Health inspection·May 24, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medically needed social services were provided for one resident (Resident #4) out of three residents reviewed. The resident was charged $100.00 for someone to accompany him each time he went out to an appointment. There were 117 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Review of the facility's Transportation to an Appointment Policy and Procedure (no written date); Policy Statement-Our facility will assist residents in arranging transportation to/from appointments when necessary; Policy Interpretation and Implementation-1) Should it become necessary to transport a resident to an appointment, when necessary, outside the facility, the Social Service Designee or Charge Nurse shall notify the resident's representative and inform them of the appointment; 2) The resident's representative will be responsible for transporting the resident to his or her appointment; 3) Should it become necessary for the facility to provide transportation, the Social Service Designee will be responsible for arranging the transportation; 4) A member of the Nursing Staff or Social Services will accompany the resident to the appointment center when the resident's family is not available and 6) The use of volunteers to transport residents to appointments must be approved by the Director of Nursing. Review of t Resident #4 's Demographic Face Sheet documented the resident was admitted on [DATE] with a diagnosis that included but not limited to encounter for surgical aftercare following surgery on the digestive system, dysphagia, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, peripheral vascular disease, parkinsonism, depression and shortness of breath. The resident was discharged to home on 3/18/2024. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #4 dated 3/05/2024 documented the resident had a Brief Interview of Mental Status (BIMS) Summary Score of 09 out of 15 indicating mild cognitive impairment, wore eyeglasses, required substantial/maximal to dependence assistance for ADLs (Activities of Daily Living) and had no impairment on both upper and lower extremities. Telephone interview on 5/22/2024 at 4:05 PM with the Complainant and the resident's daughter. She revealed that when her father had an appointment with the doctor, the facility required her to pay $100.00 for transportation and to have someone with him when he goes to the doctor. She stated, I communicated with a [ staff member] concerning the money for transportation. The facility would only accept $100.00 in cash. Page 1 of 2 105498 105498 05/24/2024 Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Progress Notes for Resident #4 documented the following: Dated 01/11/2024 02:41 PM-Nursing Note: Resident return from medical appointment with [ name of medical doctor, general surgeon] in stable condition. Nursing Notes dated 01/16/2024 06:37 PM: Resident returned from Endovascular appointment with [ medical doctor]. Review of the Consults for Resident #4 documented the following: Dated 01/11/2024: Resident was seen by [name of medical doctor], general surgeon for Mesenteric Ischemia and note dated 01/16/2024: Resident was seen by [name of medical doctor] for endovascular. Review of Payment by Company for Appointment for Resident #4 documented the following: Letter dated 1/04/2024: I have delivered today 1/04/2024 $100.00 for [ Resident #4] Doctor's appointment on January 11, 2024; Signed by [name of Resident #4's family friend]; Letter dated 1/13/2024: Money for transportation 1/16/2024, received $100.00 from [name of Resident #4's family friend] and Letter dated 1/15/2024: Money for appointment with [medical doctor's name] on 1/18/2024; Received $100.00 cash from [family friend] signed by [Unit Secretary]. Review of the facility's admission Packet revealed no documentation of payment for transportation to an appointment or payment for someone to accompany a resident to an appointment. On 5/24/2024 at 8:51 AM, interview with the third Floor Secretary. She stated, The patient is accompanied by a family member to appointments and if the family member cannot go, then we have to look for a person in the community to accompany them. The family has to pay $100.00 to accompany the patient. The family brings cash or check. [name] is a close family friend, and the daughter gave authorization for him to pay the $100.00. If the family cannot pay the $100.00 we have to look for a CNA (certified nursing assistant) to go with the resident to an appointment. The daughter never said she could not pay the $100.00. If she would have said that she couldn't pay it, I would have to go to the DON to get authorization for a CNA to accompany the resident to an appointment. On 5/24/2024 at 10:06 AM, interview with the Social Services Director. She stated, We don't charge for transportation to an appointment, but we do charge for someone from the community to accompany the resident for an appointment. On 5/24/2024 at 10:48 AM, interview and record review with the Director of Nursing (DON). She stated, He was discharged on 3/18/24 and he was here for rehab. There is no charge for transportation. When they call me and tell me they have no family to go with to appointments, I get my CNA to go with them. They get someone from the community to go with the resident and they do not pay. Record review with the DON revealed payment by the company for appointment for the following: Letter dated 1/04/2024: I have delivered today 1/04/24 $100.00 for [Resident #4] Doctor's appointment on January 11, 2024; Signed by Resident #4's family friend; Letter dated 1/13/2024: Money for transportation 1/16/2024, received $100.00 from [name of Resident #4' family friend]and Letter dated 1/15/2024: Money for appointment with [name of medical doctor] on 1/18/2024; Received $100.00 cash from [name of family friend] and signed by [Unit Secretary]. She stated, I did not know they were collecting $100.00 for someone to go with the resident to an appointment. On 5/24/2024 at 11:53 AM, interview with the Administrator. He revealed that he was not aware of the facility staff member collecting money for someone to go out with a resident to an appointment. He told the staff that practice stops today. 105498 Page 2 of 2