Health inspection·November 6, 2020

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that ordered splinting interventions for preserving range of motion and mobility were in place for two (Resident #161, Resident #23) out of four residents sampled for range of motion. Findings included: 1. On 11/04/20 at 10:42 a.m., 11/05/20 at 5:10 p.m., and 11/06/20 at 10:16 a.m., Resident #161 was observed with no splint on the right wrist and hand, and no splint was observed on visible surfaces in his room. During observations, the resident's right wrist and fingers were observed in a flexed position with his hand forming into a fist. Review of the admission record for Resident #161 revealed he was a long term care resident and had resided in the facility for over 4 years with diagnoses to include cerebral infarction (stroke), altered mental status, and aphasia (inability to comprehend or formulate language). The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief inventory of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed that the resident was totally dependent for all mobility, required extensive assistance for dressing, toilet use, and personal hygiene. A review of the physician orders for Resident #161 revealed an order for, Resident to wear Right Wrist hand orthosis. Donn (put on) with AM care, Doff (remove) at HS (hour of sleep) or as tolerated with a start date of 02/14/2019. The treatment administration record (TAR) for Resident #161 revealed the splint order with an apply time of 6:00 a.m. and splint removal time of 9:00 p.m. The November 2020 TAR revealed that for the dates of 11/01/20 - 11/06/20 splint application and removal was entered with a check mark with according to the charting codes meant Administered. The care plan for Resident #161 revealed a focus area documented as Contractures: I have an alteration in musculoskeletal stats r/t (related to) contracture of the right hand . initiated 06/28/2019 and last revised 09/30/2020. Interventions related to that focus area included Assist me with the use of supportive device, splint to right hand, as recommended .Right hand splint daily, on with AM care, off at hs (hour of sleep) as tolerated . Positions documented as responsible for the interventions were Certified Nursing Assistant (CNA), Registered Nurse (RN), Licensed Practical Nurse (LPN). On 11/06/20 at 10:16 a.m., Staff G, Certified Nursing Assistant (CNA) was interviewed at the bedside of Resident #161. She confirmed that she was assigned care for the resident that day and confirmed that there was no splint on the right wrist/hand of the resident. She stated she didn't know anything about a splint and said that was something that restorative nursing or therapy staff did. Staff G was unable to locate the splint from the room. She stated that she did not know where it was and could not recall seeing it. She said the resident had changed rooms, and maybe it got left in the old Page 1 of 4 105525 105525 11/06/2020 Manatee Springs Rehabilitation and Nursing Center 5627 9th St E Bradenton, FL 34203

F 0688 room. Level of Harm - Minimal harm or potential for actual harm 2. On 11/04/20 at 11:00 a.m.,11/05/20 at 5:20 p.m., and 11/06/20 at 10:12 a.m., Resident #23 was observed with no splints on and no splints were visible on surfaces in her room. Residents Affected - Few Review of the admission record for Resident #23 revealed that she was a long term care resident and had resided in the facility for approximately 6 years with diagnosis to include contracture. The MDS completed on 08/20/20 revealed a BIMS score of 00, indicating severe cognitive impairment. The MDS revealed that the resident was totally dependent for all mobility and care and had upper extremity (shoulder, elbow, wrist, hand) impairment on both sides. Review of physician orders for the resident revealed an order for a right palm guard and left soft splint during the day as tolerated. The TAR did not contain the splint order or documentation of application. The care plan for Resident #23 did not reveal any focus area or interventions related to splinting. On 11/06/20 at 10:12 a.m., Staff J, Certified Nursing Assistant (CNA) was interviewed at the bedside of Resident #23. She confirmed she was assigned care for the resident that day and confirmed that there were no splints on the resident. She stated she saw them on the resident sometime last week .therapy or restorative puts them on. She searched in the drawer of the resident's bedside table and found the splints. She began to apply the splints and said, I don't even know how these are supposed to go on. 3. At 10:31 a.m. on 11/06/20, Staff H, Restorative CNA, was interviewed and confirmed that neither Resident #23 nor Resident #161 were on caseload with restorative nursing and that any splinting application was the responsibility of the floor nursing staff. Staff I, Licensed Practical Nurse (LPN) was interviewed on 11/6/20 at 10:37 a.m. She confirmed that she was in charge of the facility's restorative nursing program and confirmed that Resident #161 was not on the restorative nursing caseload and said, he should be on floor maintenance. She reviewed the electronic health record (EHR) for Resident #161 and confirmed there was an order for a splint but said, we never got that one .I have no idea what happened .I'm clueless. Regarding Resident #23, she confirmed that she was not on caseload with restorative nursing. She reviewed the EHR for Resident #23, confirmed there was an order for splints and said, the therapist never gave that to me. She reported that the process for putting a resident on caseload with restorative nursing was that a referral form was completed by a therapist and given to her. She reported that once restorative nursing program was completed, management of needs was transferred to the floor staff. She said, getting the aides to pick up what they're supposed to do is a problem. On 11/06/20 at 11:16 am. the facility Director of Rehabilitation (DOR) was interviewed. She confirmed that when a resident was discharged from therapy with a splint, the process was for the therapist to provide a referral form to restorative nursing. She revealed that Resident #161 had been transferred to restorative nursing in the past with instructions for splinting. Regarding Resident #23, she consulted the EHR and confirmed there was an order for splints but stated she did not have any other information and could not locate the referral form for restorative nursing. She asked Staff K, Occupational Therapist (OT) to join the interview. Staff K confirmed she had been the treating therapist for Resident #23 and had initiated the splinting and confirmed that the resident was no longer on therapy caseload. Regarding transfer of care for splinting she said, I worked with the CNA .can't tell you her name .I dropped the ball .I didn't have her sign anything and I didn't send anything to restorative about her. Staff K said, typically I would go through a series of sessions with the restorative aides to train them, then write up a restorative form and give one to [Staff I]. She 105525 Page 2 of 4 105525 11/06/2020 Manatee Springs Rehabilitation and Nursing Center 5627 9th St E Bradenton, FL 34203

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed again that she had not completed a restorative nursing referral form for Resident #23. She confirmed that she had entered the order for splinting in the EHR. She said, I thought I communicated well enough with the aid .was a total fail on my part .I should have gone through the process. An interview was conducted on 11/06/20 at 11:54 a.m. with the facility MDS Coordinators Staff L, RN and Staff M, LPN, and the facility Director of Nursing (DON). The DON confirmed that the facility process for splinting was transfer from therapy to restorative nursing and then from restorative nursing to floor staff management. She confirmed that splinting interventions for floor management should be on the CNA task list and said, '[Staff I] takes form from therapy and enters into tasks. She confirmed that splinting was not on task lists for Resident #161 and Resident #23. Regarding no entry for splinting on the TAR for Resident #23 she stated that the person putting the order in the system had to select that option and revealed that the EHR reflected that didn't happen for the order for Resident 23 and said, [Staff K] didn't do that .that's why its not there. The DON did not have an explanation for the nurses signing off on the TAR for Resident #161 to indicate that the splint had been administered when it wasn't. The DON stated that her expectation was that if a nurse signed off on something as administered, they would have seen it to verify before signing off. The DON followed up on 11/06/20 after the interview and reported that she had spoken with nurse who had last entered on the TAR for Resident #161. The DON stated that the nurse acknowledged that she knew the splint was in a drawer in the resident's room. The nurse told the DON that the resident refuses the splint, and the nurse acknowledged that she should have documented refusal on the TAR rather than administered. The DOR followed up at approximately 4:00 p.m. on 11/06/20 and reported that the splint for Resident #161 had been found in a drawer in his room and applied. The facility policy titled, Restorative Nursing Program with creation date of 01/20 revealed the following within the section titled Procedure: 2. Therapy will send a restorative referral sheet to the Licensed Restorative Nurse/designee for initiation of restorative program(s) indicating the resident's current level of participation and anticipated goals/interventions. 4. Licensed Restorative Nurse will review the program with the therapy staff and implement the recommended program(s). 5. A care plan will be developed and information shared with involved staff. 7. The nursing staff will be educated on the established program by the restorative nurse or therapist if special instructions required regarding the service needed. 105525 Page 3 of 4 105525 11/06/2020 Manatee Springs Rehabilitation and Nursing Center 5627 9th St E Bradenton, FL 34203

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review the facility did not ensure that a controlled substance was locked and stored in a permanently affixed compartment and separate from other medications in one (Hibiscus) of two medication storage rooms. Findings included: During the task of Medication Storage and Labeling the locked medication room for the Hibiscus unit was accessed on 11/04/20 at 3:56 PM by the evening Unit Manager/Staff A, Registered Nurse (RN). The small refrigerator was unlocked by Staff A to reveal a small plastic case unsecured in the refrigerator. The clear plastic box was closed with a green tamper proof seal and the contents could be seen through the plastic. It contained two, 2mg/ml vials of the controlled substance lorazepam and two, 10ml insulin multidose vials. The box was not secured in the affixed compartment present in the refrigerator and the box did not have an accompanying label for its contents. Staff A stated that they probably couldn't find the key to lock it up and that the box was their emergency kit. Closer observation revealed the small case was closed with a green tie wrap and was not labeled with anything other than the pharmacy name and the large numeral 5. A subsequent interview was conducted on 11/04/20 at 4:28 p.m. with the Director of Nursing (DON) and Staff B, Licensed Practical Nurse (LPN) about the storage of the box containing the lorazepam. They stated that they received and signed for the controlled meds from the pharmacy and then placed them in the fridge or the lockbox on the wall. They stated that two nurses were required to access the medication because one nurse had the door key, and the other had the key to the lockboxes. They could not find the key to the small affixed lockbox in the refrigerator to store the lorazepam securely. Staff B stated that she did not recall the last time she had seen the small case containing the lorazepam locked in the affixed compartment. The DON stated on 11/06/20 at approximately 4:00 p.m. that she had procured new boxes to secure the controlled substance in a separate permanently affixed compartment in the refrigerators. The DON was asked for their medication storage policy on 11/04/20 at approximately 4:30 p.m. and provided a document with a subject of Medication Storage in the Facility. Section 10 of the document revealed Schedule II through V controlled medications were stored separately from other medications in a designated double locked drawer. A telephone interview with the pharmacist consultant was conducted on 11/10/20 at 2:43 p.m. The pharmacist confirmed that he had observed the Hibiscus medication room during his most recent visit in October, 2020. He stated that he made a verbal recommendation for the small case containing the controlled substance lorazepam to be moved to the inside of the locked and permanently affixed box inside the refrigerator. Photographic evidence was obtained. 105525 Page 4 of 4