Health inspection·September 18, 2024

F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F623 and F626 Based on interview and record review, the facility failed to document in the medical record the reasons why they could not meet the needs and readmit one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the Face Sheet revealed Resident #1 was originally admitted to the facility in June of 2023 with diagnoses to include multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. The Face Sheet showed Resident #1 was discharged on 9/9/24 at 9:25 AM. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Review of Psychiatry Provider Advanced Registered Nurse Practitioner (ARNP) note dated 08/14/2024 showed the following. Per staff, patient has been stable, is cooperative with care, does not have behavioral disturbances, anxiety nor agitation noted. Behavior has been stable; uneventful and medication compliance is good. No side effects are reported or evidenced .Will d/c [discontinue] PRN [as needed] Haldol and start Ativan 0.5 mg [milligram] BID [twice daily] for agitation and anxiety .Continue to monitor how patient tolerates changes and follow up in 1 week. Review of a nursing progress note on 08/17/2024 showed Resident #1 was being disruptive, attempting to exit the building, attempting to hit a staff member. Review of a nursing progress note on 08/19/2024 showed that an Emergency Discharge to the hospital was ordered. Review of a Certificate of Professional Initiating Involuntary Examination dated 08/19/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious Page 1 of 10 105292 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0622 Level of Harm - Actual harm Residents Affected - Few bodily harm to self or others. The patient presents with unstable mood, aggressive behaviors, combative with staff members, trying to attack and bite. These behaviors continue to worsen over the past several weeks. Psychopharmacological interventions have been ineffective. We are unable to stabilize the patient within the facility and he poses a danger to himself and others therefore he is requiring a higher level of care at this time. This document was signed by the Psychiatric Provider. Review of a nursing progress note dated 08/29/2024 showed the resident returned to the facility with several medication dosage changes and an additional medication order for a monthly injection was also added with the next dose due on 9/22/24. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. Review of the hospital's psychiatric initial consult note dated 9/2/24 revealed the patient presented from a long term care facility due to report of expressed suicidal ideation. Patient adamantly denying that he ever expressed suicide to anyone in the facility. He seems to be as well-documented baseline. He was discharged from another inpatient psychiatric unit less than 48 hours before being sent back to our emergency department. Patient has had chronic behavioral issues at the long term care facility and now they are refusing to take him back. Patient will not be held involuntarily. Further inpatient psychiatric hospitalization will not modify his chronic behavioral issues secondary to his developmental delay. An interview with the Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and his plans were never changed. An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 12:41 PM. The NHA said, I got a call from the hospital after he had been there a couple days, they felt we should take him back. They felt that he had not been deemed incompetent. I tried to tell them he had said he wanted to die. My thoughts were that he needed a secured unit. They thought we should have put him on 1:1 supervision. I told them we could not take residents who are exit seeking. I told them I could not keep him safe. That was why we did not take him. The NHA stated Resident #1 was a long-term resident and his plan of care was to remain at the facility. She stated after the elopement incident she felt they could not keep him safe. The DON stated he had become aggressive and suicidal. She stated the documentation may not reflect what actually happened that evening. The NHA stated they should have documented better. A follow-up interview with the NHA and DON on 09/18/2024 at 2:45 PM confirmed Resident #1 did not have a discharge plan because they only do so if the resident was discharging home or to an ALF. The NHA said, He was [Emergency Discharge] because he had learnt the code [access code to open external doors], he left the building and waved at the camera, he knew what he was doing. The NHA stated the resident was not seen in person by the doctor who gave the order to send him to the hospital involuntarily. The physician was aware because we called her. I know there is nothing documented. We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not 105292 Page 2 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0622 Level of Harm - Actual harm Residents Affected - Few have plans to discharge anywhere else. The DON said, He had become aggressive. He wanted to kill himself. The DON stated we sent him to the hospital involuntarily to get him stabilized. The NHA stated there were other residents currently residing in the facility with a BIMS of 10 who could also learn the door code. The NHA stated they should have had the doctor assess Resident #1 in person to confirm he was not safe at this facility. The NHA and DON confirmed the resident's medical record did not clearly document the course of the events relating to Resident #1's transfer and rationale for not allowing the resident to return. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on [DATE]. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. Telephone interview was conducted with the hospital's Manager of Case Management (MCM) on 10/2/24 at 4:24 PM. The hospital's MCM stated Resident #1 was at the hospital in observation status from 9/1/24 to 9/6/24. She said orders for his discharge back to the nursing home where he had lived since June of 2023 were written by the physician on 9/2/24, but the nursing home refused to accept him back. The hospital MCM reported that it took four additional days to find him placement, and Resident #1 showed no behaviors during this timeframe. The hospital MCM stated it was not good for the patient, the facilty, or the hospital when a resident was not permitted to return, especially when the resident had lived at the facility for well over a year. Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. Determine if the resident still requires the services of the facility and is eligible for Medicare/Medicaid nursing services. b. Ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility and/or through visits by facility staff to the hospital. c. Find out from the hospital the treatments, medications and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications and services needed the facility may not be able to meet the resident's needs. 105292 Page 3 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0622 d. Work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. Level of Harm - Actual harm Residents Affected - Few 105292 Page 4 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F622 and F626 Residents Affected - Few Based on interview and record review, the facility failed to provide a written transfer and discharge notice to the resident representative, and a copy to the Office of the State Long-Term Care (LTC) Ombudsman for one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the Face Sheet revealed Resident #1 was originally admitted to the facility in June of 2023 with diagnoses to include multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. The area to complete to show that the notice as given to the resident, legal guardian or representative and the local long term care ombudman council was incomplete/blank. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on [DATE]. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. The family member did not report receiving a written notice from the facility relating to his discharge from the facility. An interview with the Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and 105292 Page 5 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0623 his plans were never changed. Level of Harm - Minimal harm or potential for actual harm An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 2:45 PM. The NHA stated they did not have a discharge plan for Resident #1 because they only do so if the resident was discharging home or to an ALF. The NHA said, We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not have plans to discharge anywhere else. NHA and DON confirmed the resident's medical record did not clearly document the course of the events relating to Resident #1's transfer/discharge from the facility. Residents Affected - Few Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: -The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident. -An immediate transfer or discharge is required by the resident's urgent medical needs. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the LTC ombudsman when practicable. 105292 Page 6 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F622 and F623 Based on interview and record review, the facility failed to permit readmission from the hospital for one (#1) of two residents reviewed for transfer and discharge rights. Findings included: Review of the undated facility Policy titled Transfer or Discharge, Facility-Initiated, revealed: When residents are sent emergently to an acute care setting, theses scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting such as a hospital, are permitted to return to the facility. If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. Determine if the resident still requires the services of the facility and is eligible for Medicare/Medicaid nursing services. b. Ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility and/or through visits by facility staff to the hospital. c. Find out from the hospital the treatments, medications and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications and services needed the facility may not be able to meet the resident's needs. d. Work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. Review of the Face Sheet for Resident #1 revealed an original admission date in June of 2023. The Face Sheet showed Resident #1 was discharged from the facility on 9/9/24 at 9:25 AM. The diagnoses on the Face Sheet included multiple sclerosis (MS), dysphagia, autistic disorder, dysarthria, attention-deficit hyperactivity disorder (ADHD), irritability, bipolar disorder, anxiety, insomnia, and depression. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. 105292 Page 7 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0626 Level of Harm - Actual harm Review of Resident #1's care plan for discharge with an original start date of 06/13/2023, and last reviewed/revised on 06/29/2024, revealed the resident's mother has chosen to have resident remain in this facility for long term care and has no plans for him to return to the community or other care setting at this time. Residents Affected - Few Review of Psychiatry Provider Advanced Registered Nurse Practitioner (ARNP) note dated 08/14/2024 showed the following. Per staff, patient has been stable, is cooperative with care, does not have behavioral disturbances, anxiety nor agitation noted. Behavior has been stable; uneventful and medication compliance is good. No side effects are reported or evidenced .Will d/c [discontinue] PRN [as needed] Haldol and start Ativan 0.5 mg [milligram] BID [twice daily] for agitation and anxiety .Continue to monitor how patient tolerates changes and follow up in 1 week. Review of a nursing progress note on 08/17/2024 showed Resident #1 was being disruptive, attempting to exit the building, attempting to hit a staff member. Review of a nursing progress note on 08/19/2024 showed that an Emergency Discharge to the hospital was ordered. Review of a Certificate of Professional Initiating Involuntary Examination dated 08/19/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The patient presents with unstable mood, aggressive behaviors, combative with staff members, trying to attack and bite. These behaviors continue to worsen over the past several weeks. Psychopharmacological interventions have been ineffective. We are unable to stabilize the patient within the facility and he poses a danger to himself and others therefore he is requiring a higher level of care at this time. This document was signed by the Psychiatric Provider. Review of a nursing progress note dated 08/29/2024 showed the resident returned to the facility with several medication dosage changes and an additional medication order for a monthly injection was also added with the next dose due on 9/22/24. Review of a Certificate of Professional Initiating Involuntary Examination dated 09/01/2024 showed there was substantial likelihood that without care or treatment the individual will cause serious bodily harm to self. The supporting evidence showed the resident had opened a door of the facility after learning the security code, was making suicidal statements as he claimed his father passed away, was in clear danger to himself, and needed a higher level of care as the facility could not ensure his well-being at that time. This document was signed by the Psychiatric Provider. No progress notes, change in condition form, evaluations, or assessments were completed by staff from the facility relating to the 9/1/24 transfer to a higher level of care. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 9/1/24 with an effective date of 10/1/24. The location to which the resident was transferred to was the name of the hospital, the hospital address, and the hospital phone number. The reason for the discharge or transfer was your needs cannot be met in this facility. The notice was signed and dated 9/1/24 by the DON as the NHA's designee. The DON documented that the resident's family member was notified by phone on 9/1/24. Review of the hospital's psychiatric initial consult note dated 9/2/24 revealed the patient presented from a long term care facility due to report of expressed suicidal ideation. Patient adamantly 105292 Page 8 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0626 Level of Harm - Actual harm Residents Affected - Few denying that he ever expressed suicide to anyone in the facility. He seems to be as well-documented baseline. He was discharged from another inpatient psychiatric unit less than 48 hours before being sent back to our emergency department. Patient has had chronic behavioral issues at the long term care facility and now they are refusing to take him back. Patient will not be held involuntarily. Further inpatient psychiatric hospitalization will not modify his chronic behavioral issues secondary to his developmental delay. A phone interview was conducted with Resident #1's family member on 09/18/2024 at 3:28 PM. She stated she was notified by the facility when Resident #1 was taken to the hospital on [DATE]. She did not know Resident #1 was not allowed back to the facility until she was called by the hospital and told the facility refused to take Resident #1 back. Telephone interview was conducted with the hospital's Manager of Case Management (MCM) on 10/2/24 at 4:24 PM. The hospital's MCM stated Resident #1 was at the hospital in observation status from 9/1/24 to 9/6/24. She said orders for his discharge back to the nursing home where he had lived since June of 2023 were written by the physician on 9/2/24, but the nursing home refused to accept him back. The hospital MCM reported that it took four additional days to find him placement, and Resident #1 showed no behaviors during this timeframe. The hospital MCM stated it was not good for the patient, the facilty, or the hospital when a resident was not permitted to return, especially when the resident had lived at the facility for well over a year. An interview with the facility's Social Services Director (SSD) was conducted on 09/18/2024 at 11:15 AM. The SSD stated Resident #1 did not have any discharge planning because he was a long term care resident and his plan was to remain at the facility. The SSD said Resident #1 did not have anywhere to go and his plans were never changed. An interview with the Nursing home Administrator (NHA) and Director of Nursing (DON) was conducted on 09/18/2024 at 12:41 PM. The NHA said, I got a call from the hospital after he had been there a couple days, they felt we should take him back. They felt that he had not been deemed incompetent. I tried to tell them he had said he wanted to die. My thoughts were that he needed a secured unit. They thought we should have put him on 1:1 supervision. I told them we could not take residents who are exit seeking. I told them I could not keep him safe. That was why we did not take him. The NHA stated Resident #1 was a long-term resident and his plan of care was to remain at the facility. She stated after the elopement incident she felt they could not keep him safe. The DON stated he had become aggressive and suicidal. She stated the documentation may not reflect what actually happened that evening. The NHA stated they should have documented better. A follow-up interview with the NHA and DON on 09/18/2024 at 2:45 PM confirmed Resident #1 did not have a discharge plan because they only do so if the resident was discharging home or to an ALF. The NHA said, He was [Emergency Discharge] because he had learnt the code [access code to open external doors], he left the building and waved at the camera, he knew what he was doing. The NHA stated the resident was not seen in person by the doctor who gave the order to send him to the hospital involuntarily. The physician was aware because we called her. I know there is nothing documented. We gave him the discharge notice. The NHA confirmed this was Resident #1's place of residence. He did not have plans to discharge anywhere else. The DON said, He had become aggressive. He wanted to kill himself. The DON stated we sent him to the hospital involuntarily to get him stabilized. The NHA stated there were other residents currently residing in the facility with a BIMS of 10 who could also learn the door code. The NHA stated they should have had the doctor assess Resident #1 in person to confirm he was not safe at this facility. The NHA and DON confirmed the resident's medical record did not 105292 Page 9 of 10 105292 09/18/2024 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0626 clearly document the course of the events relating to Resident #1's transfer and rationale for not allowing the resident to return. Level of Harm - Actual harm Residents Affected - Few 105292 Page 10 of 10