Health inspection·May 8, 2023

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's physician was immediately informed when there was a laboratory result that required physician notification for infection that resulted in a delay of care and transfer to a higher level of care and failed to ensure that a resident representative was notified of the change in condition for 1 of 3 residents reviewed for change in condition and wound care (Resident #1). Findings include: Review of the admission record for Resident #1 documented the resident was admitted to the facility on [DATE] with a diagnosis that included schizoaffective disorder, major depressive disorder, hypertensive heart disease without heart failure, Picks disease (frontotemporal dementia), hyperlipidemia, generalized anxiety disorder, unspecified dementia, and on 4/18/2023 a new diagnosis of pressure ulcer of right ankle. Review of the nursing progress note for Resident #1 dated 4/4/2023 at 8:29 AM reads, Observed reopened area on r (right) outer ankle size of a dime. Review of the wound care physician progress note for Resident #1 dated 4/7/23 read, Right lateral ankle. Wound status: New, Acquired in house: yes, Etiology: pressure wound unstageable, Drainage amount: moderate, Drain description: serosanguinous, Other: skin prep periwound. Review of the wound care physician progress note for Resident #1 dated 4/14/23 read, Right lateral ankle: 1.59 cm (centimeters) x 1.29 cm x 0.20 cm, Wound status: worsening, Etiology: pressure wound unstageable, Drainage amount: moderate, Drain description: serosanguinous, Periwound: erythema (redness), Other: skin prep periwound. Review of the wound care physician progress note for Resident #1 dated 4/20/23 read, Right lateral ankle: 2.06 cm x 1.98 cm x 1.30 cm, Wound status: worsening, Acquired in house: yes, Etiology: pressure ulcer Stage 4, Additional wound bed details: exposed bone, Drainage amount: moderate, Drain description: serosanguinous, Periwound erythema, Other: skin prep periwound, recommend wound cx (culture), CMP (complete metabolic profile), CBC (complete blood count), ESR (erythrocyte sedimentation rate), CRP (C reactive protein) and x-ray to rule out osteomyelitis (inflammation and infection of the bone) . Review of the physician's order for Resident #1 dated 4/20/23 read wound culture, right ankle. Page 1 of 3 105649 105649 05/08/2023 Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785

F 0580 Review of Resident #1's medical record revealed no laboratory results for a CMP, CBC, ESR or CRP. Review of the physician orders documented no orders for a CMP, CBC, ESR or CRP. Level of Harm - Actual harm Residents Affected - Few Review of the right ankle wound culture for Resident #1 documented a collection date of 4/20/23 at 2300 (11:00 PM) and a reported date of 4/24/23 at 10:57 AM that read, Final report: Gram stain: two plus gram negative rods, two plus gram positive cocci no, WBC (white blood cells) seen. Result moderate growth, normal skin flora, moderate growth gram negative rods: Escherichia coli isolate 1, morganella morgani isolate #2, providencia stuartii isolate #3. Review of the medical record for Resident #1 documented no notification of the wound culture results to the admission physician or nurse practitioner who ordered the tests. Review of the wound care physician progress note for Resident #1 dated 4/27/2023 read, Right lateral ankle: 2.94 x 2.71 x 1.30, Wound status: worsening, Etiology: pressure ulcer Stage 4, Additional wound bed details: exposed bone, Drainage amount: heavy, Drain description: serosanguinous, Other: skin prep periwound, refer to hospital ASAP (as soon as possible), stalled wound healing cycle despite treatment, underlying osteomyelitis. Review of the Skin/Wound care progress note for Resident #1 dated 4/27/2023 read, wound plan of care: wound culture positive for E coli, morganella morgani and providencia stuartii. This writer called PCP (Primary Care Physician), ARNP (Advanced Registered Nurse Practitioner) [ARNP's name] at the bedside and discussed deterioration of wound. Discussed high possibility for osteomyelitis. Recommended labs ordered last week was not done. X-ray was unremarkable. Discussed the need for resident to go to hospital ASAP (as soon as possible) for osteomyelitis treatment. PCP and ARNP agreed. During an interview on 5/8/2023 at 10:30 AM, Resident #1's son stated, I was not notified that her ankle [wound] was worsening until the day they sent her to the hospital. I did not know that they did a wound culture and then didn't give her any antibiotics until I got to the hospital with her. They should have let me know when it began to worsen. They should have called her doctor and gotten her some treatment before they did. My mother has dementia and could not tell me herself about her leg, or that it was worsening. When I saw her, she always had on socks and shoes. They should have done something before they did and maybe she would still have her leg. She has had a below the knee amputation because of this. During an interview on 5/8/2023 at 12:45 PM the Director of Nursing (DON) stated, The nurse practitioner did not place the orders in PCC (point click care) and gave the nurse a verbal order for the x ray, wound culture and all the labs in her note. The labs should have been done. I don't know why they weren't. I don't think the nurse practitioner can place the orders in for labs, the staff need to do that. I can't say why the culture wasn't called to the wound care APRN or the primary doctor. I don't see any notes indicating they were called. They should have been called right away. Staff should have completed documentation either in a progress note or change of condition SBAR (Situation, Background, Assessment, Recommendation) for the wound culture and we should have notified the family that the wound was worsening. I can't find any indication that her son was notified that the wound was worsening. During an interview on 5/8/2023 at 12:58 PM Staff A, Licensed Practical Nurse (LPN) stated, I missed this and did not order the labs, I just didn't hear her say them. I only heard for the x-ray and the wound culture. I did not hear the nurse practitioner say she wanted the labs. We put the labs in for the wound care. I was rounding with her (the wound care APRN) that day. I should have followed 105649 Page 2 of 3 105649 05/08/2023 Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785

F 0580 Level of Harm - Actual harm Residents Affected - Few up and made sure I got everything that she wanted. We will usually notify the family that there has been a decline in the wound. I did not call her son. I did not call the family. I was involved the day she was sent to the hospital, although I wasn't her nurse. I got the culture, but did not see any wound culture results, but I know I passed along to his nurse that one was done, and they should be following up on that. Any wound culture should be called to the doctor. Any cultures at all should be called to them. During a telephone interview on 5/8/2023 at 1:11 PM APRN stated, I did ask for a CMP, CBC, CRP, ESR, wound culture, and x-ray as her [Resident #1] wound significantly worsened and wasn't getting better. I don't know why the labs weren't ordered, I asked for them. When I saw her the following week, her wound deteriorated even further, and I discussed with medical the need to send her out for probable osteomyelitis. That is when I saw that her labs weren't ordered. These were ordered to determine if she had an infection and osteomyelitis. I was not notified that her wound culture had come back, I saw it the day she was sent to the hospital. I would have liked it if I was notified. I do think that there was a delay in care and that the delay was potentially harmful to the patient. Had I been notified; I definitely would have recommended IV (intravenous) antibiotics and possibly vascular studies or to possibly been sent out to the hospital. When I saw the further wound deterioration, I felt we should immediately send her to the hospital for evaluation of her osteomyelitis. It was my opinion that she could not be treated here and needed to go to the hospital. I believe that there was a delay in getting antibiotics started and that did worsen her wound, and this could worsen her outcome. Review of the policy and procedure titled Change of Condition dated 4/1/2022, approval date of 01/2023 read, Policy: It will be the policy of this person's facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 1. Observe resident during routine care and during monthly/quarterly/annual assessment periods to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etcetera. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative (if applicable) to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 105649 Page 3 of 3