Health inspection·January 31, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provided physician ordered medications to one (Resident #2) of three residents sampled for pharmacy services. Findings included: A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Wilson's Disease, autistic disorder, borderline personality disorder, and generalized anxiety disorder. Resident #2 was discharged from the facility on 1/13/2024. A review of Resident #2's physician's orders revealed an order, dated 12/21/2023 for Lorazepam 1 milligram (mg) by mouth two times a day at 9:00 AM and 5:00 PM for anxiety. A review of Resident #2's care plan revealed a focus area, initiated 12/21/2023, Resident #1 used anti-anxiety medications related to a diagnosis of generalized anxiety disorder. Interventions included to administer anti-anxiety medications as ordered by the physician and monitor for side effects and effectiveness every shift. A review of Resident #2's Medication Administration Record (MAR) for December 2023 revealed Resident #2 did not receive Lorazepam 1 mg from 12/21/2023 at 5:00 PM until 12/25/2023 at 5:00 PM. The medication was documented as 2=Drug Refused on 12/24/2003 at 9:00 AM and 5=Hold/See Progress Notes on 12/24/2023 at 5:00 PM. The remaining entries during the time period were documented 9=Other / See Progress Notes A review of Resident #2 Progress Notes for December 2023 revealed the following MAR notes related to Resident #2's Lorazepam 1 mg not being administered: - A note dated 12/21/2023 at 10:10 PM: pharmacy notified. The note did not reveal notification of Resident #2's physician. - A note dated 12/22/2023 at 9:32 AM: on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/22/2023 at 7:54 PM: on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/23/2023 at 12:11 PM: on order. The note did not reveal notification of Resident Page 1 of 3 105634 105634 01/31/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0755 #2's physician or an attempt to contact the pharmacy. Level of Harm - Minimal harm or potential for actual harm - A note dated 12/23/2023 at 5:30 PM: Awaiting script (prescription). Will monitor. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. Residents Affected - Few - A note dated 12/24/2023 at 10:27 AM: Resident is awaiting for script. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. The note also did not reveal Resident #2 refusing the medication as documented in the MAR. - A note dated 12/24/2023 at 9:35 PM: Pending pharmacy on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/25/2023 at 9:21 AM: on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/25/2023 at 5:29 PM: awaiting medication. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. A review of Resident #2's MAR for January 2024 revealed Resident did not receive Lorazepam 1 mg on 1/7/2024 at 9:00 AM. The MAR also revealed Resident #2 did not receive Lorazepam 1 mg from 1/8/2024 at 9:00 AM through 1/9/2024 at 5:00 PM. The MAR revealed Resident #2 did not receive Lorazepam 1 mg on 1/10/2024 at 5:00 PM and on 1/12/2024 at 9:00 AM. The entries in the MAR on those dates and times were documented 9=Other / See Progress Notes. A review of Resident #2 Progress Notes for January 2024 revealed the following MAR notes related to Resident #2's Lorazepam 1 mg not being administered: - A note dated 1/7/2024 at 9:31 AM: awaiting script from provider. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 1/8/2024 at 12:07 PM: Script was for 14 days. Call placed to psych for further directions. Resident aware. Awaiting return call. - A note dated 1/8/2024 at 4:04 PM: Awaiting new Rx (prescription) from psych MD (Medical Doctor). The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 1/9/2024 at 12:23 PM: Awaiting script. PCP (Primary Care Provider) notified. Office to fax it in to pharmacy. - A note dated 1/9/2024 at 6:32 PM: awaiting med (medication). The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 1/10/2024 at 6:21 PM: Pending delivery from pharmacy. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 1/12/2024 at 8:47 AM: Awaiting delivery from pharmacy. MD notified. The note did not reveal an attempt to contact the pharmacy. 105634 Page 2 of 3 105634 01/31/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 1/31/2024 at 2:45 PM with the facility's Director of Nursing (DON). The DON stated she would expect nursing staff to reach out to the pharmacy if they needed a medication for a resident and the nursing staff should reach out to the resident's physician if a new prescription for the medication was needed. The DON also stated the medication could be pulled from the facility's emergency drug kit (EDK) if the resident had a prescription. If the the resident did not have a prescription, the resident's physician could send the prescription to the pharmacy and the nursing staff would receive a code from the pharmacy to pull a dose of the medication from the EDK. The DON stated she would not expect nursing staff to wait until the resident had no medication left before attempting to get the resident a new prescription and order more doses of the medication from the pharmacy. The DON also stated she would expect nursing staff to reach out to the resident's physician at least once a shift if a new prescription was still needed. During the interview, Staff A, Licensed Practical Nurse (LPN) and Unit Manager (UM) entered the room and was interviewed. Staff A, LPN UM stated she was not notified of Resident #2's medication not being available upon his admission to the facility and was not notified of Resident #2 not receiving his medications during his admission. A review of the facility's EDK medication list revealed Lorazepam 1 mg was available in the facility's EDK. An interview was conducted on 1/31/2024 at 4:07 PM with Staff B, Registered Nurse (RN). Staff B, RN stated if a resident was out of medications and needed a new prescription, they call the resident's physician to obtain the prescription. If the physician delays to send the prescription, the pharmacy will not release the medication. Staff B, RN also stated he had experienced difficulties in the past with physician's not answering calls on the weekends or during the night and it had been difficult to obtain new prescriptions for residents. A review of the facility policy titled Pharmacy Services, revised on 1/31/2024, revealed under the section titled Policy it is the policy of the facility to ensure that pharmaceutical services are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The policy also revealed under the section titled Compliance Guidelines the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident. The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable state laws. 105634 Page 3 of 3