Health inspection·July 10, 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 observation, interviews and record review, the facility failed to maintain a complete and organized medical record for 1 of 3 residents reviewed for respiratory care (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] for diagnoses that included Acute and Chronic Respiratory Failure, Dependence on respiratory ventilator and Muscular Dystrophy. Physician orders included full code, tracheostomy (trach) care and to be on the ventilator at night. Resident #1 was able to breathe without the ventilator during the day with oxygen at 3 liters per minute. Review of the medical record revealed from [DATE]-[DATE] the resident was using oxygen 3 liters per minute during the day and on the ventilator at night. On [DATE] at 8:42 AM, a nursing progress note was written as a late entry. The note stated Resident was found to be unresponsive by RT (Respiratory Therapist) approximately 5:50 AM. Code blue called, CPR initiated, HR (heart rate) diminished at 42, 911 called at 6 AM. 911 came and left with resident at 6:15 AM. No family contact found on face sheet, physician assistant was made aware. On [DATE] at 7:18 PM, a progress note written by a Respiratory Therapist revealed around 5:50 AM, while doing my regular round, I found the resident unresponsive, nurse called, CPR (Cardiopulmonary Resuscitation) started and 911 called, took over and leave with the resident. Further record review revealed that no CPR sheets were available, no transfer form to the hospital was in the medical record, no documentation of which hospital the resident was transferred to was in the medical record. There was no documentation of Resident #1's weight in the medical record and no diet order or nutritional assessment. A review of the resident's care plan revealed a care plan for tube feeding but the resident did not have a feeding tube. An interview was conducted with the Administrator on [DATE] at 1:00 PM regarding lack of notification to Resident #1's representative at the time of the hospitalization because there were no contacts on the face sheet. She stated in November that the contacts that were from the hospital records were not put into the contacts in the facility records and since then the person in that department has been let go. Currently the contacts are put into the facility records. Also discussed that the code blue sheets are missing, and she acknowledged that they are not in the medical record. Page 1 of 2 105372 105372 07/10/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on [DATE] at 2:30 PM with Staff A, Minimum Data Set (MDS) Coordinator, that the resident was coded on the discharge MDS as having a feeding tube. She stated she would modify the MDS. On [DATE] at 10:00 AM, an additional interview was conducted with the Administrator. Discussed lack of documentation in the medical record, lack of a contact for the resident representative and lack of a clear timeline of when and where Resident #1 went to the hospital. The Administrator acknowledged the findings. 105372 Page 2 of 2