timely completion of an X-ray ordered after a fall, which resulted in the resident sustaining a
fractured right hip (#2). The total sample was 16 residents.
Findings:
Cross Reference F225.
1. Resident #1 was admitted to the facility on [DATE] with [MEDICAL CONDITIONS], dysphagia due to [MEDICAL
CONDITION]
disease, muscle weakness, [MEDICAL CONDITION], hypertension, and diabetes mellitus type II.
Review of the Situation, Background, Assessment, Appearance and Request (SBAR) form, dated [DATE] at 3:30 PM, revealed
documentation from licensed practical nurse (LPN) H who noted that the resident stood up from her wheelchair and fell to
the floor, striking the back of her head on the floor.
Review of facility policy and procedures for Head Injury, effective date [DATE], read, Licensed nursing personnel will
stabilize the resident with a head injury. Procedure: Call physician. Monitor vital signs. Contact emergency transport and
transfer to local hospital emergency room . Note: Any resident with acute injury could develop changes at a later date due
to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in
awareness, change in communication or decline in activities of daily living (ADLs), which would indicate subdural hematoma
or stroke.
An interview with LPN H on [DATE] at 3 PM confirmed the resident sustained [REDACTED]. He said he was the nurse who
completed the SBAR form and the pain evaluation sheet, and notified the advanced registered nurse practitioner (ARNP). He
said the fall was not witnessed. He stated She (resident #1) was in her room, stood up from her wheelchair and fell to the
floor, striking the back of head on the floor. I don't know if the alarm was going off. I told the ARNP that she hit her
head and that is why she ordered ice.
A review of the Pain Evaluation Sheet, not dated, noted an onset of sharp head pain when the resident fell and hit her head
on the floor. An anatomical picture was marked to show the right side, back of head as the area of pain. The level of pain
was documented as 4 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain.
In an interview on [DATE] at 1:40 PM, the ARNP stated, I was told on the phone the nurse found her on the floor. He said he
went in and she had slipped out of the chair and hit her head on the wheelchair. It was unwitnessed. I was not told the
resident hit her head on the floor. I ordered neuro (neurological) checks and told the nurse to call if there was any
obvious trauma or change to contact me. I did not come in and see her.
Review of the medical record found neurological (neuro) checks initiated on [DATE] at 3:30 PM.
Review of the physician's orders [REDACTED]. apply ice to injury, head every 20 minutes PRN (as needed). 2. Neuro check
list. 3. Call if any change in mental status.
During an interview on [DATE] at 4:30 PM, the director of nursing (DON) said, The fall protocol is our fall policy. After a
fall, the nurse is to assess the resident, complete an SBAR, and notify the family and physician. Neuro checks should be
done for 72 hours after a fall. They should document in the nurses' notes any changes in condition and call the physician
and family.
When an injury occurs, loss of brain function can occur even without visible damage to the head. The trauma can potentially
cause bleeding in the spaces surrounding the brain It is important to remember that a head injury can have different
symptoms and signs, ranging from a patient experiencing no initial symptoms to coma In some situations, concussion type
symptoms can be missed. Patients may experience difficulty concentrating, increased mood swing, lethargy, or aggression,
and altered sleep habits A medical evaluation is always wise even after an injury has occurred . (emedicinehealth.com).
Review of the Neurological Assessment Flow Sheet, dated [DATE], did not show neuro checks documented at 8:30 PM. This flow
sheet revealed the following data: level of consciousness, pupil response, motor function, pain response, vital signs, and
observations. An injury to the head requires a full neurological assessment to help determine the extent of the injury.
Neuro checks are used to monitor the condition of the patient and evaluate a patient's status. (www.ehow.com).
Review of nurses' notes following the fall did not have documentation from [DATE] until [DATE] at 7:45 PM.
In an interview on [DATE] at 3 PM, LPN O said she was the nurse assigned to resident #1 on [DATE] on the 11 PM to 7 AM
shift. She said, She (resident #1) was awake all night. She did finally go to sleep, but I really don't know when. It was
not usual for her to be awake all night. She would usually be sleeping when I came on shift and would sleep through the
night. I was able to give 6 AM medications. She had no problem taking them. I reported to the day nurse the resident was
awake all night. LPN O did not say she contacted the physician about the resident's restlessness, which was not the
resident's normal behavior. Resident #1 had a recent history of a fall, complaint of head pain after the fall, and a
history of a previous [MEDICAL CONDITION].
In an interview on [DATE] at 5 PM, LPN A said she was assigned to assist resident #1 on [DATE] on the 7 AM to 3 PM shift.
She said she received report from LPN O who told her the resident had not slept all night and was still awake at 6 AM. She
said, Between 7 AM and 8 AM, I tried to wake her up. She looked at me but she wasn't awake. I thought she just needed to
sleep, so I left her sleeping. I went back to wake her after 8 AM to give her medications. She opened her eyes but was not
able to take her medication. I did not call the doctor and tell him I had held the medication. I don't know if I called or
told the ARNP that she was sleepy but I didn't write it down. I can't remember if I did or did not talk to her. I think I
did but I don't know for sure. I didn't document in my nursing notes she could not take her medications. Her brother was
here around 11 AM, he did say to me that she wasn't as she normally was. I told him it was because she hadn't slept the
night before. The CNAs (certified nursing assistants) came to me and told me she wasn't eating. Normally she would eat
really good, but not that day. She was sleepy because she was tired, she didn't sleep the night before, so it was ok that
she slept through my shift. If someone was awake all night it would be normal for them to sleep all through my shift. It
wasn't a big deal. She said she gave report to the 3 to 11 PM nurse (LPN J). She told her the resident had been sleeping
all day and if she didn't eat dinner, she should call the doctor, because that would be too long. LPN A did not say that
the physician was contacted when the resident, who had a recent history of a fall and complaint of head pain after the fall
and a history of previous [MEDICAL CONDITION], exhibited this declined change in condition.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 105861 If continuation sheet
Previous Versions Obsolete Page 1 of 10
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
F 0224 (continued... from page 1)
An interview with CNA E on [DATE] at 2:50 PM revealed she worked the 7 AM to 3 PM shift on [DATE] and was not assigned to
Level of harm - Immediate the resident on [DATE], but remembered resident #1 was sleeping and didn't open her eyes. She said she helped another CNA
jeopardy to pull her up in bed for breakfast to feed her, but she would not eat. She stated Normally we set her food up. She always
ate all her food. She would usually eat sitting up in her chair or in bed. She did not open her eyes that day. I told LPN A
Residents Affected - Few and she came in and looked at her, but I don't know what she did about it. When something is different, I tell the nurse
and she is supposed to do something. She is the nurse. In the afternoon, her son came in. We did all her care that day.
During her bath, she never opened her eyes. She just slept.
In an interview on [DATE] at 1:30 PM, CNA R said she usually works with resident #1 and was assigned to her on [DATE] for
the 7 AM to 3 PM shift. She stated, She (resident #1) could tell you what she wants, what to eat, and could use the
bathroom. She needed help getting up to the chair and to the bathroom. She would hold on and stand up when she used the
bathroom so we could clean her. She would talk to you and she knew who I was. She had her mind, but sometimes she is
forgetful. I was with her that day. The night CNA (Q)told me she was sleepy and didn't want to wake up. Normally when I
came in, she was awake. She would eat and then go back to sleep. When I tried to wake her, she would answer me with Ya Ya
but she would just go back to sleep. She said she told LPN A she had tried to get her to eat and could only get her to take
one sip of milk and she went right back to sleep. She said LPN A told her to keep an eye on her. CNA R stated, Her
(resident #1's) brother came in to see her and I asked her (resident #1) if she wanted to get up for lunch. I told her it
was time to get up. I put a wash cloth on her face to wake her up and she woke up and then went right back to sleep, and
she just slept. She did not eat lunch. I washed and cleaned her. She could not hold on to the bed rail. She was very sleepy
at the end of my shift. It is not normal for her to sleep like that. Her family said Get her up. Get her up. He asked if
something has to be done and I told him the nurses will do what they have to do. CNA R said she was not aware the resident
had a fall on [DATE].
An interview was conducted with the ,[DATE] hall unit manager (UM) on [DATE] at 3:20 PM. She said she was the UM on the unit
for resident #1 on [DATE]. She said the resident was sleeping more during the day. She said, The nurse (LPN A) told me that
she was sleepy, but that it was because the roommate kept her up. I did not know that she wouldn't eat or open her eyes.
They never told me she wouldn't wake up. I had assumed they could wake her up, but when I came in the next day, night shift
told me she wouldn't wake up. She said LPN A took care of her that day. The UM did not say that she contacted the physician
when the resident, who had a recent history of a fall and complaint of head pain after the fall and a history of previous
[MEDICAL CONDITION], exhibited this declined change in condition.
During an interview on [DATE] at 3:30 PM, LPN J said she was assigned to assist resident #1 on [DATE] on the 3 to 11 PM
shift. She stated, I had her on the 21st ([DATE]) and sent her out to the hospital. The son and daughter-in-law were in the
room that day. I came on shift and the nurse told me she had been up all night. This isn't normal for her. I was told she
went to sleep right at shift change in the morning of the 21st and slept during the day. At beginning of my shift, I went
in to check on her and I checked her blood sugar and pupils. At the beginning of the shift, she opened her eyes, looked at
me, and grimaced. She was able to grasp my hands but she wasn't awake like her normal. This was not her normal behavior.
This was at about 3 PM. The day shift nurse (LPN A) said they had called the physician before I came in. I called the ARNP
and left messages with the physician's answering service but I can't remember when and I did not document this in my
nurse's note. I did a sternal rub and she (the resident) only looked at me. She normally would have slapped you if you had
done that. This just wasn't normal for her to be up all night. She usually goes to bed and sleeps all night. I knew
something was going on, but I didn't know what. I thought maybe a stroke or maybe it was her time. I wrote everything on
scrap paper not in my nurses' notes. I only wrote down when they called back and I only wrote down one set of vitals (vital
signs).
In an interview on [DATE] at 4:30 PM, the DON revealed she was aware of resident #1 being less awake on [DATE]. When asked
if this was the resident's baseline, she replied, No, normally this resident will talk to you and is awake. She was just
sleepy because she didn't sleep the night before. I wasn't worried. The DON did not say that she contacted the physician
when the resident, who had a recent history of a fall and complaint of head pain after the fall and a history of previous
[MEDICAL CONDITION], exhibited this declined change in condition.
When asked if she was aware of where the resident was now, she replied, Yes, she died . She had a stroke and died in
hospice. When asked if she had initiated any investigation to prevent this from happening again, she replied, Why would we?
We didn't do anything wrong. She was sleepy. We didn't think it was anything. She said she had not done an investigation or
any training for the staff related to this incident.
In an interview on [DATE] at 1:40 PM, the ARNP stated, I received a call in the afternoon on [DATE], sometime between 3 and
5 PM. I am not sure of the exact time. The nurse told me she had been sleeping a lot today. She skipped breakfast and
participated in therapy. She did not tell me about a low blood sugar at this time. I wasn't concerned because they told me
her roommate kept her awake all night. There was some [MEDICAL CONDITION] going around, so I thought maybe it was that. I
ordered a chest X-ray and labs, because they heard something in her lungs. They called me back around 7 PM because her
blood sugar was low and she had not eaten. They wanted to know if they should hold the insulin. I asked more questions and
based on their answers, they told me she was really sleepy and difficult to arouse, and based on that, I didn't like it, so
I sent her to the hospital.
In a telephone interview on [DATE] at 4:15 PM, CNA P said she did remember taking care of resident #1 on [DATE] during the 3
to 11 PM shift. She said, She was not awake when I came on shift. She kept her eyes closed and she did not talk to me. I
tried to feed her but she never opened her eyes. I told the nurse. The family was there, I think the daughter and the son.
This was the first time I ever took care of her.
2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].
In an interview on [DATE] at 11:10 AM, LPN V said that she heard resident #2 call for help around 9 PM on [DATE]. She said,
The doctor ordered an X-ray in the AM. I did not call Mobilex (portable X-ray company). I gave the ,[DATE]-,[DATE] 11 PM-7
AM nurse the information to call for the X-ray. Sunday Morning ([DATE]) I went to give (resident #2) her medications. She
wanted to get up. I gave her medications and checked her blood pressure. When I realized the X-ray was not done, I called
it in STAT (immediately). Mobilex told me the report would be back in hour. They called and told me it was a fracture. I
called the doctor and she went out with .ambulance.
Review of facility SBAR form and progress note dated [DATE] regarding the fall revealed the following: Functional status
changes - decreased foot mobility, fall sustained skin tear; Assessment (RN) or appearance (LPN). LPN documented complaint
of pain to right hip. The Request section did not have anything checked.
Nurses' notes with additional information on the resident's change in condition read, At 2100 (9 PM) heard a patient
(resident #2) calling for help upon entering the room noted patient on the floor in her bedroom. (Resident) stated that PT
& OT (physical therapy & occupational therapy) told her she could walk so she decided to try walking and fell . (Resident)
is complaining of pain to right hip during range of motion. (Resident) also sustained skin tear to right foot and right
elbow. Dr. (doctor) was notified, new orders for x-ray of right hip. Patient will only attempt to walk with PT. Will
continue to monitor. A resident family member was notified on [DATE] at 9:30 PM time of incident was identified.
On [DATE] at 9:15 PM, the physician was notified and orders were received: Clean right leg with normal saline apply
[MEDICATION NAME] and cover with dry dressing until healed. X-ray to right hip, result in AM to MD.
The following interdisciplinary note shift reports and 24 Hours Reports beginning on the 11 PM-7 AM shift on [DATE] through
7 AM on [DATE] were completed by 5 nurses involving 5 shifts, none of which identified that the X-ray ordered in the early
evening of [DATE] was completed or reviewed.
Review of the Mobilex tracking form, dated [DATE], was changed to [DATE] for resident #2, and the claim number was noted.
During the survey, a Mobilex customer service representative was contacted [DATE] at 4:06 PM. He stated that there was an
X-ray order for resident #2 on [DATE] at 8:38 AM and completed at 12:55 PM. He confirmed that there was no X-ray ordered or
completed on [DATE] or [DATE].
Review of the radiology report dated [DATE] and reviewed by the radiologist at 1:57 PM of the Hip unilateral complete
minimum 2 views Right. Results: There is a fracture involving the right femoral trochanteric region with mild displacement.
Conclusion: Acute right [MEDICAL CONDITION] as described above.
There was no documentation on the 24 Hour Reports that noted that the X-ray was completed on [DATE] or [DATE], as ordered by
the physician. This resulted in 2 days passing after a fall before an ordered X-ray was completed. When the X-ray and
report was finally completed on [DATE], the resident was sent to the hospital for [MEDICAL CONDITION] repair.
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
The facility neglected to provide services necessary to avoid physical harm by not completing a physician's orders
Level of harm - Immediate [REDACTED].
jeopardy Review of the facility's policy Resident Abuse included a section for neglect. It read in part that neglect includes Failure
to provide services that result in harm to the resident Neglect -failure to take precautionary measures to protect the
Residents Affected - Few health and safety of the resident Lack of attention to physical needs
The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM.
These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of
[DATE].
F 0225 1) Hire only people with no legal history of abusing, neglecting or mistreating
residents; or 2) report and investigate any acts or reports of abuse, neglect or
Level of harm - Immediate mistreatment of residents.
jeopardy **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to thoroughly investigate an incident after a fall for 1 of 16
Residents Affected - Few sampled residents (#1).
Failure to do a thorough investigation after resident #1 fell caused a delay in providing proper care and treatment to the
resident. Resident #1 fell and hit the back of her head on the floor on [DATE]. The resident was not transferred to acute
care after the fall per the facility policy. On [DATE], the resident had a serious change in condition, was transferred to
the hospital with a [DIAGNOSES REDACTED]. After 5 days of treatment in the hospital, the resident never regained
consciousness. She was placed on hospice care and died on [DATE]. The facility could not demonstrate that such neglect was
caused by factors beyond the control of the individuals providing care to resident #1.
The facility's failure to thoroughly investigate the fall and fully assess the resident's condition resulted in an Immediate
Jeopardy for resident #1.
Findings:
Cross Reference F224. Resident #1 was an [AGE] year old female resident who was admitted to the facility on [DATE] with
[DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment done on [DATE] showed the resident's BIMS
(Brief
Interview of Mental Status) score of ,[DATE] (score ,[DATE] is moderately impaired). She was able to feed herself in her
room after the tray was set up by staff. She required one person assistance with toileting, transfers, and bed mobility.
She was at risk for falls. The care plan listed an alarm on the wheelchair, which was added on [DATE] during the last
quarterly review.
A review of the facility Fall Root Cause Investigation Report revealed on [DATE], resident #1 fell to the floor while
standing up from the wheelchair, and struck head on the floor. The resident was watching TV prior to the fall.
Resolution/intervention for minimizing future occurrences was the use of a chair alarm. The report did not address the
cause of the fall. The facility's Policy and Procedure for Falls Committee (Quality Assurance), effective date [DATE], read
to Investigate to determine cause.
A review of the Quality Assurance Accident/Incident and Follow-Up log of [DATE] noted the date and time of incident as
[DATE] at 3:30 p.m. The type of injury was not listed.
On [DATE] starting at 8 a.m., licensed practical nurse (LPN) A from the 7 AM-3 PM shift, and LPN J from the ,[DATE] PM shift
did not identify that the resident had a serious change in condition, as exhibited by not being able to stay awake, speak,
or eat. The resident could not take any of her medications by mouth or eat breakfast and lunch, but LPN A gave 2 units of
regular [MEDICATION NAME] at 6:30 a.m. and [MEDICATION NAME] ,[DATE] insulin 21 units at 8 a.m. The resident's blood
sugar
was 168 at 6:30 AM. The physician was not notified of these changes until a call was placed to the advanced registered
nurse practitioner (ARNP) sometime about 5 p.m. on [DATE].
On [DATE] at about 4:30 p.m., the director of nursing (DON) was asked what the facility did to prevent the reoccurrence of
the delay in assessment, reporting to the physician, and providing care, and when staff was re-educated about these issues,
after the facility found out the resident had a stroke and died . She replied, No, why would we? We didn't do anything
wrong. She was sleepy. We didn't think it was anything.
In an interview with the ARNP on [DATE] at 1:40 PM, she said the nurse called her in the late afternoon on [DATE] and told
her the resident had been sleeping a lot, and did not eat breakfast. The ARNP said not eating breakfast was not a change
because the resident often would get up at noon. Another call was placed to the ARNP at about 7:45 p.m. on [DATE] to inform
her of the resident's low blood sugar of 87 from 4 PM that day, that was not reported earlier to her. At that time, the
resident was more lethargic, not arousable, and did not open her eyes. The resident was then transferred to the hospital
and diagnosed with [REDACTED]. After 5 days of treatment in the hospital from [DATE] to [DATE], the resident never regained
consciousness. She was placed on hospice care and died on [DATE].
On [DATE] at 12:50 p.m., the medical director stated he was unaware of the incident involving the resident's fall, and was
not aware the facility failed to follow procedure for fall and head injury and delay of treatment for [REDACTED]. He said
the last QA (Quality Assurance) meeting was in [DATE] and this issue was not discussed at that meeting.
The facility did not ensure that the alleged violation of neglect was reported immediately to the administrator of the
facility and to other officials in accordance with State law.
The facility could not provide evidence that the alleged neglect violation was thoroughly investigated, and did not prevent
further potential neglect while the investigation was in progress.
[DATE].
F 0281 Make sure services provided by the nursing facility meet professional standards of
quality.
jeopardy Based on observation, interview and medical record review, the facility failed to provide nursing care for a resident with a
fall and change of condition based on professional Standards of Quality Nursing Care per the American Nurses Association
Residents Affected - Few Standards of Practice and Nurse Practice Act for 1 of 16 sampled residents by failing to appropriately assess and provide
care (#1). The facility failed to ensure 1 sampled resident received an ordered X-ray promptly after a fall with complaint
of pain (#2). The sample was 16 residents.
Findings:
American Nurses Association Standards of Practice include: Standard 1. Assessment - The registered nurse collects
comprehensive data pertinent to the healthcare consumer ' s health or the situation. Standard 2. Diagnosis - The registered
nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. Outcome Identification - The registered nurse
identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Standard 4. Planning -
The registered nurse develops a plan of care that prescribes strategies and interventions to attain expected outcomes.
Standard 5. Implementation - The nurse implements the interventions identified in the plan. Standard 5A. Coordination of
Care Standard 6. Evaluation - The registered nurse evaluates progress toward attainment of outcomes. (ferris.edu).
The Florida Statutes Chapter 464 The Nurse Practice Act. (SS464.001.461.027) defines the Practice of professional nursing as
the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied
principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The
observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling
of the ill, inured, or infirm, and the promotion of wellness, maintenance of health and prevention of illness of others 2.
The administration of medications and treatments as prescribed or authorized by a dully licensed practitioner authorized by
the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
the theory and performance of any of the above acts.
Level of harm - Immediate 1. Resident #1's medical record indicted she was [AGE] years old, had a history of [REDACTED]. She sustained a fall on
jeopardy [DATE] at 3:30 PM as per review of Situation, Background, Assessment, Appearance and Request (SBAR) form completed by
licensed practical nurse (LPN) H on [DATE]. It noted that the resident stood up from her wheelchair and fell to the floor,
Residents Affected - Few striking the back of her head on the floor.
Review of the facility policy and procedures for Head Injury, effective date [DATE], noted the following: Call physician,
monitor vital signs. Contact emergency transport and transfer to local hospital emergency room . Note: Any resident with
acute injury could develop changes at a later date due to trauma resulting in swelling of the brain. Report any changes
such as restlessness, increased confusion decrease in awareness change in communication or decline in activities of daily
living, which would indicate subdural hematoma or stroke.
According to an interview with LPN H on [DATE] at 3 PM, he confirmed he was the nurse who completed the SBAR report. He said
the resident stood up from her wheelchair, fell and struck her head on the floor. This was an unwitnessed fall. He said the
resident provided him with the information about the fall. Review of the pain evaluation form, not dated, read, Onset of
pain was after fall - hit head on floor. The anatomical picture was marked showing the right side, back of head as the site
of complaint of pain by resident #1.
A physician's telephone order, obtained from the advanced registered nurse practitioner (ARNP) and dated [DATE] read, Apply
ice to injury to head every 20 minutes PRN (as needed), neuro (neurological) checks, and call if any change in mental
status.
In an interview on [DATE] at 2:50 PM with CNA E and CNA R on [DATE] at 1:30 PM, they both said the resident was usually
awake for breakfast, needed her tray to
be set up, and would feed herself either in bed or in the chair. They said the resident was able to make her needs known and
needed assistance to the bathroom. They said the resident knew who she spoke with when they spoke with her. They said on
[DATE] on the 7 AM 3 PM shift, she was not normal, she kept her eyes closed most of the time, she would not eat her
breakfast and she did not talk to them like she usually did. They gave her a bed bath and she did not wake up. They said
they reported to LPN A that the resident was not the same but they were not sure what LPN A had done. CNA R said she put a
wash cloth on the resident's face to wake her up and she woke up and then went back to sleep. When the resident's lunch
tray arrived, CNA R said she tried to wake the resident up to eat but she did not wake up. CNA R said it was not normal for
the resident to sleep like that.
In an interview on [DATE] at 3:30 PM, LPN J said she was the nurse assigned to resident #1 on the ,[DATE] PM shift on
[DATE]. She said she had taken care of the resident before. She stated, I was told in report the resident had been up all
night, went to sleep at shift change and had slept all day. This was not normal for her. I went in to check on her at the
beginning of my shift. She opened her eyes, looked at me, and grimaced. She wasn't awake like normal. About 3 PM, I did a
sternal rub and she only looked at me. She normally would have slapped you if you had done that. This just wasn't normal
for her. I knew something was going on, but I didn't know what. I thought maybe a stroke or maybe it was her time. She
confirmed she had not written any nurses' notes to document the resident's drowsy sluggish condition on [DATE].
During an interview on [DATE] at 4 PM, the ADON stated, I started the nurse's note when the family came to me and said she
(the resident) was acting different. It was in the afternoon around 3:30 PM. Her son was the one who came and told me. I
shook her a little bit and she opened her eyes and went back to sleep. She was sleepier than she was the day before.
Normally she will open her eyes and say a few words. She interacts with you. This compared to her baseline was very
different. I spoke with the day shift staff and they told me that she had been up all night and was tired. I don't know if
the nurses did neuro checks that day. I didn't do a neuro check. I don't know why I didn't put the times on the nurses'
notes. She confirmed her nurses' notes were not timed and did not indicate that the resident slept all day, was drowsy,
sluggish, and did not take any food or medication. When asked if this was normal for this resident, she said, No, it isn't.
She always eats and responds to you when you enter the room. She confirmed she had not known about the resident's condition
or assessed the resident until approximately 3:30 PM on [DATE], when the son reported it to her. She said she did not
assess the resident before 3:30 PM on [DATE]. The ADON did not say she contacted the physician about the resident's change
of condition at that time.
During interview on [DATE] at 4:30 PM, the director of nursing (DON) stated, Our fall protocol is our fall policy. She could
not provide a specific fall protocol. She said the nurses were to assess the resident, complete an SBAR and notify the
family and physician. Neuro checks should be done for 72 hours after a fall and they should document in the nurses' notes
any changes in condition and call the physician and family. The facility's Neurological Assessment Flow Sheet did not
indicate assessments to be completed for 72 hours. The DON said she was aware of resident #1 being less awake on [DATE].
She said this was not the resident's baseline. She stated, Normally, she (the resident) will talk to you and is awake. She
was just sleepy because she did not sleep the night before. We didn't think anything was wrong. She confirmed she had not
done an investigation or educated nursing staff about failure to accurately assess and report to the physician the
resident's change in condition. She stated, Why would we? We didn't do anything wrong. She was sleepy. We didn't think it
was anything. The DON did not say she contacted the physician about the resident's change in condition.
The Neurological Assessment Flow Sheet for resident #1, dated [DATE], was reviewed. At 8:30 PM and 11 PM on [DATE], and on
[DATE] at 3 AM, information was not documented on the sheet for those dates and times. Review of nurses' notes did not show
any documentation indicating resident #1's condition after the fall from [DATE] until [DATE] at 7:45 PM.
In an interview on [DATE] at 5 PM, LPN A said she was assigned to the resident on [DATE] on the 7 AM to 3 PM shift. She
stated, I received report from the night nurse (LPN O) and she told me the resident had not slept all night and was still
awake at 6 AM. I tried to wake her between 7 AM and 8 AM. She looked at me but wasn't awake. At 8 AM, I tried to give her
medications and she was not able to take them. I did not call the doctor to report the resident had not taken her
medications or that she was very sleepy. She confirmed she had not written a nurse's note on [DATE] describing the
resident's condition or that she was unable to give the resident her medications. When asked if she called the physician on
her shift on [DATE], she stated, I can't remember if I did or did not talk to her. I think I did, but I don't know for
sure. LPN A said the resident's brother was visiting around 11 AM and told her the resident wasn't as she normally was. She
stated, I told him it was because she had not slept the night before. She stated, The CNAs told me the resident was not
eating and the resident usually ate well. She was sleepy because she was tired. She didn't sleep the night before, so it
was ok that she slept though my shift. If someone was awake all night, it would be normal for them to sleep all through my
shift. It wasn't a big deal. I told the night nurse she had been sleeping all day and if she didn't eat dinner, she should
call the doctor, because it would be too long. LPN A never mentioned that the resident had a history of [REDACTED]. LPN A
did not say that the physician was called because of the resident's change in condition.
On [DATE] at 1:40 PM during a telephone interview, the ARNP said she was not aware the resident had hit her head on the
floor on [DATE] at 3:30 PM. She stated, It was reported to me the resident had hit her head on the back of the wheelchair.
I told the nurse to call me if there was any obvious trauma or change. I did not come in to see her.
During a telephone interview on [DATE] at 2:39 PM, CNA Q, who worked on [DATE] on the 11 PM to 7 AM shift, said the resident
was awake most of the night on [DATE] into [DATE]. She stated, She (the resident) was still awake at 11 PM and complaining
of pain in her foot. She was awake until 3 or 4 AM and then she went to sleep. About 5 or 6 AM, I changed her and she was
very groggy but I felt that was normal because she had pain medication.
In an interview on [DATE] at 2:50 PM, LPN O said that on her 11 PM to 7 AM shift, the resident was restless and awake most
of the night on [DATE] into [DATE]. She said this was not normal for the resident, as she usually slept through the night.
Nursing documentation was not found to indicate the resident's neurological status on [DATE] on the 11 PM to 7 AM shift.
Review of the Medication Administration Record [REDACTED].) 2 tablets at 10 PM. There were no other pain medications
documented as given. There was no documentation showing the resident had complained of pain.
Review of facility policy and procedures for Head Injury, effective date [DATE], read, Licensed nursing personnel will
stabilize the resident with a head injury. Procedure: Call physician. Monitor vital signs. Contact emergency transport and
transfer to local hospital emergency room . Note: Any resident with acute injury could develop changes at a later date due
to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in
awareness, change in communication or decline in activities of daily living (ADLs), which would indicate subdural hematoma
or stroke.
Assessment when a resident falls includes: Check the vital signs and the apical and radial pulses .check the skin for
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
pallor, trauma, circulation check the nervous system for sensation and movement in the lower extremities. Assess the
Level of harm - Immediate current level of consciousness and determine whether the patient has had a loss of consciousness. Look for subtle cognitive
jeopardy changes. (nursing center.com).
Every neuro check involves an assessment of the patient's ability to move. Movement also includes an evaluation of strength
Residents Affected - Few the neuro check is comparing the patient's ability at the initial assessment to the current condition. Watch for any
decrease in strength or lack of mobility Any abnormal behavior requires notifying the treating physician . An eye
examination that focuses upon the pupils is part of the neuro check (ehow.com).
The initial assessment should be a comprehensive exam covering several critical areas: level of consciousness and mentation,
cranial nerves, movement, sensation, cerebellar function, and reflexes Evaluation of level of consciousness (LOC) and
mentation are the most important part of the neuro exam. A change in either is usually the first clue to a deteriorating
condition (modernmedicine.com).
Nursing staff did not assess accurately resident #1's status and ultimate change in condition. On [DATE], the resident had a
serious change in condition, was transferred to a hospital with a [DIAGNOSES REDACTED]. After 5 days of treatment in the
hospital, the resident never regained consciousness. She was placed on hospice care and died on [DATE].
2. Resident #2's medical record revelaed [DIAGNOSES REDACTED].
Review of the most recent quarterly MDS assessment, dated [DATE], noted that the resident She had 1 fall prior to the
assessment. She was receiving occupational and physical therapy since [DATE].
On [DATE] at 9 PM, the SBAR Communication form revealed the resident complained of pain to the right hip during range of
motion and indicated that The patient (resident) stated that PT & OT told her that she can walk, so she decide(d) to try
walking and fell . Pt. is complaining of pain to right hip.
On [DATE], the resident's phyiscian ordered an X-ray of the right hip.
There was no documentation on the 24 Hour Report that noted the X-ray was completed on [DATE] or [DATE], as ordered by the
physician.
The 24 Hour Report for [DATE] read, 11 PM to 7 AM S/P fall S/T to right leg/left arm intact. PRN pain increased depression
Transport to hospital. ,[DATE] PM left facility at 4:15 PM via stretcher
On [DATE] at 4:06 PM, a representative from the portable X-ray company said there was no X-ray ordered or completed on
[DATE] or [DATE].
On [DATE] at 11:10 AM, LPN V said, On Sunday morning ([DATE]), I went to give resident #2 her medications. She wanted to get
up. I gave her medications and checked her blood pressure. When I realized the X-ray was not done, I called it in STAT.
Mobilex told me the report would be back in hour. They called and told me it was a fracture. I called the M.D. and she went
out with .ambulance.
On [DATE], an X-ray of resident #2's hip was ordered by the physician at 9:30 PM but was not completed until [DATE] at 12:55
PM. The X-ray report read, Acute right [MEDICAL CONDITION] Approximately thirty nine (39) hours passed from the time the
hip X-ray was ordered to the time it was completed.
[DATE].
F 0309 Provide necessary care and services to maintain the highest well being of each resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Immediate Based on observations, interviews and record review, the facility failed to implement necessary care and services for 2 of
jeopardy 16 sampled residents. The facility failed to monitor 1 sampled resident to ensure her condition did not deteriorate after a
head injury and when she began to experience a change in mental status and condition (#1). The facility failed to ensure 1
Residents Affected - Few sampled resident received an ordered X-ray promptly after a fall with complaint of pain (#2).
Resident #1 fell on [DATE] and hit her head on the floor. She complained of head pain at the time of the fall. Nursing staff
failed to follow the policy and procedures (P&Ps) for Falls and Head Injury. Nursing staff failed to identify signs of
complications due to head injury, as listed in their P&P and implement appropriate measures to address the resident's
change in condition.
As a result of the failure to provide necessary care and services following a fall on [DATE] with a head injury, the
resident did not receive prompt treatment when the change in condition occurred. When resident #1 experienced restlessness
on [DATE], three (3) days following a fall with complaint of head pain, and then had progressive decreased awareness and a
change in communication, the physician was not notified for approximately eighteen (18) hours. As a result of this failure,
the resident was not transferred to a higher level of care for approximately eighteen (18) hours after she exhibited a
change in condition. The resident was transferred to the emergency room where she was diagnosed with [REDACTED].
The delay in treatment resulted in Immediate Jeopardy for resident #1, starting on [DATE], and determined to be ongoing as
of the exit date on [DATE].
Resident #2 fell on [DATE] at 9 PM and orders for an X-ray were obtained on [DATE] at 9:15 PM. The X-ray was completed on
[DATE] at for 12:55 PM. The X-ray revealed a [MEDICAL CONDITION] femoral trochanteric region with mild displacement. The
resident was transferred to the emergency room at 4:15 PM on [DATE], forty-three (43) hours after the fall.
Findings:
1. Resident #1's medical record revealed on [DATE] at approximately 3:30 PM, she sustained an unwitnessed fall in her room.
She was admitted to the facility on [DATE]. Her clinical [DIAGNOSES REDACTED].
A review of the individual resident daily participation records from January, February, March, and [DATE] indicated resident
#1 actively participated in various activities including bingo, religious services, outings with family, music, group
discussions, movies, and sing-alongs.
Her Minimum Data Set (MDS) assessment, completed on [DATE], showed she had clear speech, was able to make needs known, and
had clear comprehension for understanding others. The brief interview for mental status (BIMS) Score was 12. A resident
with a score of ,[DATE] has a moderately impaired mental status. The resident was able to recall the year, month, and two
of three recall items. The MDS assessment, completed on [DATE], did not identify any acute changes from her last yearly
assessment. Resident #1 required extensive assistance with activities of daily living (ADLs). This included one person
assistance with transfers, and the ability to eat independently after setup. A quarterly data collection, completed on
[DATE], noted she had an alteration in safety awareness due to cognitive decline at night. Nursing staff recommendation at
that time was to add side rails for safety. She was independently mobile once assisted to her wheelchair. The resident's
current fall risk score was 11. A total score of 10 or above deems the resident is at risk for falls.
Review of the Physician order [REDACTED]. Order: 1. Apply ice to injury, head, Q-20 mins, PRN. 2. Neuro check list. 3. Call
if any change in Mental Status. Indication: patient fall.
A Pain Evaluation Form, completed on [DATE], indicated that the resident complained of pain on the back of her head After
fall - Hit head on floor.
Review of the Neurological Assessment Flow Sheet revealed checks were initiated on [DATE] at 3:30 PM. The last check was
documented on [DATE] at 7 PM. No other neurological checks were documented for resident #1. The checks included level of
consciousness, pupil response, motor function, pain response, and vital signs. On [DATE] at 4:30 PM, the director of
nursing ( DON) and administrator both said the facility did not have a policy for neuro checks, only the Neurological
Assessment Flow Sheet.
In an interview on [DATE] at approximately 3:35 PM, the resident's son said, My mother was always awake and alert. She would
talk to me all the time. He said his mother told him about this fall the next day on [DATE] during their daily visit. He
said he spoke with a male nurse, name unknown, in which this male nurse confirmed the fall.
Interviews with staff members noted the resident's usual interactions with others:
In an interview on [DATE] at 2:50 PM, certified nursing assistant (CNA) E stated, I was working the 7 AM to 3 PM shift on
[DATE]. (Resident #1) was not on my assignment that day. Usually (Resident #1) eats and opens her eyes, look and speak with
us. She knew who we were, could tell us what she wanted, and let us know what she needed. She was sleeping that day. She
wouldn't open her eyes. We pulled her up in bed so we could feed her but she wouldn't eat. Normally, we set her food up.
She always ate all her food. She would eat in her chair or bed. I told LPN A, and she came in and looked at her but I don't
know what she did about it. When something is different, I tell the nurse and she is supposed to do something. She is the
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
nurse. We did all of her care that day, a bath, food, and she never opened her eyes, she just slept.
Level of harm - Immediate On [DATE] at 3 PM, licensed practical nurse (LPN) H said he was the nurse assigned to resident #1 on the ,[DATE] PM shift on
jeopardy [DATE]. He said he entered resident #1's room for unknown reasons at approximately 3:30 PM and found her lying on the
floor. He said after assessing the resident, he assisted her back to bed and called the ARNP to inform her of the fall.
Residents Affected - Few On [DATE] at 3:30 PM, the unit manager (UM) for resident #1 stated, she had some intermittent confusion, but she was
cooperative and pleasant.
In an interview on [DATE] at 3:30 PM, LPN J stated, I have taken care of (resident #1) before. I sent her out to the
hospital. The family was in the room that day ([DATE]). In report when I can on shift, LPN A told me she (resident #1) had
been up all night. This isn't normal for her. I was told she went to sleep right at shift change in the morning of the 21st
and she slept during the day. After report, I went in to check on her. I checked her sugar (blood sugar) and pupils. I was
worried because she is a diabetic and hadn't eaten all day. I did a sternal rub and she only looked at me. Normally she
would have slapped you if you had done that. It isn't normal for her to be up all night. She usually goes to bed and sleeps
all night. I knew something was going on but I didn't know what. During the assessment she opened her eyes and looked at me
and grimaced. She was able to weakly grasp my hands. Her pupils were equal and reactive but she wasn't awake like her
normal. This was not her normal. This was around 3 PM. (LPN A) said she had called the physician and the ADON before I came
in. I then called after I came on shift. At 7:45 PM, the ARNP called me back, and gave orders to send (resident #1) to the
hospital. (Resident #1) opened her eyes when EMS (emergency medical services) was here. I was telling them, EMS, that this
wasn't normal for (the resident).
In an interview on [DATE] at 4 PM, the ADON (assistant director of nursing), a registered nurse (RN) stated, I started the
nursing note when the family came to me and said she was acting different. It was in the afternoon around 3:30 PM.
(Resident #1's) son was the one who came and told me. I assessed (resident #1) in bed. I went in and shook her a little
bit. She opened her eyes and went back to sleep. She was sleepy. She opened her eyes and went back to sleep. (Resident #1)
was sleepier than the day before. Normally she will open her eyes, talk and interact with you. This compared to her
baseline was very different. I spoke with the day shift staff and they told me that she had been up all night and was just
tired. I spoke with the ARNP and she gave STAT (immediate) orders for a chest X-ray and lab (laboratory blood work) in the
morning. When I talked to LPN J, she said the vital signs were fine thought she heard some rattle in her lungs. I thought
maybe it was a UTI (urinary tract infection) or pneumonia. I know the nurses did neuro checks the day (resident #1) fell
([DATE]) but I don't know if they did it that day ([DATE]). LPN J checked her pupils and vital signs only, she was just
sleepy. I didn't do a neuro check. We did not call the resident's family that day. He (the resident's son) was there when I
went into the room. (LPN J & LPN A) told me she hadn't been eating that day but it was because she didn't sleep the night
before. The ADON confirmed this was not normal for resident #1. She said, She (the resident) always eats and responds to
you when you enter the room. ADON confirmed her handwritten note on the Interdisciplinary Progress Notes. She stated, I
don't know why I didn't put the times on the notes. I just didn't. The ADON said, She (resident #1) would interact with
you.
In an interview on [DATE] at 4:30 PM, the DON stated, I was in the room with (LPN A). I went in and assessed this resident.
She opened her eyes, and then went back to sleep. I did not take vital signs. (LPN A) had already done them. I did not
complete a neuro check. (LPN A) had done that. I just shook her to see if she would wake up. She looked at me and went back
to sleep. Normally this resident will talk to you and is awake. She was just sleepy because she didn't sleep the night
before. I wasn't worried. She said, After a fall, nursing staff is to evaluate the resident and call the physician and
family. They will then get orders from the physician and begin our Fall Protocol. We do not actually have a fall protocol
other than our Fall Policy. A Situation Background Assessment Appearance and Request (SBAR) is completed, the physician and
family are called, orders are obtained, neuro checks are started and completed for the next 72 hours. The nursing staff are
to assess and document any changes to the resident and notify the physician and family immediately.
In an interview on [DATE] at 5 PM, LPN A confirmed she was the 7 AM-3 PM shift nurse assigned to resident #1 on [DATE]. LPN
A stated she received morning shift report from LPN O on the morning of [DATE]. In report, she was told that resident #1
did not sleep the night before, and was awake until 6 AM. LPN A stated she went in to wake up resident #1 around 7 or 8 AM,
she said, I tried to wake her up, and she (resident #1) looked at me but she wasn't awake. I thought she just needed to
sleep, so I left her sleeping. I went back to wake her after 8 AM to give her morning medications. She opened her eyes but
she wasn't awake, so I held the medications. I didn't let the doctor know that I held her medications or that she hadn't
eaten, because I wanted her to sleep. I don't know if I called or told the ARNP that she was sleepy but I didn't write it
down. I cannot remember if I did or did not talk to her. I think I did but I don't know for sure. I didn't document
anywhere that she couldn't take her medications and I didn't want to bother the doctor. (Resident #1's) brother was here
around 11 AM. He did say to me that she wasn't as she normally was but he didn't seem worried, and I told him it was
because she hadn't slept the night before. The CNAs came to me and told me she wasn't eating. Normally she would eat really
good, but not that day. She was sleepy because she was tired. She didn't sleep the night before, so it's ok that she slept
though my shift. If someone is awake all night, it would be normal for them to sleep though my shift. It wasn't a big deal.
(Resident #1) did not take any medications or eat at all during my shift. During report with the ,[DATE] PM nurse (LPN J) I
told the nurse that (resident #1) had been sleeping all day. The resident would wake and look at me but not stay awake. I
told her that if (resident #1) didn't eat dinner, she (LPN J) should call the doctor, because after dinner would be too
long for her to go without food or medications.
In an interview on [DATE] 1:40 PM, the ARNP said, I was told on the phone that the nurse found her (resident #1) on the
floor (on [DATE]). He told me that he went in, she had slipped out of the chair and hit her head on the wheelchair. It was
unwitnessed. There did not appear to be an injury, and per the patient (resident #1), she said she hit her head, but there
was no evidence of trauma. The resident was complaining of pain. I was not told that she hit her head on the floor. I
ordered neuro checks and to call if there was any obvious trauma. I ordered ice for pain, and to contact me if there was
any change. She said, I received a call in the afternoon, ([DATE]). It was between 3 and 5 PM. That was the first time they
contacted me. The nurse told me (resident #1) had been sleeping a lot today, skipped breakfast, and participated in
therapy. I wasn't concerned because they told me her roommate kept her awake all night. During that time, there was
[MEDICAL CONDITION] going around, so I thought maybe it was that. I ordered a chest X-ray and labs because I was told they
heard something in her lungs. They called me back around 7 PM because her sugar was low and they wanted to know if they
should hold the resident's insulin. I was told her blood sugar was low and she was not eating. I then began to ask more
questions. They told me she was really sleepy and difficult to arouse, and based on what they were telling me, I didn't
like the answers. So I sent her to the hospital for evaluation. (Resident #1) did not remember names, she knew the roles
they played in her care. Like she knew I was her doctor. She could always tell you what was wrong.
In an interview on [DATE] at 1 PM, CNA G, a restorative CNA, she said she completed passive ROM (range of motion) exercises
with resident #1 on [DATE]. She said, I worked with her for approximately 30 minutes on that day. Normally she (resident
#1) would participate with the therapy and talk with you the entire time but that day she just slept. Because she was so
sleepy,I only did passive range of motion with her. When I was done with her treatment, I went out and told LPN A that the
resident was very sleepy and not talking. She told me that the resident had been up all night and was very tired. The
Restorative Tracking Form from [DATE] had documentation that resident #1 was seen by CNA G on [DATE] for 30 minutes. CNA
G
confirmed she completed the form and initialed it.
In an interview on [DATE] at 1:30 PM, CNA R stated, I worked with (resident #1) on [DATE] on the 7 AM-3 PM shift. (Resident
#1) can tell you what she wants, what to eat, and she can use the bathroom. She needs help getting up to the chair and to
the bathroom. She will stand up and hold on when you are cleaning her in the bathroom. She will talk to you, and she knows
who I am. She has her mind, but sometimes she is forgetful. When I come in, I would set her up for breakfast, she would
eat, and then go back to sleep. She can feed herself but if she didn't eat enough, I would help her eat. (CNA Q) told me
during our shift report that (resident #1) was sleepy and didn't want to wake up. I told (LPN A) hat I tried to get her to
eat, and I only got her to take a sip of milk. She went right back to sleep. I told (LPN A) to check on her. (LPN A) told
me that her blood sugar and blood pressure (BP) were fine, and to keep an eye on her. (Resident #1's) brother came in to
see her and I asked her if she wanted to get up. I washed her face with a wet washcloth to wake her up and she went back to
sleep. When her lunch tray came, we tried to give her some MedPass and ice cream, but she only took a sip and went back to
sleep. I washed and changed her but she couldn't help, so the nurse helped me change and wash her. She was very sleepy at
the end of my shift. (Resident #1's) family came to me and said 'Get her up. Get her up, something has to be done.'
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
(Resident #1's) son asked how her sugar was, and I told him her sugar and BP were fine. I kept going back in there to check
Level of harm - Immediate on her all day because she was so sleepy. Normally I would take her to activities but she didn't go to Bingo that day. She
jeopardy didn't go to any activities. CNA R confirmed that she did not know that resident #1 had fallen on [DATE].
In an interview on [DATE] at 2:08 PM, CNA Q said she cared for resident #1 on [DATE]. She said the resident was awake until
Residents Affected - Few about 3 or 4 AM, and then went to sleep. She said, When I went in to change her around 5 or 6 AM, she was very groggy but I
thought it was from the pain medication. For (resident #1) to be awake all night would not have been normal for her. She
would go to bed late sometimes, 11 or 12 PM, but usually she would be in bed asleep when I would come on shift.
In an interview on [DATE] at 2:50 PM, LPN O said, (Resident #1) was up till about 3 or 4 AM in the morning during the shift
of [DATE]. It was not usual for her to be up till then. Normally it's till 11 PM. That was the report I gave in the
morning. (Resident #1) was always able to talk with me I wasn't aware that she fell and hit her head. LPN O confirmed that
she gave the resident her morning medications at 6 AM on [DATE], including [MEDICATION NAME] (for [MEDICAL
CONDITION]),
[MEDICATION NAME] (for pain), and took an Accu-Check/Fingerstick to test her blood sugar. The resident's blood sugar was
165 and she was given 2 units of [MEDICATION NAME] per sliding scale. A Sliding Scale is a tool that is used for insulin
administration. Based on the blood sugar score, the scale indicates the amount of insulin a resident is to receive per
physician's orders [REDACTED]. That's when she told me she was going to sleep. I told (LPN A) that I was able to give her
medicine and that (resident #1) told me she was going to sleep.
Review of the Situation, Background, Assessment, Appearance and Request form (SBAR), Communication Form and Progress Note,
completed by LPN H dated [DATE], read, I'm calling about a Fall The resident appears fine. Only complaint is pain at injury
site head [DATE] 1530 hr (3:30 PM), Resident stood up from w/c (wheelchair) and fell to the floor, striking the back of her
head on the floor. No loss of consciousness (LOC) - Neuro (neurological) check initiated. NP (nurse practitioner) notified
Ice to injury/pain site Q (every) 20 min PRN (as needed). Continue Neuro check, and call if any change in mental status.
The Medication Administration Record [REDACTED]. Resident #1 did receive [MEDICATION NAME] ,[DATE] injection 21 units
subcutaneously before breakfast. [MEDICATION NAME] ,[DATE] is a short and long acting insulin for diabetics.
Interdisciplinary Progress Notes from [DATE] to [DATE] were reviewed. The ADON confirmed her entries on the form. One note
on [DATE] read, Resident slightly lethargic today. Not eating. Family in to visit. Doctor notified and N/O (new order) for
STAT CXR (chest X-ray). Another note on [DATE], Resident in bed all day. Turned and repositioned. Abnormal lung sounds.
There was another entry on this form after the ADON's entries. It read, [DATE], resident slept all day, lethargic, no food
intake or medications. Brother at bedside to visit. Reported haven't been sleeping all night. Will continue to monitor.
Interdisciplinary Progress Notes from [DATE] revealed the following: LPN J confirmed all of the entries were written by her.
On [DATE] at 7:45 PM, it read, Recall to ARNP about change in mental status for (resident #1). Patient (resident) has
become more lethargic, harder to arouse. The note on [DATE] at 8:10 PM read, Return call ARNP advised us to send (resident
#1) via 911 to hospital for AMS (altered mental status), possible pneumonia.
Nurses's Medication Notes on [DATE] read, Unable to take medication all day/asleep. This form was signed by LPN A.
Physician order [REDACTED]. A second entry written by LPN J on [DATE] at (8:10 PM) read, Discharge (D/C) to hospital via 911
for Altered Mental Status (AMS), possible pneumonia, per ARNP.
A SBAR was completed on [DATE] at 9:45 PM, after the resident was sent to the hospital. It read that the onset was [DATE],
symptoms were 'lethargic'. Received report 7a-3p nurse. Patient (resident) has been sleeping all day. Not eating, drinking,
or taking her medication. Patient became hard to arouse. Recall to physician - talk with ARNP advised to send to hospital
911 for AMS, pneumonia.
The CNA ADL Tracking Form from [DATE] showed that on [DATE], resident #1 required total assistance with bathing which was
not her normal need as previously noted before that date.
Review of the facility's policy for Change in Resident Condition read, The Clinical Nurse will recognize and appropriately
intervene in the event of a change in resident condition. The primary Clinical Nurse will communicate to the nurse
manager/supervisor any change in resident condition as it occurs. In the event of an emergency situation, 911 will be
called and the Physician/Family/Responsible Party will be notified as soon as possible. With change of resident status, the
Clinical Nurse will gather all subjective and objective assessment information. The Nurse is responsible to complete an
assessment of the resident's condition to include Vital Signs, level of consciousness and any other symptoms related to the
condition and make any judgment calls regarding the course of action to be taken.
Review of the facility's policy for Head Injury, effective date [DATE], read, Licensed nursing personnel will stabilize the
resident with a head injury Any resident with acute injury could develop changes at a later date due to trauma resulting in
swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in awareness, change in
communication or decline in ADL, which would indicate subdural hematoma or stroke.
On [DATE] on the 11 PM - 7 AM shift, resident #1 began having a significant change in condition, which was not identified by
nursing staff and not reported to the physician until 7:45 PM that evening. There was a delay of twenty (20) hours and
forty-five (45) minutes before the resident's change in condition was assessed, and reported to the physician. The change
in condition resulted in resident #1 being transported to the hospital. Resident #1's [DATE] CT scan revealed a large
acute-to-subacute right middle cerebral artery [MEDICAL CONDITION] infarction. The resident never regained consciousness
and died under hospice care on [DATE].
2. Resident #2 was admitted to the nursing home on [DATE]. Present [DIAGNOSES REDACTED].
Review of the most recent quarterly MDS assessment, dated [DATE], noted that the resident was able to understand others and
make herself understood. The BIMS identified resident #2 as a 13 (,[DATE] indicates cognitively intact). Her functional
status was noted as extensive assistance of one person for bed mobility and transfer, and she did not walk in the room or
corridor. She was not steady but was only able to be stabilized with staff assistance. Mobility devices included a walker
and wheelchair. She had 1 fall prior to the assessment. She was receiving occupational and physical therapy since [DATE].
On [DATE] at 9 PM, the SBAR Communication form revealed the resident complained of pain to the right hip during range of
motion and had a skin tear to the right foot and right elbow. It indicated that The patient (resident) stated that PT & OT
told her that she can walk, so she decide(d) to try walking and fell . Pt. is complaining of pain to right hip.
Nurses' notes for additional information on the change in condition indicated that, At 2100 (9 PM) heard a patient
(resident) calling for help. Upon entering the room, noted patient on the floor in her bedroom. Pt. state that PT/& OT told
her she could walk so she decided to try walking and fell . Pt. is complaining of pain to right hip during range of motion.
Pt also sustained skin tear to right foot and right elbow. Dr. was notified, new orders for X-ray of right hip. Also
notified pt.'s daughter. Patient will only attempt to walk with PT. Will continue to monitor. A resident family member was
notified on [DATE] at 9:30 PM. The physician was notified at 9:15 PM, and orders were received. The order read, Clean right
leg with normal saline, apply [MEDICATION NAME], and cover with dry dressing until healed. X-ray to right hip, result in AM
to MD. Resident was sitting in wheelchair watching TV in bed room. No environmental concerns. LPN V noted on [DATE], no
date, that the resident felt she could walk because of therapy. Patient was educated to use call light for assistance.
On [DATE], an interdisciplinary progress (IDT) note at 3 PM, read, Post fall complaint to right leg relieved by [MEDICATION
NAME] right leg dressing change.
On [DATE], an IDT note at 3 AM read, status [REDACTED]. Relieved by as needed Tylenol; O2 maintenance.
On [DATE] (time not legible), an IDT note read, Noted status [REDACTED]. Upon further evaluation and question, patient
admits she has a pain level on scale of ,[DATE] is 5. Patient stated 'I am OK. Get me up please.' X-Ray order received
report. Call Dr., left message.
On [DATE], an IDT note (time not legible) read, Call Dr. (medical director) gave report, received new orders to send patient
to the hospital.
On [DATE], an IDT note at 9:10 PM read, Resident left facility at 4:15 PM via stretcher
The 24 Hour Report for [DATE] read, 11 PM to 7 AM S/P fall S/T to right leg/left arm intact. PRN pain increased depression
Transport to hospital. ,[DATE] PM left facility at 4:15 PM via stretcher
There was no documentation on the 24 Hour Report that noted the X-ray was completed on [DATE] or [DATE], as ordered by the
physician.
On [DATE] at 4:06 PM, a representative from the portable X-ray company said there was no X-ray ordered or completed on
[DATE] or [DATE].
On [DATE] at 3:30 PM, the resident was observed in her bed lying with the head of bed slightly elevated and her heels
floated on a pillow. An interview was conducted with resident #2 at that time. She stated that she fell on [DATE] when she
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
dropped her lower dentures into her wheel chair They wiggled my legs, I said no pain. They manually set me back in my
Level of harm - Immediate wheelchair with 2 people and checked my vitals. They helped me back to bed. Then on [DATE], at breakfast after getting up,
jeopardy everything started hurting. They (staff) told me to take it easy. I got up and went to Bingo. I was walking to the bathroom
and it started hurting. The night of [DATE], I did not sleep well and took two Tylenol. On [DATE], I was still hurting.
Residents Affected - Few X-rays were done. There was something wrong there. Then they thought it was a good break, a bigger break. I still hurt,
they gave me Tylenol. I was sent to the hospital on [DATE]. I was operated on [DATE] and returned here on [DATE].
On [DATE] at 11:10 AM, LPN V said that she heard resident #2 called for help around 9 PM on [DATE]. She went to the
resident's bedroom and found her lying on her back by the door. She said she observed skin tears and had a little pain when
she moved. She said, I told her not to move, would call Dr. and family, assisted her to the chair and had 2 CNAs to help.
The resident thought she could walk because she was in PT/OT and walking. The doctor ordered an X-ray in AM. I did not call
Mobilex (portable X-ray company). I gave the ,[DATE]-,[DATE] ,[DATE] AM nurse the information to call in the X-ray. On
Sunday morning ([DATE]), I went to give resident #2 her medications. She wanted to get up. I gave her medications and
checked her blood pressure. When I realized the X-ray was not done, I called it in STAT. Mobilex told me the report would
be back in hour. They called and told me it was a fracture. I called the M.D. and she went out with .ambulance.
On [DATE], an X-ray of resident #2's hip was ordered by the physician at 9:30 PM but was not completed until [DATE] at 12:55
PM. The X-ray report read, Acute right [MEDICAL CONDITION] Approximately thirty nine (39) hours passed from the time the
hip X-ray was ordered to the time it was completed.
[DATE].
F 0490 Be administered in an acceptable way that maintains the well-being of each resident .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Immediate Based on observation, interview and record review, the facility failed to efficiently and effectively coordinate the
jeopardy implementation of policies and procedures to prevent resident neglect in order to maintain the highest practicable measure
of care to 1 of 16 sampled residents. This failure put the other 154 residents at risk for potential neglect.
Residents Affected - Few Administration failed to ensure accurate and appropriate assessment of a resident with a history of [MEDICAL
CONDITIONS]/stroke, and failed to ensure the provision of prompt care when there was a change in resident condition. This
resulted in Immediate Jeopardy for resident #1 (#1).
Findings:
Cross Reference F224, F225, F281 and F309. Review of Executive Director's I Job Description, date unknown, read, As
Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for
carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility and
ensures compliance with all state and federal regulations. Supervises Director of Clinical Services Maintain and guide the
implementation of facility policies and procedures in compliance with state, federal, and other regulatory guidelines
Support and guide the facility's quality improvement process Maintain a file for and monitor incident reports
Review of the Director of Clinical Services' I Job Description, date unkown, read, As Director of Clinical Services I, you
are delegated the administrative authority, responsibility and accountability necessary for carrying out planning,
organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the
delivery of high quality, efficient nursing care Supervises Assistant Director of Clinical Services, Clinical Nurses and
Nurse Techs Maintain and guide the implementation of current policies and procedures Assure compliance with resident rights
Establish and monitor compliance with an effective medical record documentation Actively participate in the quality
improvement process for the facility
Resident #1 sustained a fall on [DATE] which resulted in the resident complaining of head pain. The resident had a history
of [REDACTED]. The nurse did not report the correct information to the Advanced Registered Nurse Practitioner (ARNP) after
the fall, which consisted of increased lethargy.
The resident had a change in condition which included a change in mental status starting on [DATE] on the 11 PM to 7 AM
shift, three days after the fall. The night nurse did not notify the physician or the family at the time the change began.
The resident continued to have a declined change in condition and mental status on the 7 AM to 3 PM shift on [DATE]. The
resident was unable to verbalize to staff, eat her meals or take her medications for the entire 7 AM to 3 PM shift on
[DATE]. The nurse did not notify the physician that the resident was unable to eat, speak, and take her medications during
the day shift. On [DATE], the 3 to 11 PM nurse, LPN J, notified the advanced registered nurse practitioner (ARNP) between 3
PM and 5 PM but did not give an accurate report of the resident's condition. The resident's family was present on [DATE]
and reported to the nurse that the resident was not her normal self. The family was told by nursing staff that the resident
was just sleepy because she was restless and awake the night before.
In an interview on [DATE] at 4:40 PM with the executive director (ED) and the director of nursing (DON), the DON said she
was aware of the incident and stated, The resident would normally talk to her and is awake. She was just sleepy because she
didn't sleep the night before. I wasn't worried. When asked if she knew what had happened to the resident after she left
the facility, she answered, Yes, she had a stroke and died . When asked if administration investigated the incident, she
replied, No. Why would we? We didn't do anything wrong. She was sleepy. We didn't think it was anything. She confirmed they
had not done a complete investigation of the [DATE] fall and the change in condition on [DATE]-[DATE], and had not educated
the staff on following their policy for Head Injury which included assessing for change in condition, and documenting after
falls and change in condition. The ED did not comment on any of the questions.
On [DATE] at 10:08 AM, the ED indicated that adminsitration communicates with nursing staff daily at Stand Up and Stand Down
meetings. The unit managers attend the morning Stand Up meetings and communicates back to unit nurses and certified nursing
assistants (CNAs) daily. The ED was not specific about how the unit managers communicate with staff from the other shifts,
evening and night shifts, and how administration monitors the care to ensure qaulity.
[DATE].
F 0497 1) Review the work of each nurse aide every year; and 2) give regular in-service training
based upon these reviews.
Level of harm - Minimal
harm or potential for actual Based on record review and interview, the facility failed to ensure that 3 of 7 sampled certified nursing assistant (CNA)
harm performance reviews were completed in a timely manner out of 85 CNAs (E, F & G).
Findings:
Residents Affected - Few Seven CNA personnel records reviewed on 6/06/15 revealed the following:
1. CNA E was hired on 9/15/05. Her last performance review was done on 10/25/11.
2. CNA F was hired on 9/16/10. There was no performance review in this CNA's personnel record.
3. CNA G was hired on 5/28/03. Her last performance review was done on 7/05/11.
On 6/06/15 at 1:05 p.m., the acting administrator of the day confirmed that the above 3 CNAs did not have performance review
done in a timely manner. On 6/10/15 at 4:30 p.m., the director of human resources stated none of the CNA staff had had
performance evaluation done since she has started working at the facility in January 2015. She said there was no set
schedule for CNA performance evaluation as of that date.
F 0514 Keep accurate, complete and organized clinical records on each resident that meet
professional standards
Level of harm - Minimal **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
harm or potential for actual
harm
Residents Affected - Few

OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
Based on interview and medical record review, it was determined the facility failed to accurately document assessments,
Level of harm - Minimal reassessments, and changes in condition for 1 of 16 sampled residents (#1).
harm or potential for actual Findings:
harm Review of resident #1's paper medical record from March to April 2015 found the following information:
Physician order [REDACTED].>On 4/17/15, licensed practical nurse (LPN) H did not enter the time the order was given.
Residents Affected - Few On 4/17/15, LPN H did not enter the time the order was given.
On 4/18/15, LPN H did not enter the time the order was given.
In an interview on 6/04/15 at 3 PM, LPN H confirmed that he wrote the physician orders [REDACTED].
On 4/21/15, the assistant director of nursing (ADON) did not enter a time when the order was received. On 6/04/15 at 4 PM,
the ADON confirmed her entry on the physician's orders [REDACTED].
Neurological Assessment Flow Sheet:
4/17/15 at 8:30 PM, Pupil Response, Motor Functions, Pain Response, Vitals, Observation, and Signature are not completed. An
interview on 6/04/15 at 4:30 PM, the director of nursing (DON) and administrator confirmed that an entry on the form for
the 8:30 PM neurological assessment was not written.
Interdisciplinary Progress Notes:
On 3/15/15, 3/27/15, 4/17/15, and 4/22/15, the time was not written on the nurse's note.
On one Interdisciplinary Team (IDT) Progress Note from 3/15/15 to 4/22/15, resident #1's name was not on the note. On
3/29/15, the IDT Progress Notes was not timed or signed by the writer.
During an interview on 6/04/15 at 4 PM, the ADON confirmed she wrote the progress note on 4/21/15 but she did not remember
why she did not write a time.
Pain Evaluation:
Resident #1's Pain Evaluation form did not have a date, time or signature on it.
During the interview on 6/04/15 at 3 PM, LPN H confirmed that he completed the Pain Evaluation form after the fall of
resident #1 but did not know why he did not time, date, and sign the form.
Restorative:
During the month of March 2015, the Restorative Tracking Form did not have a written initial and signature for the treatment
provided.
Individual Resident Daily Participation Record:
January, February, March, and April 2015 Individual Resident Daily Participation Records did not have any written initials.
From 3/19-20/15, nursing documentation was not completed, and signature or initials for the staff member who completed the
therapy was not written.
Medication Administration Records from 4/01/15 through 4/30/15:
[MEDICATION NAME] 300 milligrams (mg.) three times a day (TID) - initials to show the dose was given for 6 AM on 4/06/15,
and the 2 PM were not written.
[MEDICATION NAME] ER 600 mg. twice a day (BID) - initial to show the dose was give on 4/15/15 at 9 PM was not written.
[MEDICATION NAME] HCL 50 mg. BID - initial to show the dose was given on 4/06/15 at 10 PM was not written.
[MEDICATION NAME] 10 mg. TID - initial to show the dose was given on 4/19/15 at 2 PM or 10 PM was not written. Resident #1's
blood pressure (BP) at 2 PM was 176/70 and at 10 PM was 148/68. The physician order [REDACTED]. The systolic is the top
number on a BP reading.
[MEDICATION NAME] gel 4 grams topically to knees four times a day (QID) - initials that this medication was applied at 6 AM
on 4/01, 10, and 15/15, at 12 PM on 4/01, 11, 15, 17, 18 and 19/15 were not written.
Check Placement of [MEDICATION NAME] every shift - initials to show the patch was assessed on the 11 PM-7 AM shifts on 4/01,
06, 07/15, or the 3 PM-11 PM shifts on 4/02, 04, 07/15 were not written.
Wound right heel, clean with [MEDICATION NAME], cover with Non-stick [MEDICATION NAME] dressing on the 11 PM-7 AM,
was not
initialed that it was completed on 4/19 and 20/15.
Monitor Blood Pressure Three Times Daily Prior to [MEDICATION NAME] - BP entries for the 6 AM dose on 4/06/15, 2 PM BP on
4/12 and 13/15, and 10 PM BP on 4/02 and 07/15 were not written.
Accu-check Before Meals and at Bedtime with Sliding Scale Coverage did not have any written initials or blood sugar level
for 6:30 AM on 4/06/15 or at 10 PM.
Float Heels when in bed - initials to show this task was completed on the 11 PM-7 AM on 4/06 and 15/15 were not written.
Apply Barrier Cream to Buttocks every shift: initials to show treatment was given to resident #1 were not written.
F 0520 Set up an ongoing quality assessment and assurance group to review quality deficiencies
quarterly, and develop corrective plans of action.
jeopardy Based on observation, record review and interview of the facility's Quality Assurance (QA) program committee did not
evaluate and identify nursing non-compliance with the facility's fall/accident/assessment program, head injury, and change
Residents Affected - Few in condition, in order to identify and correct quality deficiencies to ensure the safety and wellness of residents in the
facility for 1 of 16 residents reviewed for falls, head injury and change in condition. These actions caused a delay in
care for resident #1 and resulted in Immediate Jeopardy starting on [DATE] (#1).
Findings:
Cross Reference F224, F225, F281, F309, and F490. Resident #1 sustained a fall with a head injury on [DATE] at 3:30 PM which
was verified by review of Situation, Background, Appearance and Request form (SBAR) dated [DATE] and interview with
licensed practical nurse (LPN) H on [DATE] at 3 PM. LPN H confirmed the resident had fallen and sustained a head injury on
[DATE]. He said the fall was unwitnessed, but the resident had told him she hit her head on the floor and she complained of
pain.
In an interview on [DATE] at 3:20 PM, the Advanced Registered Nurse Practitioner (ARNP) stated, I was not told the resident
had hit her head on the floor when the nurse called me. I was told the resident had slipped out of her chair and hit her
head on the back of the wheelchair.
Review of the medical record did not show any documentation the resident was transferred to local hospital emergency room
after sustaining a head injury after a fall on [DATE], as indicated by the facility's Head Injury policy.
On [DATE], resident #1 had a change in condition starting on the 11 PM to 3 PM shift. The resident was reported as being
awake most of the night, which was unusual for her. On [DATE] on the 7 AM to 3 PM shift, LPN A said the resident was asleep
most of the day, did not talk with the staff, did not take medication, and did not eat. It was reported to the 3 to 11 PM
LPN J that the resident was kept up all night by her roommate and was sleepy. LPN A, the 7 AM to 3 PM shift nurse, did not
call the ARNP to report the resident's change in condition. LPN J did not notify the ARNP with any information about the
resident until sometime between 3 PM and 5 PM. At that time, the ARNP was not informed that the resident had not eaten all
day, had slept all day, was not verbal with staff, and her blood sugar results from 4 PM was low at 87. It was not until
7:45 PM on [DATE], the ARNP was informed about the resident's total change in condition, and then the resdient was sent to
the hospital in an unresponsive state.
In an interview on [DATE] at 4:30 PM, the Executive Director (ED) and Director of Nursing (DON) were interviewed. The ED
said she was the lead for the QA&A (Quality Assessment & Assurance) meetings and was also the Risk Manager (RM). The ED and
DON were asked if they had investigated or brought before the QA&A committee the incident of a fall with head injury and
for nursing not communicating a change in condition accurately to nursing staff and the physician. They were also asked if
they knew what happened to resident #1 after she left the facility. The DON answered, Yes, she died . The ED did not reply.
When asked if they had identified, investigated any risk factors from the fall with head injury on [DATE] or the lack of
assessment and communication on [DATE] for resident #1, and whether it had been discussed in QA&A, the DON said, No. Why
would we? We didn't do anything wrong. We didn't think it was anything. The ED did not reply to the question.
On [DATE] at 12:50 PM, the medical director said the facility has monthly QA (quality assurance) meetings and the committee
reviews any issues and ongoing management concerns. He said they talk about falls, incidents, and change in condition. He
said. I don't remember response time being brought up for delay in care and services at these meetings. When asked if he
OMB NO. 0938-0391
CORRECTION NUMBER
105861
MELBOURNE, FL 32934
was required to review medical records for specific concerns, he replied, Yes, but I haven't had to review a chart for that
Level of harm - Immediate (change in condition).
jeopardy On [DATE] at 10:08 AM, the ED indicated that administration reviews daily at the Stand Up Meeting the following: environment
concerns, new admissions, resident concerns from previous shifts, and falls.
Residents Affected - Few The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM.
These actions caused a delay in care for resident #1 and resulted in Immediate Jeopardy starting on [DATE]. It was
determined to be ongoing as of the exit date of [DATE].

Consulate Health Care of Melbourne 6/10/2015 Inspection Report

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Consulate Health Care of Melbourne 6/10/2015 Inspection Report

Hochgeladen von

Copyright:

Verfügbare Formate

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:1/5/2018

CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

Residents Affected - Few

Das könnte Ihnen auch gefallen