Health inspection·October 14, 2021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to accurately complete the two most current Minimum Data Set (MDS) assessments, and the two most current Nursing Quarterly assessments for one (Resident #48) of thirty-six sampled residents. Residents Affected - Few Findings included: During observations on 10/11/2021 at 1:00 p.m., 10/12/2021 at 12:50 p.m., and 10/13/2021 at 12:45 p.m. and 2:10 p.m., Resident #48 was seated either in her room, the main dining room, or out in the smoking courtyard. During these observed times, Resident #48 was seated, slightly reclined, in a padded [Brand name] chair. Further observations revealed thigh straps that were attached to the chair and both of her legs. These straps were observed preventing her from rising up from the chair. Resident #48 was not able to self release these straps, and therefore they were identified as a trunk restraint. Resident #48 did not present with any behaviors, pain, or discomfort related to the trunk restraint. An interview with the [NAME] Unit Manager on 10/11/2021 at 1:15 p.m., confirmed Resident #48 utilized a trunk restraint when up out of bed and seated in her [Brand name] chair. She said that Resident #48 had diagnoses related to shaking and convulsions and the restraint was used for that reason. The [NAME] Unit Manager confirmed that the restraint was only used on Resident #48 when she was up out of bed and seated in her special padded chair. Attempts to interview Resident #48 on 10/11/2021, 10/12/2021, 10/13/2021, and 10/14/2021 related to her restraint or care and services were unsuccessful. Review of Resident #48's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #48 was her own decision maker, with family involvement in making decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Huntington's disease, communication deficit, unsteadiness of gait, lack of coordination, and Encephalopathy. Review of the current Physician's Order Sheet dated for the month of 10/2021, revealed an order for use of [Brand name] chair with bilateral thigh straps when out of bed to maintain upright positioning, and safety. May release for care and services, activities, and meals. Original order date was 6/8/2021. Education on the device and consent for use of the device was signed and dated by the resident and a family member on 5/27/2020. Review of the five day Minimum Data Set (MDS) assessment, dated 8/23/2021, revealed, Cognition: Page 1 of 3 105477 105477 10/14/2021 Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Brief Interview Mental Status (BIMS) score of 15 of 15, which indicated the Resident #48 should have been able to be interviewed related to her care and services. Restraints: Not checked as used. Review of the previous quarterly MDS assessment dated [DATE] revealed: Restraints: Other, 1. Used less than daily. This assessment did not identify the use of a trunk restraint, but rather other. There was no documentation to indicate what other specified. Review of the Nursing Quarterly data collection dated 7/8/2021, revealed no documentation for utilization of restraints. Review of the Nursing Quarterly data collection dated 10/8/2021, revealed no documentation for utilization of restraints. On 10/14/2021 at 9:30 a.m., an interview with the Director of Nursing (DON), the Nursing Home Administrator (NHA), the MDS Coordinator, and the Physical Therapist was conducted. The Director of Nursing confirmed that Resident #48 had an order for a trunk restraint, specifically a [name brand] chair with thigh straps, since 6/8/2021. The DON confirmed that the last two Minimum Data Set (MDS) assessments, dated 7/8/21 and 10/8/21, did not identify that the resident used a trunk restraint. The DON further confirmed that the Quarterly Data Collection assessment, dated 7/8/2021 and 10/8/2021, both did not indicate Resident #48 used restraints. The MDS coordinator confirmed that the MDS assessments dated for 7/8/2021 and 10/8/2021 did not reflect that Resident #48 used a trunk restraint. The MDS coordinator indicated that they were trying to assess during those periods of whether she was actually using a restraint or not, and trying to assess for the least restrictive restraint. He revealed that the Interdisciplinary Team concluded that they would indicate the device as other, rather than a trunk restraint. The DON and the Nursing Home Administrator both confirmed the device Resident #48 used was a restraint and confirmed the restraint was for the trunk to prevent rising. The MDS coordinator revealed that they did not think to document in the assessments that Resident #48 utilized a trunk restraint because the Interdisciplinary team believed the thigh straps were something else. However, the DON, NHA, and MDS coordinator indicated that Resident #48 currently used a restraint that prevented her trunk from rising, therefore it should have been assessed as a trunk restraint. The policy overview revealed; The facility will promote quality of life and resident centered care. Restraints will be used only when necessary to treat a medical symptom and not used for staff convenience. The least restrictive restraint, for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being. The facility will demonstrated and document the presence of specific medical symptoms that require the use of the restraint to treat the cause of the symptom by evaluating resident condition, circumstances and environment. The evaluation includes determining if a device is a restraint or an assistive device. The policy definition of Physical Restraint is: Any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy further indicated Restraints include, but are not limited to, the following: Chair that prevents rising, Devices used with a chair such as trays, tables, bars or belts that the resident cannot easily remove or that prevent them from rising. 105477 Page 2 of 3 105477 10/14/2021 Bay Pointe Nursing Pavilion 4201 31st St S Saint Petersburg, FL 33712

F 0641 The Restraint management section of the policy indicated: Re-Evaluation resident status at the care plan and or standards of care meetings quarterly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105477 Page 3 of 3