Health inspection·October 26, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 interview, the facility failed to follow-up on monitoring residents with a change in condition for 1 of 2 sampled residents reviewed for death in the facility, Resident #1. Residents Affected - Few The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses to include Syncope (fainting), Heart Attack, Chronic Pulmonary Edema (fluid in lungs), Diabetes, Heart Disease, and Alcohol Use. Review of the admission progress note dated [DATE] at 7:08 AM documented the resident was admitted to the facility and was receiving oxygen at 2 liters a minute via nasal canula. The progress note further documented the resident's vital signs were within normal limits, and the resident was very drowsy and lethargic, hard to arouse, and appeared confused. Review of Resident #1's physician orders revealed orders dated [DATE] revealed an order for vital signs every shift. Further review of Resident #1's records revealed the last documentation of the resident's condition / vital signs was on [DATE] at approximately 8:30 PM. Review of the progress note documented the following: On [DATE] at 5:08 PM, the resident's oxygen level appeared to be below normal range (no oxygen level documented). Physician was notified, oxygen increased to 4 liters minute, and endorsed to oncoming nurse. On [DATE] at 11:00 PM, patient in stable condition; Awake, alert and oriented times one; Lungs were clear bilaterally; Oxygen 2 liters via nasal cannula noted; Tolerating well. No signs or symptoms of distress noted, voiced and/or reported. On [DATE] at 1:00 AM, nursing aide conducted rounding; No signs or symptoms of distress noted, voiced and/or reported; and monitoring ongoing. On [DATE] at 3:00 AM, lab rounded and ordered labs were drawn / collected by phlebotomist. Writer (nurse) conducted rounding; No signs or symptoms of distress noted, voiced and/or reported. The lab results had a collection time of 4:55 AM. On [DATE] at 5:00 AM, routine medications administered; No signs or symptoms of distress noted, voiced and or reported. Page 1 of 2 105519 105519 10/26/2023 Nspire Healthcare Plantation 6931 W Sunrise Blvd Plantation, FL 33313

F 0684 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 5:30 AM, aide conducted AM care; No signs or symptoms of distress noted voiced and or reported. On [DATE] at 6:40 AM, Advanced Registered Nurse Practitioner (ARNP) rounded and found patient unresponsive; code called and 911 notified. Residents Affected - Few On [DATE], at 6:45 AM, CPR (Cardiopulmonary Resuscitation) started, and Emergency Medical Services (EMS) and police arrived. The resident expired on [DATE] at 6:48 AM. Review of the Physician Services history and physical progress note dated [DATE] at 6:45 AM, documented a chief complaint of weakness. Resident presented to the hospital after found outside supermarket with a pint of vodka near. Unsure of downtime. Was medically managed for a heart attack and was transferred to the facility for rehabilitation. Resident #1 was found unresponsive on rounds, 911 and code blue called at 6:44 AM. An interview was conducted with the Nurse Practitioner (NP) via telephone on [DATE] at 12:00 PM. The NP stated she was rounding on the resident on [DATE] at 6:44 AM, and found the resident unresponsive, cold, and rigor mortis (rigidness) had set in. The NP stated the resident had obviously been deceased for a while. The NP stated none of the nursing staff could tell her when the resident was last seen/assessed, but just stated they had 'just seen the resident'. The surveyor questioned the NP on the laboratory results documented as collected on [DATE] at 4:55 AM. The NP stated she questions the validity of the results documented for Resident #1, are they Resident #1's. The NP stated the lab results for Resident #1 were impossible due to the condition the resident was found by the NP on [DATE] at 6:44 AM (less than 2 hours later). On [DATE], an attempt was made to call the assigned night nurse and CNA (Certified Nursing Assistant) but there were no return calls. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:30 PM. The DON stated she was unaware of the above. The DON stated she was told that a resident had expired, and the resident was being seen by the NP at the time. The DON acknowledged there were no documented vital signs / condition of the resident for night shift, after the change in condition documented on evening shift. The DON acknowledged Resident #1 had a roommate. 105519 Page 2 of 2