Health inspection·July 8, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement measures to safeguard lockboxes to prevent misappropriation of personal property after the death of 1 of 3 residents reviewed for misappropriation of property of a total sample of 11 residents, (#15). Residents Affected - Few Findings: Review of the medical record revealed resident #15 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and nicotine dependence. He expired in the facility on [DATE] at 12:45 PM. Review of the resident's medical record revealed the Minimum Data Set quarterly assessment with assessment reference date of [DATE] showed the resident's Brief Interview for Mental Status score was 15 out of 15 which indicated he was cognitively intact. Resident #15 required extensive assistance with bed mobility, dressing, and personal hygiene, and limited assistance with transfers. Review of resident #15's care plan for self-administration of medication, initiated on [DATE] showed he could self-administer medication correctly, could demonstrate secure storage, identify the medication, was aware of the medication purpose, dosage, side effects, could read the instructions, and take the medication as ordered. The care plan interventions showed the interdisciplinary team assessed resident #15 and approved him for self-administration of his medication. An email dated Thursday, [DATE] at 3:31 PM, provided by the Social Services Director (SSD) to resident #15's daughter read, I have started the investigation into the missing Direct Express card and the Blue Cross debit card. The resident's daughter responded in an email dated [DATE] at 4:23 PM, that read, As far as the debit cards go, I have filed a report for lost cards, and am also filling a lost/stolen card report as well as have them stop payment to the cards with the social security office. Can you please start the process there in the facility to find out who had access to his belongings. In an email dated [DATE] at 3:21 PM, the SSD wrote, I reviewed the camera footage, it is limited view of the hallway outside the main doorway to the room. There were multiple nursing staff in and out of the room throughout the weekend and I saw a visitor visit Saturday, and on Sunday, I did not see the two lockboxes with anyone but I cannot see into the room at all. There is a wide area as you enter the door that gives access to the bathroom where his box of belongings had been when I found it, but the camera does not see that area. On [DATE] at 2:12 PM, the Executive Director of Nursing (DON) stated if a resident expired, the Page 1 of 3 105728 105728 07/08/2023 Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse would call the family. She stated some families would come and pick up the resident's belongings but if they could not, nursing staff would pack and secure the personal belongings. She stated the facility's procedure after a death was for nurses to collect the lockboxes, and secure them until the supervisor could pick them up. On [DATE] at 11:48 AM, review of a grievance for resident #15 dated [DATE] with the SSD revealed a concern related to lost items, specifically two debit cards. The SSD stated all the resident's items had been secured. He noted the Unit Manager on C wing had both lock boxes, which were still locked, inside a plastic bag, and placed behind the nurse's station by the C wing Unit Manager. He stated in searching resident #15's personal items, he found his wallet in the lock box but the debit cards were missing. He stated he was aware the resident had both cards because on [DATE] he went to the store for personal items for the resident and returned the card and personal items on [DATE] (Friday) to the resident. The SSD stated on [DATE] the daughter reported both cards were missing or stolen. On [DATE] at 12:37 PM, Registered Nurse Unit Manager on C wing stated lockboxes were usually used to lock resident's medications. She stated the usual practice was be to remove the lockbox from the resident room, and secure it if the resident deceased . She stated she removed the resident's lockboxes from his room after breakfast but before lunch on [DATE] (Monday). She stated she gave the lockboxes to the SSD. She explained, I did not see a wallet, his wallet was not in the lockbox. She then stated the lock box was locked. On [DATE] at 12:50 PM, the Social Services Director stated he received two lockboxes from the C Wing Registered Nurse Unit Manager. He said there was inhaler medication in one, and a wallet, inhaler and some cigarettes in the other. He stated the keys for both lockboxes were in a plastic bag attached to the outside of the lock boxes. This indicated resident #15's personal items inside the lockboxes with keys had been left unsecured in his room for over 23 hours after he died. On [DATE] at 1:06 PM, Certified Nursing Assistant (CNA) D validated she was the assigned caregiver for the resident on the 7 AM to 3 PM shift on [DATE]. She stated she knew he kept his lockbox key but it wasn't in the bed with him because he was wearing a gown. She said she did not pack any of his personal belongings after he died and did not think about the lock box. She explained it should have been given to the nurse for safekeeping. On [DATE] at 10:42 AM, the Executive DON telephoned License Practical Nurse B. He confirmed he was assigned to resident #15 on the 3 PM to 11 PM shift on [DATE]. He explained he did not know the resident had a lockbox as it was not mentioned by the off going nurse. He stated he would not leave the lockbox in the room because someone could access it if the keys were there. He conveyed he would have secured the lock box and called the daughter and/or given it to the supervisor. On [DATE] at 10:52 AM, License Practical Nurse C was contacted by telephone. She noted she was assigned to resident #15 from 7 AM to 3 PM shift on [DATE] She stated she was aware the resident had lockboxes in his room for medications. She was aware she needed to secure the lock box if the resident was no longer able to. She indicated she would have taken the lockbox and put it in the medication room but she did not remember to do this. The facility did not provide a policy or guidelines regarding lockboxes. The Abuse prevention program policy with an effective date of 2012 showed the facility had designated and implemented process, which strive to reduce the risk of abuse, neglect, exploitation, 105728 Page 2 of 3 105728 07/08/2023 Orlando Health and Rehabilitation Center 830 West 29th Street Orlando, FL 32805

F 0602 mistreatment, and misappropriation of residents' property. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105728 Page 3 of 3