Health inspection·January 15, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement fall risk care plan interventions of floor mats for one (Resident #30) of three residents sampled for falls. Findings included: A review of Resident #30's admission Record revealed the resident was readmitted to the facility at the end of July 2020. A review of Resident #30's quarterly Minimum Date Set (MDS) assessment, dated 8/11/2020 revealed he was unable to complete the Brief Interview for Mental Status (BIMS) interview, had short-term and long-term memory impairment, and was severely impaired for decision making. A review of a significant change MDS dated [DATE] revealed his cognitive status remained unchanged from the 8/11/2020 assessment. A review of Resident #30's Progress Notes, dated 8/15/2020 revealed the resident was found on the floor at 3:30 p.m. by a Certified Nursing Assistant [CNA]. Assessed by nurse for injuries, abrasion observed to back of lower right side of head. No s/s (signs and symptoms), resident assisted off the floor and back into bed. Abrasion treated by nurse and a call placed to physician. Perimeter mattress was put in place and responsible party was notified. A review of Resident #30's care plan, initiated 8/25/2020, revealed a focus related to falls with interventions to include floor mats to the left side of bed while in bed, perimeter mattress, to lock brakes on bed and chair before transferring, and a low platform bed. On 1/11/21 at 7:47 a.m., Resident #30 was observed lying in bed with the bed in the lowest position. No floor mats were observed on either side of the bed and it could not be determined if the perimeter bed was properly placed. An attempt to interview the resident was unsuccessful due to the resident's poor cognitive status. On 1/12/21 at 11:15 a.m., Resident #30 was observed lying in bed in the lowest position with no floor mats in place. On 1/13/21 at 9:47 a.m., the resident was again in the low bed with no floor mats in place and the perimeter bed did not appear to be properly inflated. On 1/14/21 at 8:43 a.m., Resident #30 was lying in bed under the covers without floor mats in place. Page 1 of 2 105293 105293 01/15/2021 Egret Cove Center 550 62nd St S Saint Petersburg, FL 33707

F 0656 Level of Harm - Minimal harm or potential for actual harm On 1/14/21 at 9:23 a.m., Staff A, Certified Nursing Assistant (CNA), revealed she has worked at the facility for more than 10 years and that Resident #30 just moved to her assigned rooms less than a week ago. Staff A stated Resident #30 had no known incidents of falls, no fall indicators, and was not care planned for falls. Staff A was advised of the fall interventions in place for Resident #30 and immediately went to address the concern with the nurse. Residents Affected - Few Immediately following the interview with Staff A, Staff B, Licensed Practical Nurse (LPN) was interviewed. She stated she has worked with Resident #30 for a couple months and she was not aware that the resident had interventions for falls. Staff B confirmed that the staff on the entire hall were responsible for reviewing and implementing interventions on the resident's care plan. Staff B stated she was going to review the care plan and ensure that the proper interventions were in place. On 1/14/21 at 9:43 a.m., the Risk Manager (RM) and Administrator revealed that the care plan protocol called for meetings daily with attendance by Unit Managers (UM), RM, MDS Manager, and Administrator. The RM stated she had only been at the facility for a month and she was retroactively reviewing care plans and the in-place interventions. She stated that any time she enters a resident's room she reviews the respective resident's care planned interventions and ensured they were being utilized. The RM stated Resident #30 changed rooms last week and the floor mats did not come with him when they moved rooms. The Risk Manager stated that it was unknown as to why the floor mats did not get put in place when the resident changed rooms. During a follow-up interview on 1/14/21 at 10:59 a.m., the RM stated Resident #30 was moved on 1/8/21 into the current room and the breakdown of mats not being in place occurred at that time. Moving forward, the RM has implemented Room Change Documentation to better inventory assistive and safety devices when changing resident rooms. The facility will be providing education and training on the new system. A review of the facility policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017, revealed that the facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions . The overall care plan should be oriented towards: 1) Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. 2) Managing risk factors to the extent possible or indicating the limits of such interventions. 3) Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4) Applying current standards of practice in the care planning process. 5) Evaluating treatment of measurable objectives, timetables and outcomes of care. 6) Respecting the resident's right to choose to decline treatment, request treatment or discontinue treatment. 7) Offering alternative treatment's as applicable. 8) Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. 8) Involving the resident to have a role in care planning even if adjudged incompetent, and the resident's family and/or other resident representatives as appropriate to participate in the development and implementation of his or her person-centered plan of care. 9) Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. 10) Involving the direct care staff with the care planning process relating to the resident's expected outcomes. 11) Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. 105293 Page 2 of 2