Health inspection·March 26, 2024

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a discharge plan for 3 out of 3 residents sampled for discharge to the community (Residents #3, #7 and #8). Residents Affected - Some The findings included: Review of the facility's policy titled Discharge Planning with an effective date of 11/30/14 included in part the following: To evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge planning begins the day of admission. The process involves the resident and family, Care Management/Social Services, and other members of the clinical team. An initial evaluation of a resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised at plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. Discharge planning record will be completed within 7 days after admission. Discharge planning is adjusted as appropriate. At the time of discharge, a discharge summary and home-going instructions are provided to the resident or the resident's caregiver which will include the following: Current diagnosis Rehabilitation potential Summary of prior treatment Physician's orders for immediate care Pertinent social information Community referrals as needed (e.g., home health, mental health, adult day care, etc.) Within twenty-four to forty-eight hours (or the next day) after discharge to home, another nursing facility or to another type of residential facility such as a board-and-care-home, a follow-up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided to the discharge plan. Documentation of the after-discharge contact will be made on the social service progress note and labeled Post-Discharge Note. 1. Resident #3 was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses included: Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, and Major Depressive Disorder. Page 1 of 3 105258 105258 03/26/2024 Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Minimum Data Set (MDS) for Resident #3 dated 01/25/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. The Psychosocial Evaluation for Resident #3 dated 01/17/24 did not address Discharge/Advance Planning, Prior Services, Transportation, Expectations for Outcomes and Discharge, Potential Equipment Needs, or Potential Barriers to Discharge. The Social Service Progress Note for Resident #3 dated 01/19/24 revealed the resident was seen by psychiatry on 01/15/24, and by Behavioral Health on 01/17/24. The Social Service Progress Note for Resident #3 dated 01/25/24 revealed the resident was discharged home with all personal belongings. Resident home health and DME (Durable medical equipment) was arranged. The Nursing Progress Note for Resident #3 dated 01/25/24 revealed resident alert and oriented x4. No acute distress noted. discharged home via car. Educated resident about medication and safety precaution. The Discharge Plan and Instructions for Resident #3 dated 01/25/24 was incomplete, including the discharge summary and only documented the resident was discharged to home by car. Additionally, there was no documentation of post discharge follow-up call. During an interview conducted on 03/25/24 at 11:30 AM with the Social Service Director (SSD), she stated she has been working at the facility for about 3 years. When asked about discharge planning for any resident what is the process, she stated she discusses the discharge with the resident and/or family member. When asked if she documents this anywhere in the resident's chart, she stated sometimes she puts a note in. The SSD stated when the resident is discharged , she always puts a note in the resident's chart about who the home health agency is and what Durable Medical Equipment she has arranged for. During an interview conducted on 03/26/24 at 12:40 PM with the Social Service Director (SSD), she stated she talks to the resident or family when they first come in during her assessment within 1-3 days of the resident being admitted or as soon as possible. The assessment is documented in the resident's electronic medical record (EMR) as a Psychosocial Evaluation. For discharge planning she discusses this at the initial assessment and what their goals for discharge are. The SSD does the discharge care plans for a resident. She also talks about it with family during care plan. When asked about Resident #3 she stated the resident was admitted to the facility 01/12/24 and was discharged [DATE] to home. The resident had a brother listed as emergency contact. The SSD said transportation was arranged by her based on the resident's insurance. She acknowledged she did not address discharge planning in the Psychosocial Evaluation, and she did not follow-up to ensure Resident #3 received the DME or that the home health agency had seen him or made contact with him. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to a group home in the community on 03/05/24. Review of the MDS for Resident #7 dated 03/05/24 revealed in Section C a BIMS score of 15 indicating a cognitive response. The Psychosocial Evaluation for Resident #7 dated 02/15/24 did not address Discharge/Advance 105258 Page 2 of 3 105258 03/26/2024 Aviata at the Sea - Pompano Beach 2401 NE 2nd Street Pompano Beach, FL 33062

F 0660 Level of Harm - Minimal harm or potential for actual harm Planning, Prior Services, Transportation, Expectations for Outcomes and Discharge, Potential Equipment Needs, or Potential Barriers to Discharge. The Social Service Progress Note for Resident #7 dated 02/08/24 documented the resident was seen by Behavioral Health on 02/07/24. Residents Affected - Some The Social Service Progress Note for Resident #7 dated 02/17/24 documented the resident was seen by psychiatry on 02/08/24. The Social Service Progress Note for Resident #7 dated 03/05/24 documented the resident was discharged to a group home with all personal belongings. Resident home health and DME was arranged. The Discharge Plan and Instructions for Resident #7 dated 03/05/24 was incomplete and did not address the section Social Services Discharge Summary. During an interview conducted on 03/26/24 at 12:50 PM with the Social Service Director (SSD), when she was asked about the discharge for Resident #7, she acknowledged she did not do a discharge summary for the resident or follow up to ensure Resident #7 received the DME or that the home health agency had seen him or made contact with him. She also acknowledged she did not follow up with the group home. 3. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Laceration with Foreign Body of other Specified Part of Neck and Alcohol Abuse with Alcohol-Induced Anxiety Disorder. The resident was discharged to home on [DATE]. Review of the MDS for Resident #8 dated 03/14/24 documented in Section C a BIMS score of 15 indicating a cognitive response. Review of the Psychosocial Evaluation for Resident #8 dated 03/11/24 did not address Discharge/Advance Planning, Prior Services, Transportation, Expectations for Outcomes and Discharge, Potential Equipment Needs, or Potential Barriers to Discharge. The Social Service Progress Note for Resident #8 dated 03/14/24 documented the resident was seen by behavioral psychology on 03/13/24. The Social Service Progress Note for Resident #8 dated 03/15/24 documented the resident was referred to another agency for placement. The Social Service Progress Note for Resident #8 dated 03/18/24 (Late Entry) documented the resident was discharged to home with all personal belongings. The Discharge Plan and Instructions for Resident #8 dated 03/18/24 was incomplete and did not address the section Social Services Discharge Summary. During an interview conducted on 03/26/24 at 12:55 PM with the Social Service Director (SSD), she was asked about the discharge for Resident #8. The SSD acknowledged she did not do a discharge summary for the resident or follow up with the Resident. 105258 Page 3 of 3