Health inspection·January 5, 2024

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 interview, review of policy and procedure, and record review, the facility failed to promptly notify the resident's responsible party of the resident's fall in the facility for 1 of 2 sampled residents (Resident #1). The findings included: Review of the facility policy and procedure, titled Change in a Resident's Condition or Status, revised February 2021, was provided by the Director of Nursing (DON) and it documented in the Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Resident #1 was initially admitted to the facility on [DATE] with diagnoses which included Fusion of Spine, Lumbar Region, Basal Cell Carcinoma of Skin, Hypertension, Chronic Obstructive Pulmonary Disease, Unsteadiness on Feet, Difficulty with Walking, Need assistance with Personal Care, and Urinary Tract Infection (UTI). Resident #1 had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact), and required one person assist with transfers and daily ADLs (activities of daily living). During a telephone interview conducted on 01/05/24 at 9:17 AM,with Resident #1's daughter and second emergency contact, she reported neither she nor the resident's first emergency contact, her sister, was ever notified of Resident #1 having had a fall in the facility on Tuesday 11/14/23. The resident's daughter stated that the resident was the one who called her to let her know that she had fallen in her room while getting up from her wheelchair. Resident #1's daughter went on to say that she didn't understand why the facility did not notify her nor her sister about the resident's fall, and why it was that she had to hear about this from her Mother, who was residing in the facility, for care. The resident's Fall care plan documented that on 11/14/23 Resident observed on floor, no injuries noted; 11/15/23 transfer to hospital and back after a few hours status post fall; no new orders. An interview was conducted with the Social Services Director on 01/05/24 at 3:11 PM, in which she acknowledged that Resident #1 was found sitting on the floor in her room on Tuesday 11/14/23 sometime well after lunch and she said that she reported this to Resident #1's assigned nurse, Staff A, a Registered Nurse (RN). A side-by-side computerized record review was conducted with the DON of the nurses' note effective date 11/14/23 at 4:45 PM by Staff A, in which it was documented Staff A was notified by the Social Page 1 of 2 105604 105604 01/05/2024 Covenant Village Care Center 9211 W Broward Blvd Plantation, FL 33324

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Services Director that Resident #1 was on the floor. It was also documented that Staff A went into the room to find the resident sitting on the floor in front of the bed with both legs facing the window, with the wheelchair facing the T.V. An assessment was done, vital signs taken, no obvious injuries, or complaints of pain, denied hitting head, resident was able to move all extremities without pain. It was further documented that Resident #1 indicated to Staff A that she was trying to get to her bed and her legs gave out and she sat on the floor. During an interview conducted on 01/05/24 at 3:50 PM with Staff A, Resident #1's assigned day nurse, she acknowledged that Resident #1 was found sitting on the floor in her room on Tuesday 11/14/23, and she also acknowledged that it was not documented in the medical record that Resident #1's fall had been reported to the resident's responsible party/representative. A telephone interview was conducted on 01/05/24 at 5:17 PM with Staff B, Licensed Practical Nurse (LPN), the day nurse assigned to Resident #1 on 11/15/23 after the resident's fall in the facility, in which she indicated that Resident #1's daughter was updated when she visited the facility, and not beforehand, regarding Resident #1's fall in the facility. Staff B went on to say that the resident was transferred out non-emergency to the hospital to be evaluated after Resident #1's daughter had arrived to the facility. Further computerized record review of the nurses' note dated 11/15/23 by Staff B, only described the action of Resident #1 being transferred to the hospital for further evaluation; with no official physician's order on file authorizing the hospital transfer. This note did not document that the resident's physician had been contacted and notified of the resident's fall in the facility. On 01/05/24 at 4:22 PM, an interview was conducted with Staff C, the assigned RN Evening Supervisor on the evening of the fall Tuesday 11/14/23. Staff C also acknowledged that she made no documentation in Resident #1's record with regards to her fall. Staff C went on to state that she vaguely remembered the resident and her care that evening and was unable to recall any other information pertaining to this resident. There was no notation in the nurses' note, nor anywhere in the resident's medical record to indicate that Resident #1's representatives had been contacted and made aware of her fall in the facility, at the time. The DON further recognized and acknowledged during her interview on 01/05/24 at 5:30 PM that it was not documented in the computerized medical record that Resident #1's responsible party was not notified or made aware of the resident's fall in the facility. 105604 Page 2 of 2