Health inspection·September 23, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards of practice, by delaying hospitalization for one (Resident #51) of two residents reviewed for hospitalizations from a total sample of 40 residents. Residents Affected - Few The findings include: A review of Resident #51's medical record revealed an admission date of 4/14/21 and a readmission date of 7/21/21. Her primary medical diagnosis was nondisplaced intertrochanteric fracture of right femur. Secondary medical diagnoses included osteoarthritis, dementia with behavioral disturbances, osteoporosis, and fracture of sacrum. A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell. She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order dated 7/18/21 at 1:26 PM indicated a STAT x-ray of the right femur and right knee for pain. A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order dated 7/18/2021 at 10:06 PM read, Transfer the resident to the emergency room for a right femur fracture. A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident Page 1 of 4 105710 105710 09/23/2021 Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218

F 0684 was taken to the emergency room. Level of Harm - Minimal harm or potential for actual harm An attempt to interview the nurse that transferred the resident to the hospital was made. However, the nurse was no longer employed at the facility. Residents Affected - Few A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. On 9/23/21 at 10:01 AM, an interview was conducted with the Employee B, Licensed Practical Nurse (LPN)/Unit Manager (UM). She explained that she was out of the building conducting a mock survey at another facility. The UM stated, she wasn't sure why the resident's transfer to the hospital was delayed. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When she was asked about the lapse of time between the second x-ray being ordered and Resident #51's subsequent transfer to the hospital, she stated, she wasn't sure why the delay had occurred. . 105710 Page 2 of 4 105710 09/23/2021 Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement interventions to address a resident's acute pain related to a fracture after sustaining a fall for one (Resident #51) of two residents reviewed for pain management from a total sample of 40 residents. Residents Affected - Few The findings include: A review of Resident #51's medical record revealed an admission date of 4/14/21 and a readmission date of 7/21/21. Her primary medical diagnosis was nondisplaced intertrochanteric fracture of right femur. Secondary medical diagnoses included osteoarthritis, dementia with behavioral disturbances, osteoporosis, and fracture of sacrum. A significant change assessment dated [DATE] revealed resident's cognition was moderately impaired, and she required limited to extensive assistance with activities of daily living. A nursing progress note dated 7/18/21 at 2:24 AM indicated Resident #51 was observed lying on her back next to her bed. An abrasion was noted above the right eye. The resident stated she slipped and fell. She denied pain at the time of the assessment. A post fall review dated 7/18/21 indicated the fall occurred at 2:10 AM. The resident was ambulating unassisted. A review of Resident #51's physician order dated 7/18/21 at 1:26 PM indicated a STAT x-ray of the right femur and right knee for pain. A nursing progress note dated 7/18/21 at 1:27 PM indicated Resident #51 was to have a stat x-ray of the right knee and right femur due to pain. An x-ray result dated 7/18/21 at 9:03 PM indicated a minimally displaced obliquely oriented acute intertrochanteric fracture. The examination date for Resident #51 was on 7/18/21 at 8:15 PM. A physician order dated 7/18/2021 at 10:06 PM read, Transfer the resident to the emergency room for a right femur fracture. A nursing progress note dated 7/18/21 at 11:52 PM indicated Resident #51 was diagnosed with a right femur fracture. The physician was notified, and order was obtained for transfer to the emergency room for evaluation. A nursing progress note dated 7/19/21 at 2:00 AM indicated ambulance service arrived and resident was taken to the emergency room. A review of Resident #51's hospital history and physical dated 7/19/21 indicated she presented to the emergency department with right leg pain following an unwitnessed fall around 5 AM. The note read, She was apparently ambulatory for a few hours after the fall but then reported she was having too much pain to be able to walk. She had imaging done and was found to have a right femur fracture. A review of Resident #51's physician order dated 4/14/21 revealed an order for a Lidoderm patch to be placed on the resident's lower back. The resident had no other orders for analgesics prior to the 105710 Page 3 of 4 105710 09/23/2021 Jacksonville Nursing and Rehab Center 4134 Dunn Avenue Jacksonville, FL 32218

F 0697 fall and no ordered analgesics until after returning from the hospital. Level of Harm - Minimal harm or potential for actual harm A review of the medication administration records (MAR) for July 2021 revealed pain evaluation results of 0 on each shift prior to the resident transferring to the hospital. Residents Affected - Few A review of the comprehensive care plan for Resident #51 dated 4/15/21 revealed a focus area for pain. Interventions included analgesics as ordered, evaluate characteristics of pain: location, severity on a scale of 10, and frequency, identify existing conditions that may increase pain or discomfort, observe for signs of relief/effectiveness with interventions. On 9/22/21 at 2:16 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She explained that she had worked at the facility for approximately nine years and that she was familiar with Resident #51. Regarding the fall on 7/18/2021, the nurse explained that the fall occurred on night shift and that she reported to work the following morning. She explained that as the day shift CNA was assisting the resident to stand, the resident complained of pain. The CNA notified the nurse and the nurse went in to assess the the resident. The resident pointed to her knee. The nurse explained that she notified the physician and obtained an order for a STAT x-ray. When asked about interventions to address the resident's pain, the nurse stated she believed she had given the resident tylenol. The nurse then reviewed the medical record and asked Employee B, LPN/Unit Manager to review the record. The UM stated, she didn't see anything on the 18th or 19th. On 9/22/21 at 3:13 PM, Employee A, LPN confirmed, she did not give Resident #51 anything for pain. Initially, she stated, I didn't give her anything. The doctor didn't tell me to give her anything. But, she had a lidoderm patch on her back. When asked to confirm whether the resident's acute pain was discussed with the physician, the nurse didn't answer the question but stated, I don't know, I don't remember. On 9/23/21 at 10:01 AM, an interview was conducted with the UM. She explained that she was out of the building conducting a mock survey at another facility when the resident fell. The UM reviewed the resident's record and confirmed that the record contained no documentation of interventions to treat the resident's pain. On 9/23/21 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC). She explained that the facility conducted an investigation for Resident #51's fall on 7/18/21. The RNC stated, she had spoken with the nurse about the fall after it was brought to her attention during the survey and that the nurse told her she obtained an x-ray order because the resident was grimacing while walking. The RNC acknowledged that, after reviewing the record and speaking with Employee A, LPN the resident received her routinely scheduled lidoderm patches but no other analgesics were adminsitered to treat the acute pain. A review of the facility's pain management policy titled Pain Evaluation directed staff to assess the resident's pain characteristics, contact the physician for orders, and include interventions in the resident's comprehensive plan of care. . 105710 Page 4 of 4