Health inspection·March 17, 2021

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 observations, staff interviews and review of the medical record, the facility failed to notify the Physician of behaviors and behavioral changes for one of nineteen sampled residents, (#7). Following admission, the resident presented with refusal of care, hitting, and yelling behaviors, in which the Physician was not notified. Findings included: On 3/15/2021 at 12:30 p.m., while standing outside resident #7's room, staff went in to set up and serve the meal tray. Resident #7 was first observed in her room and in bed since 9:10 a.m. While staff were serving resident #7 her meal, Resident #7 was overheard telling staff, I don't want it, leave me alone. The staff member was overheard to ask if she wanted to order something else, and Resident #7 was overheard, get the ____out, leave me alone. After leaving Resident #7's room, an interview was conducted with Employee A, who was asked why resident #7 was yelling out. Employee A indicated that Resident #7 had been presenting with behaviors since her admission and that she just likes to stay in her room, in bed, and wants to be left alone. Employee A was asked if she and other staff tell the nurse of these behaviors. She indicated that she had. On 3/15/2021 at 1:30 p.m., the unit nurse, Employee B, was asked if she knew about Resident #7 presenting with behaviors of calling out and yelling. She said that she was aware and believed the Physician was aware. Employee B indicated that Resident #7 mostly wants to be left alone and had been exhibiting yelling out, screaming and attempting to hit staff since her admission. On 3/16/2021 review of Resident #7's medical record found she was admitted to the facility on [DATE]. Review of the advance directives determined Resident #7 was her own decision maker. Review of the admission diagnoses sheet revealed diagnoses to include but not limited to: Anxiety and Depression. Review of the current Minimum Data Set (MDS) 5 day assessment, dated 3/7/2021, revealed a Cognition/Brief Interview Mental Status (BIMS) score of 13 of 15; which indicated Resident #7 was cognitively intact, interviewable and able to make her own decisions. The mood/behavior section of the MDS revealed Resident #7 did not present with any behaviors during the five days assessed. Review of the dated electronic progress notes found: Page 1 of 2 105587 105587 03/17/2021 Aviata at Countryside 3825 Countryside Blvd N Palm Harbor, FL 34684

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - 2/11/2021 13:29 - Writer and another nurse spoke with resident, confused, states, I had a fall last night and my head hurts that is why I'm here at the hospital. Writer reoriented resident, reminded she was in rehab and fell at home, resident stated, you are right, I did not fall last night, I slept through the entire night and I was warm. Continues to tell writer where she grew up. - 2/15/2021 0:400 - Writer was returning to nurse station from rounding with second nurse when both parties heard a loud thud. Both nurses began going room to room to investigate noise when entering resident's room the following was noted. Resident was lying on the floor next to the right side of her bed on the fall mat. Bed was in low position. Resident was lying on her left side with bilat legs pulled up towards her abdomen and the left side of her face and head laying on the baseboard. Resident was alert with eyes opened. Resident noted to be agitated and stating she was sorry. MD paged. EMS initiated. Xfer to Hospital and Daughter contacted and agreed. - 3/15/2021 05:00 - During morning rounds patient refused to have brief changed. She began clawing at the Aid's shirt and back punched me in my stomach. Pt stated get the ____ out, leave me alone. No injuries reported. Pt made comfortable. On 3/17/2021 at 10:00 a.m. the Assistant Director of Nursing confirmed the nurse progress notes did not reflect if the Physician was notified of behaviors to include being agitated, hitting staff, throwing things and or refusing care. She stated she would contact the nurse who documented the behaviors to see if she verbally notified the Physician of those behaviors. At approximately 12:00 p.m., the Assistant Director of Nursing reported she had spoken to the nurse and the nurse indicated she did call the Physician to let him know of results. An interview with the nurse by the survey team could not be obtained. On 3/17/2021 at 2:55 p.m., a phone interview was conducted with the resident's Physician. He indicated he was well aware of the resident and has been notified by staff around her admission time and within the last week related to things such as wounds, a Urinary Tract Infection, skin tear, and urinary incontinence. He revealed that staff had not spoken with him or his medical team related to the behaviors to include presenting with hitting, spitting, clawing at staff, refusing of care and treatment. He confirmed that he was not notified of her mood as well. Through interview with both Employees A and B, Resident #7's Physician and review of the above nurse progress notes, it was found that the Physician was not notified of behaviors to include hitting, calling out, yelling, and refusing care. On 3/17/2021 at 3:00 p.m. the Nursing Home Administrator provided the Notification of change of condition policy and procedure, with last revision date 12/16/2020 for review. Policy revealed, The Center to promptly notify the Patient/Resident, the attending Physician, and the Resident Representative when there is a change in the status or condition. The Procedure section revealed, The nurse to notify the attending physician and representative when there is a(n); Significant change in the patient/resident's physical, mental, or psychosocial status, Patient/Resident consecutively refuses medication and/or treatment (i.e. two or more times). 105587 Page 2 of 2