Health inspection·June 6, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on resident record review, staff interview, and policy review, the facility failed to have a complete accurately documented medical record for one (Resident #1) of four residents reviewed. Residents Affected - Few Findings Included: A review of the record for Resident #1 revealed a physician's telephone order dated 5/9/23 to, send to ER [Emergency Room] for eval [evaluation] per resident request. A review of Resident # 1's nursing notes revealed the last documented note was dated 5/9/23 at 6:41 p.m. The nursing note, written by Staff A Licensed Practical Nurse ( LPN) revealed, At this time [Resident # 1] has complaints of pain and discomfort but refused all medications. Lung sounds are diminished along with his bowel sounds, trouble swallowing and speaking. He is refusing to eat on a regular basis, will continue to monitor this shift. There was no documentation in the nurses' notes of the transfer to the hospital per resident request, no documentation of the resident's condition upon transfer and no documentation that the family was notified of the transfer. An interview with the Director of Nursing (DON) on 6/6/23 at 1: 38 p.m., revealed she could not locate an SBAR (Situation, Background, Assessment, Recommendation) form that should have been completed when the resident was sent to the hospital. On 6/6/23 at 2:54 p.m., the DON confirmed there was no nursing note or any other documentation related to the transfer to the hospital. She stated that a transfer form was not completed if a patient requested to go to the hospital. She stated, We notify the physician and send them with a face sheet and a medication list and call report to the hospital, we don't do a transfer form. An interview was conducted with Staff A, the LPN who wrote the last documented nursing note on 5/9/23. She stated Resident #1 requested to be sent out to the hospital that evening. She stated he was adamant about it . He was feeling so sick by that point, I think. He wasn't eating or drinking. Staff A stated she called EMS (Emergency Medical Services) for him. Staff A stated she was an orientee at that time and did not recall who she was orienting with . She stated she did not know why there was no nursing note regarding Resident #1 being sent to the hospital. Staff A stated she could not recall if the family was notified that Resident # 1 was transferred to the hospital. At 5: 28 p.m., DON stated there was no policy for medical records documentation. Review of a policy entitled Transfers, Reducing Acute Care revised 11/8/2021, revealed Page 1 of 2 105037 105037 06/06/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0842 Level of Harm - Minimal harm or potential for actual harm Policy statement: Transfers to acute care hospitals will be minimized in situations where early intervention would make such transfers avoidable and in situations where the resident's directives specifically request that he or she remain in the facility. Policy Interpretation and Implementation Residents Affected - Few 4. Symptoms or problems that may require physician or practitioner intervention will be documented in a format that will facilitate adequate information when communication occurs. For example: d. Situation: Information about the condition , situation or sign; e Background - Information about the resident, medications, vital signs, recent lab results and changes related to the problem (i.e., mental, functional, respiratory changes, etc. ), including advance directive information. f. Assessment or Appearance - What appears to be going on with the resident; and g. Request _ suggestions or requests for the provider ( i.e., labs, x- ray, acute care transfer, etc.). 5. Should it become necessary to make an emergency transfer or discharge to the hospital or other related in-situation, our facility will implement the following procedures: e. Prepare a transfer form to send with the resident (including Bed Hold). F. Notify the representative (sponsor) or other family members. i. Document disposition and actions in the chart. 105037 Page 2 of 2