Health inspection·June 26, 2023

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain laboratory results timely and report timely to the physician, resident and/or their families for three residents (#3, #4, #5) of three sampled residents. Findings included: 1. Review of the admission Record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Resident #3's diagnoses included but were not limited to cerebral vascular accident with hemiplegia (CVA), aphasia, seizures and depression. Review of the Annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 99 (resident was unable to complete the interview). Section G Functional Status showed she needed extensive assistance of one for bed mobility and was totally dependent on two for transfers and toileting. Review of the current physician orders and June 2023 Treatment Administration Record (TAR) showed an order for a urinalysis (U/A) and culture and sensitivity (C and S) on 06/11/2023 and performed on 06/12/2023; an order for a U/A and C and S on 06/17/2023 and performed on 06/19/2023; an order for Cipro 500 mg (milligrams) for a Urinary Tract Infection (UTI) as of 06/20/2023. Record review of the Urinalysis and C and S results, dated 06/12/2023, were as follows: Appearance slight cloudy or abnormal Blood 50-150 or abnormal Protein 15-30 or abnormal Leukocytes 25.0 or abnormal Bacteria 2+ or abnormal Amorphous crystals few or abnormal. C and S dated 06/12/2023 showed: Organism Proteus Mirabilis Colony Count over 100,000. Page 1 of 4 105299 105299 06/26/2023 Whispering Oaks 1514 E Chelsea St Tampa, FL 33610

F 0773 Level of Harm - Minimal harm or potential for actual harm Record review of the progress notes starting on 06/01/2023 showed no progress notes documented regarding the U/A and C &S until 06/20/2023: On 06/20/2023 at 15:25 (3:25 p.m.) showed the result for U/A, C &S received and physician office updated. See new order per physician office to start Cipro 500 milligrams (mg) twice a day for 5 days. Residents Affected - Some On 06/20/2023 at 23:39 (11:39 p.m.) showed resident was on by mouth antibiotic, Cipro 500 mg two times a day for UTI. Dose was given and no signs and symptoms (S/S) of side effects was noted. Oncoming nurse was aware. On 06/21/2023 at 16:04 (4:04 p.m.) showed resident was afebrile (not feverish). Antibiotic for UTI in progress, no adverse effect noted. On 06/22/2023 at 23:23 (11:23 p.m.) showed resident continues with by mouth antibiotic for UTI, resident denies pain or discomfort. No s/s of acute distress noted. On 06/23/2023 at 16:13 (4:13 p.m.) showed resident was afebrile, Antibiotic ongoing for UTI. No adverse effect noted. Review of care plans showed an antibiotic care plan related to antibiotic therapy related to infection for UTI. Interventions included but were not limited to administer medications as ordered. Care plan related to incontinence. Interventions included but not limited to observe for foul smelling, cloudy urine, change in urinary output, mental status change. Care plan related to Seizure disorder showed interventions included but not limited to monitor labs and report any sub therapeutic or toxic results to physician, obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. The labs ordered on 06/17/2023 and performed on 06/19/2023 were not located by the facility. 2. Review of the admission Record showed Resident #4 was admitted on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included but were not limited to fractured right femur, hypertension, anemia, kidney failure. Review of the Quarterly MDS, dated [DATE], showed a BIMS score of 10 (moderately impaired). Section G, Functional Status showed he needed supervision for bed mobility, transfers, and limited assistance for toileting. Review of the current physician orders and June 2023 Treatment Administration Record (TAR) showed an order for a Vitamin D level on 06/24/2023 performed on 06/24/2023. Review of the lab results dated 06/24/2023 showed Vitamin D-3 level of 23 or low. Record review of the progress notes showed on 06/24/2023 at 06:27 (6:27 a.m.) blood drawn for Vitamin D labs this morning. No further documentation was provided. Review of the Nutritional care plan showed to obtain and review lab/diagnostic work as ordered. Report results to physician and follow up as indicated. 3. Resident #5 was admitted on [DATE] and readmitted on [DATE]. Resident #5's diagnoses included but not were not limited to osteomyelitis of sacral vertebra, weakens, dysphagia, pressure ulcer left 105299 Page 2 of 4 105299 06/26/2023 Whispering Oaks 1514 E Chelsea St Tampa, FL 33610

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some heel, fibromyalgia, anemia, diabetes, morbid obesity, asthma, and hypertension. Review of the Quarterly MDS, dated [DATE], showed a BIMS score of 14 (cognitively intact). Section G, Functional Status showed he was totally dependent on two persons for bed mobility, transfers, and toileting. Review of the current physician orders and June 2023 TAR showed an order for CBC (Complete Blood Count), BMP Basic Metabolic Panel), U/A, C&S ordered on 06/24/23. Review of the labs, dated 06/24/2023, showed the following as abnormal: CBC showed: RBC (Red Blood Count) 4.29 or low Hemoglobin 12.0 or low Hematocrit 37.3 or low RDW (Red Cell Distribution Width) (used to help diagnose anemia) 16.1 or high. BMP showed: BUN (Blood Urea Nitrogen) (shows kidney function) 26 or high. Record review of the progress notes showed: On 06/24/2023 at 06:27 blood drawn for CMP, BMP, urine collected for urinalysis, urine culture and sensitivity this morning. On 06/24/2023 at 06:28 (6:28 a.m.), chest x-ray done. Waiting for results. The oncoming nurse will be made aware. There was no reference to the lab results in the progress notes. Review of the Nutritional care plan showed to obtain and review lab/diagnostic work as ordered. Report results to physician and follow up as indicated. During interview on 06/26/2023 at 3:20 p.m. with Staff A, Registered Nurse/Unit Manager (RN/UM) she stated the lab process was for either the UM or the floor nurse to access the lab results from the lab computer site. The results were to be printed off. The results were then placed into the physician's notebook for review. The lab results, after the physician reviews, were then filed into the resident's hard chart. Staff A looked in the physician's notebook and in hard charts for Resident #3, #4, and #5 and was unable to find the lab results. Staff A, RN/UM then went to the computer, onto the lab's website and printed all three of the resident's labs. She verified that Resident #4 had labs ordered on and performed on 06/20/2023 and it was documented in the resident's e-chart that there were no new orders as of 06/22/23. He also had labs performed on 06/24/2023, which there was no documentation in the e-chart that the physician had been notified of the results. Staff A stated if the labs were normal, they place the results in the physician's notebook and the physician will look at them on Monday. When asked if they were reviewed today (Monday), she stated the APRN (Advanced Practice Registered Nurse) did not come in today. Staff A then verified Resident #5 had labs performed on 105299 Page 3 of 4 105299 06/26/2023 Whispering Oaks 1514 E Chelsea St Tampa, FL 33610

F 0773 Level of Harm - Minimal harm or potential for actual harm 06/24/2023 for urinalysis and BMP. She again was unable to find the results in the physician's notebook nor in the hard chart. She printed them from the lab's computer site. She verified there was no documentation the physician or family was called with the results. Then Staff A reviewed Resident #3's labs and progress notes and verified the labs were performed on 06/12/2023 but the antibiotic was not ordered until 06/20/2023. She stated that she did not know why there was such a delay in reporting to the physician. Residents Affected - Some During an interview on 06/26/2023 at 3:59 p.m. the Director of Nursing (DON) stated they were to get an order and follow that order. They insert the order into the e-chart. Once the labs have been drawn or picked up, they would advise the physician of the pick-up time and date, if it was going to be delayed. The nurse was then to look for the results on the lab's website. They were to use the nurse-to-nurse report to let the next nurse know of the labs. Each nurse was to follow-up during their shift until the lab results were obtained. She stated a C & S result could take up to three or four days. They were to check on the lab's website in the computer. They were to print the results. She stated sometimes the lab will fax over the results. The nurse should then notify the physician and obtain orders as needed. If the resident was their own person, the nurse can notify the resident of the results. If they aren't then the families are to be notified of the lab results and any changes in orders. Some of the families want to know everything and if the resident was okay with that, then they are told. They follow the wishes of the resident. The nurse should document in the chart they notified the physician and resident and/or family of the results. The lack of following up on the lab results and informing the physician could result in a negative outcome they could miss something; they could miss a critical lab result. Record review of the facility's policy titled, Laboratory Services, effective January 1, 2020, showed the facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. Procedure: 1. Assure laboratory tests or completed results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by a physician. 3. Assure Nursing notifies the physician promptly of the findings. 5. Assure the laboratory reports submitted by the laboratory are filed in the resident/patient's clinical record contain at least the following: a. Date b. resident/patient name c. name and address of the testing laboratory. 6. Monitor services, timeliness, and quality through the Quality Assurance Committee. Record review of the facility's policy titled, Resident Rights, effective February 2021, showed the facility strives to assure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. 105299 Page 4 of 4