Health inspection·June 15, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident representative of a change in condition related to a fall and pending x-ray for 1 of 2 residents reviewed for falls of a total sample of 13 residents, (#2). Findings: Review of resident #2's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His diagnoses included Parkinson's disease, urinary tract infection, dementia, and repeated falls. Review of the Minimum Data Set admission Assessment with assessment reference date of 1/23/23 revealed resident #2 had a Brief Interview for Mental Status score of 5 out of 15, which indicated he had severe cognition impairment. Review of a progress note dated 1/27/23 indicated an x-ray of the right knee taken on 1/26/23 was reviewed by the Advanced Practice Registered Nurse. The note revealed resident #2 was scheduled for a follow up appointment with the orthopedic specialist on 1/30/23. Review of a progress note dated 1/31/23 indicated it was a late entry for 1/25/23. The note revealed resident #2 was observed by therapy staff with upper body on the bed and lower body on the ground with knees bent and leg underneath the air conditioner unit at approximately 9:30 AM. The note indicated resident #2 reported he was trying to reach his phone on the windowsill and fell onto the floor. There was no telephone on the windowsill. Therapy and nursing staff evaluated resident for injury and no apparent injuries noted. Knee brace was not in place. Resident assisted back in bed. Review of a progress note dated 1/31/23 revealed resident #2's family was informed of the fall which occurred 6 days before on 1/25/23, and the results of the x-ray performed the next day. The note included resident #2's daughter was told by a therapy staff member on 1/27/23. A care plan for Actual Fracture: admitted with fracture to right patella and right humerus was initiated on 3/9/23. The interventions included, Keep me and my family informed. On 6/15/23 at 4:56 PM, the Director of Nursing (DON) explained resident #2 sustained 3 falls while he resided at the facility. She indicated the facility protocol was to review all falls during the morning clinical meetings. She recalled she heard about resident #2's first fall from therapy during a clinical meeting. She noted she looked in the medical record to review the documentation and did Page 1 of 2 105376 105376 06/15/2023 West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not find an incident report or change in condition report. She explained it was then she started her investigation. She indicated she asked the former C-Wing Unit Manager (UM) to enter the incident report because the assigned nurse was no longer employed by the facility. The DON stated an x-ray of the right knee was performed the day after the fall. The DON confirmed there was no documentation in the medical record showing resident #2's family was notified of the fall or the x-ray. She stated nurses were expected to report falls and any changes in condition to the resident's family on the day it happened. Review of the facility's policy and procedure Change of Medical Condition of Resident / Guest(s) dated 11/28/16 revealed the purpose was, To keep the physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions and other resident/guest representative informed of the resident/guest(s) medical condition so they may direct the plan of care as needed. The document indicated Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest(s) condition. The policy provided examples of a change in condition including accidents/incidents resulting in suspected injury. 105376 Page 2 of 2