Health inspection·February 13, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document the occurrence of falls in the medical record for two (#3 and #4) of three residents sampled for documentation related to falls. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and dementia. A diagnosis of traumatic subdural hemorrhage without loss of consciousness was added on 12/23/2023. Resident #3 was discharged from the facility on 1/15/2024. A review of the facility's incident log for December 2023 revealed Resident #3 had an unwitnessed fall on 12/19/2023 at 4:34 PM. A review of Resident #3's progress notes dated 12/19/2023 at 9:00 PM revealed Resident #3 was transferred to the hospital and was diagnosed with a subdural hematoma. A review of Resident #3's progress notes did not reveal documentation related to Resident #3's fall on 12/19/2023 at 4:34 PM. Further review of Resident #3's medical record did not reveal documentation or assessments related to Resident #3's fall on 12/19/2023 at 4:34 PM. A review of a facility report dated 12/19/2023 at 4:34 PM revealed Resident #3 was observed sitting on the floor next to the toilet in his bathroom after a fall. The report also revealed Resident #3 had a small laceration to his nose and a small scraped area on his forehead with a yellow colored bruise on the left side of his nose. Resident #3 was assessed by the facility's Director of Nursing (DON) and sent to the hospital for evaluation. The facility report was not part of Resident #3's medical record. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and atrial fibrillation. A review of the facility's incident log for February 2024 revealed Resident #4 had an unwitnessed fall on 2/12/2024 at 2:13 PM. A review of Resident #4's progress notes did not reveal documentation related to Resident #4's fall on 2/12/2024 at 2:13 PM. Page 1 of 2 105352 105352 02/13/2024 Vivo Healthcare Sebring 3011 Kenilworth Blvd Sebring, FL 33870

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #4's medical record did not reveal documentation or assessments related to Resident #4's fall on 2/12/2024 at 2:13 PM. A review of a facility report dated 2/12/2024 at 2:13 PM revealed Resident #4 was observed sitting on the floor in his room with his head next to the wall beside the residents bed. Resident #4 was assessed by the DON and a lump was discovered on the back of Resident #4's head. Resident #4 was sent to the hospital for further evaluation. The facility report was not part of Resident #4's medical record. An interview was conducted on 2/13/2024 at 1:31 PM with the DON. The DON stated she was not able to find any documentation in Resident #3's medical record related to the resident's fall on 12/19/2023 at 4:34 PM. The DON also stated when a fall occurs in the facility, nursing staff should assess the resident for any injuries and document the call in a progress note and a change in condition assessment in the resident's medical record. The DON stated she was not able to find any documentation in Resident #4's medical record related to the resident's fall on 2/12/2024 at 2:13 PM. The DON stated the falls were documented in a facility record but she was unsure if the facility record was part of the resident's medical record. A review of the facility policy titled Documentation in Medical Record, last revised on 8/25/2022, revealed under the section titled Policy each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 105352 Page 2 of 2