Health inspection·June 3, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to notify the physician of an acute (requires immediate care), significant change of condition for 1 of 3 residents reviewed for Quality of Care and Treatment, of a total sample of 3 residents, (#1). Residents Affected - Few Finding: Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from an acute care hospital on 4/16/24. The resident had diagnoses that included metabolic encephalopathy (brain dysfunction), sepsis (blood infection), myocardial infarction (heart attack), hypertension, dysphagia (difficulty swallowing), Urinary Tract Infection (UTI), muscle weakness, bipolar disorder, and cognitive communication deficit. On 4/21/24, the resident was transferred back to an acute care hospital via 911 Emergency Medical Services. The Minimum Data Set 5-day Assessment with Assessment Reference Date 4/21/24 noted the resident was unable to complete the Brief Interview for Mental Status, and she had severely impaired cognitive skills. The assessment showed the resident had not exhibited behaviors, psychosis, or rejection of evaluation or care symptoms. The resident had functional range of motion limitations to both lower extremities and was dependent on staff to complete Activities of Daily Living (ADL). She was incontinent of bladder and bowel functions, received high-risk anti-anxiety, anti-depressant, antibiotic, and anti-platelet medications, and required supplemental intermittent oxygen during the look back period. Resident #1's Comprehensive Care Plan included focuses for staff assistance with ADL care, high risk of falls and injury, UTI, and dependence on staff for physical and social needs with interventions to notify the physician of health status changes or concerns. In a telephone interview on 6/02/24 at 9:21 AM, Licensed Practical Nurse (LPN) A recalled she worked the 11:00 PM to 7:00 AM shift on 4/21/24, and resident #1 was on her assignment. The LPN explained she was concerned after she assessed the resident and stated, She didn't look good. She said the resident's oxygen saturation was low, so she administered supplemental oxygen and then called the Assistant Director of Nursing (ADON) per the facility's policy. The LPN said the ADON told her to monitor the resident and attempt to provide oral fluids. She said after the phone call, she felt uncomfortable because the resident had difficulty swallowing and she didn't want her to aspirate. The LPN said she became further concerned because the resident wasn't improving much, so she placed a crash cart outside the resident's door. The LPN stated, I didn't want to over-react; I should have called the doctor. Page 1 of 3 105250 105250 06/03/2024 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/02/24 at 10:04 AM, in a telephone interview, Registered Nurse (RN) B said he worked the 11:00 PM to 7:00 AM shift on 4/21/24, and recalled at approximately 3:00 AM, LPN A requested his assistance with resident #1 because she was concerned the resident wasn't doing well. The RN stated, I thought she had called the doctor. In a telephone interview on 6/03/24 at 11:38 AM, the RN Weekend Supervisor recalled she reported for work on the 4/21/24 at approximately 6:30 AM, and LPN A asked her to assess resident #1. The RN explained she told LPN A to call the doctor and they needed to send the resident out via 911. Referring to resident #1, the RN stated, She wasn't responding to me; she had labored breathing and was using her accessory muscles. On 6/02/24 at 11:51 AM, the ADON recalled on 4/21/24, she was the Interim Director of Nursing (DON) when she spoke on the telephone with LPN A in the middle of the night about resident #1's change in condition. She said LPN A told her she had called the physician and he had not responded. The ADON said she told LPN A to use nursing judgement about sending her out, and she had not received any additional calls until the next morning after the resident left the facility. The ADON stated, She (LPN A) should have called the doctor; I thought that happened and expected that to happen. Review of the eInteract Change in Condition Evaluation - V 5.1 form revealed LPN A noted on 4/21/24 at 1:02 AM, resident #1 was identified with functional decline (worsening function and/or mobility) and worsening symptoms or signs that had not occurred before. The evaluation read, Vitals declined and O2 [oxygen] levels continued to stay in the low 90's after placing resident on O2 at 3 liters [per minute], via nasal cannula. Resident grimaced when taking blood pressure, like she was in pain . Resident's body was limp and she was unable to perform any strength/neuro tests, in which she used her hands . While doing my rounds at 1:00 AM this morning, I noticed resident was having labored breathing, her vitals were B/P [blood pressure] 94/64, Pulse 106, Respirations 18, Temp [temperature] 97.4 and O2 sat [saturation] 89% on room air. I immediately placed resident on O2 at 3 liters [per minute] via nasal cannula and called the ADON. I was advised to encourage increased thickened fluids and to continue O2 and to monitor the resident closely. The Provider Notification and Feedback section showed the primary care clinician was notified on 4/21/24 at 7:36 AM, over six hours after the resident's significant decline in condition was identified. In a joint interview with the Nursing Home Administrator (NHA), ADON, and DON at 12:05 PM on 6/02/24, the NHA explained, the facility reviewed the incident, and found LPN A discovered resident #1's change in condition at approximately 1:00 AM on 4/21/24 but did not notify the physician until around the time of her transfer to the hospital. The NHA stated, We think she should have called the doctor. On 6/03/24 at 12:42 PM, in a telephone interview, the Medical Director said he expected nurses to call and inform him when there was a significant change in a resident's condition. He recalled resident #1's emergency transfer to the hospital and stated, I probably would have sent her out earlier if I had known of a significant change in her condition . but had the opinion this would not have affected the outcome for her in this case. The facility's standards and guidelines dated 8/16/22 titled Notification of Changes, read, . Compliance Guidelines . Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. 105250 Page 2 of 3 105250 06/03/2024 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0684 Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105250 Page 3 of 3