Health inspection·November 2, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident/resident representative interviews, the facility failed to provide requested medical record access, and copies of medical records for one (#2) of two sampled residents. Findings included: Review of the medical record for Resident #2 revealed admission to the facility on [DATE] as per the admission face sheet. Review of the advance directives revealed resident #2 had a POA (power of attorney) for care and financial decisions, and was confirmed as a family member. Further review of the POA document, revealed it was signed and dated as of 11/11/2022 and signed by the resident, notary public and two witnesses. Further review of the medical record did not indicate any further change of POA status, leading up to Resident #2's transfer to the hospital on [DATE]. Review of the 10/2/2023 8:30am - SBAR (situation, background, assessment and recommendation) note revealed; Shortness Of Breath (SOB) and seems different as usual, talks less. Recommendation to send to Emergency Department for evaluation. During a telephone interview with Resident #2's family member, who was the designated POA, the POA revealed she formally requested copies of Resident #2's medical records on 10/04/2023. She revealed she discussed this request with the Director of Nursing (DON) and was informed there would be a charge for the records. Resident #2's POA paid a fee in the sum of $30.00 for copies of the record. The POA confirmed she had not received the requested medical records. Review of a medical records receipt revealed; Receipt #723247, dated 10/4/2023 and with $30.00 received from Resident #2's POA, and signed by the Director of Nursing. The receipt noted: Medical record request. Continued Record review on 11/2/2023 did not reveal any evidence the medical records request was complete and records were provided to Resident #2's POA. On 11/2/2023 at 12:15 p.m. during an interview with Staff A, Receptionist (formally the Medical Records Tech) revealed she was hired at the facility around 5/2023. She revealed she has previous experience with Hospital record keeping, prior to her hire at this nursing facility. Staff A said she had been learning while here at this facility and believed when a resident or representative requested a copy of a portion or portions of the medical record; they (the facility) had 30 days to honor that request. She did not know where that was documented and was unaware of the facility's policy related to the medical record request process. Staff A said she was knowledgeable of Resident #2 and her Page 1 of 5 105634 105634 11/02/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few POA and revealed that the POA had made a request to get Resident #2's medical record on 10/4/2023. Staff A said she put the request in with administration to include the Director of Nursing. On 11/2/2023 at 1:30 p.m. an interview with the Director of Nursing (DON) revealed she did remember Resident #2's POA requesting medical records copies after Resident #2 was transferred/discharged out to the hospital on [DATE]. The DON confirmed Resident #2's POA requested records on 10/4/2023 and paid $30.00 for copies of the record to be made and provided to her. The DON confirmed she wrote the paid receipt, which was receipt #723247. The DON revealed she had to send the request to the corporate office and did not know Resident #2's POA had not received the records as of yet. The DON revealed the process of records request is either the resident or the resident's representative will make a verbal or written request for medical records review or medical records copies. If it is a request for medical records copies, they will charge a fee for paper and time making the copies. She revealed management at the facility will also send a request to the corporate office and they usually will give permission within a few days. The DON confirmed that Resident #2's POA should have received the copies of previously paid for medical records, and there was not a reason why it would take longer than the 2 days. During an interview on 11/2/2023 at 1:45 p.m. the Nursing Home Administrator (NHA) provided a blank copy of Authorization for Use and Disclosure of Protected Health Information, that is provided to residents and or their representatives when making medical records requests. Under the Understanding and Agreement of Requestor section, #3, it revealed; The Health Insurance Portability and Accountability Act (HIPPA) allows healthcare providers (2) days to process records requested by the resident. If we need more time to process your request, we can take another 30 days if we notify you that additional time is needed. The facility strives to provide records timelier, however, occasionally the full 30 days are required. On 11/2/2023 at 1:45 p.m. the NHA provided the Release of Medical Records policy and procedure, with a revised date of 10/2023, for review. The policy revealed; Medical records will be released with a valid request and in accordance with state and federal laws. The Policy Explanation and Compliance guidelines revealed the following but not limited to: 1. Medical records are a collection of documents prepared and maintained during the course of a resident's stay in the facility that records the clinical/medical care of the resident. These documents can be written or electronic information and include progress notes, physician orders, nursing notes, consultations, laboratory and diagnostic reports, and plans of care. These documents do not include risk management reports such as incident reports, investigation reports, witness statements, or other quality assurance documents such as skin reports, weight loss reports, etc. 2. Requests for records should be referred to the Director of Nursing or Administrator or another staff member previously designated by the facility. 3. Upon request to access or obtain copies of the medical record, the facility should review the authorization to ascertain access rights of that person. Authority to access or release records is only granted by the resident or the resident's legal representative. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. 105634 Page 2 of 5 105634 11/02/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4. The corporate office/risk manager should be notified of the request for records. Records should not be released prior to discussion with the corporate office/risk manager, to further validate authenticity of the request. 5. Upon receipt of a request for medical records copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available 2 days after receipt of payment for the copies. Copies should not be released prior to the receipt of payment for copying charges. Review of the Access Rights to Medical Information of the policy, revealed information is as follows but not limited to: (a.) The resident (current resident) - The resident's record is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request. The resident is encouraged to review the record in the presence of the attending physician or a representative of the facility. The resident may have designated a legal representative who can exercise the same rights as the resident. The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of: - Labor for copying the records request by the individual, whether in paper or electronic form; - Supplies for creating the paper copy or electronic media if the individual requested that the electronic copy be provided on portable media, and - Postage when the individual has requested the copy be mailed. The facility must ensure that information is provided to each resident in a form and manner the resident can access and understand including in an alternative format or in a language that is in a language that the resident can understand. (b.) Resident's Family - The resident's family has no right to access the resident's medical record without a valid authorization by the resident or his/her legal representative. 105634 Page 3 of 5 105634 11/02/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident representative interviews, and medical record review, the facility failed to provide one (#2) of two sampled residents with a Bed Hold Notice, prior to and/or after the resident was transferred to a higher level of care facility. Findings included: On 11/2/2023 during medical record review for Resident #2, the admission record revealed she was admitted to the facility on [DATE]. Review of the electronic nurse notes revealed the following: 1. SBAR (situation, background, assessment and recommendation) note dated 10/2/2023 8:30amShortness of Breath and seems different as usual, talks less. Recommendations to send to ED [emergency department] for evaluation. 2. Nurse progress note dated 10/2/2023 8:30am - Resident presented with Shortness of Breath RR [respiratory rate] 22, O2 [oxygen] 65@ 2L/M [liters per minute] via NC [nasal cannula], productive cough, wheezing and rales in lower bilateral lobes. Patient did not respond to verbal stimuli. BP [blood pressure] 86/50 HR [heart rate] 60. Resident sent to Emergency Department for eval [evaluation]. Medical Doctor and family notified. Review of the Discharge/Transfer Summary dated 10/2/2023 revealed the facility could not meet needs and Resident #2 needed higher level of care (hospitalization). On 11/2/2023 the Director of Nursing (DON) provided the Bed Hold Notice allegedly provided to Resident #2 and/or the resident's POA (power of attorney). Review of the notice showed only had the resident's name handwritten by staff and also a handwritten note, unable to sign. The notice did not have a date, it was not signed by a facility official, nor did the notice indicate a reason why it was being presented. There was a section that had a choice of either, 1. admission to Hospital, 2. Temporary therapeutic leave from the facility; neither boxes were checked. The DON confirmed she completed the form and did not put the date and did not sign. During a telephone interview with Resident #2's Power of Attorney she confirmed she had not received a Bed Hold notice from the facility Review of the policy titled, Bed Hold Notice Upon transfer, with a last revision date of 8/2023 showed: Policy; At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. The Definition section of the policy revealed the following but not limited to: 105634 Page 4 of 5 105634 11/02/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0625 Bed-Hold means the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Level of Harm - Minimal harm or potential for actual harm The policy explanation and compliance guideline revealed; Residents Affected - Few Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident/or the resident's representative written information that specifies: a. The duration of the bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility; - The resident requires the services which the facility provides; - The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 105634 Page 5 of 5