Health inspection·January 13, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer antihistamine nasal spray for 1 of 1 resident of a total sample of 45 residents, (#16). Residents Affected - Few Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, schizophrenia, and allergic rhinitis. The resident's annual Minimum Data Set (MDS) assessment with reference date 10/1/21 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 9/15. On 1/10/22 at 11:54 AM, an 11.1 milliliters Fluticasone Propionate allergy relief nasal spray was observed on the overbed table next to the resident's bed. Resident #16 said she took the nasal spray twice a day because her nose was always runny. On 1/11/22 at 10:19 AM, the Fluticasone Propionate allergy spray remained on the over-bed table next to the resident's bed. When questioned about the spray, the resident got into her wheelchair and took the nasal spray to the License Practical Nurse (LPN) D. LPN D stated she administered the spray to the resident yesterday but recalled she did not leave the nasal spray at the bedside. This medication is given twice daily, so someone may have left it there. LPN D said residents needed to be assessed for self administration of medications and we must have orders for the resident to self-administer their medications. She noted the resident was able to administer the spray into each nostril while she watched her, but explained the spray needed to be kept in the medication cart. On 1/13/22 at 3:19 PM, the Regional Nurse stated, When we find medication at the bedside, it is removed, and nurses are provided in-service to always check for medications at the bedside. All residents must be assessed before they can self-administer medication. The meds must be kept in a safe and secure place, not accessible to other residents. Review of the medical record revealed resident #16 was not assessed to self-administer medications. There were no recommendations or orders for self-administration of medications. Review of the most recent plan of care completed on 10/7/21 revealed no plan of care for self -administration of medications. The Medication Pass Self-Administration of Medication: Evaluation of Resident's Ability dated 12/2016, read, . the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Page 1 of 3 105839 105839 01/13/2022 Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record accurately reflected the resuscitation status of 1 of 1 resident reviewed for Advanced Directives out of 45 total sampled residents, (#9). Findings: Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital with diagnoses that included lung disease, traumatic brain injury, and partial paralysis. Review of resident #9's Minimum Data Set quarterly assessment with Assessment Reference Date of 12/28/21 revealed he had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. A care plan for Advanced Directives, Do Not Resuscitate (DNR) code status initiated 9/24/21 indicated family would provide copies of the DNR form. Interventions included a quarterly review of his Advanced Directives and as needed to ensure, Decisions made were still desired. An additional care plan for Advanced Directives initiated on 10/29/21 revealed resident #9 elected DNR as of 6/23/21. Interventions directed staff to obtain physician's order and to follow physician's orders. In telephone interviews on 01/11/22 at 10:27 AM and at 4:11 PM, resident #9's wife stated that as his Power of Attorney, she did not wish for him to be resuscitated with Cardiopulmonary Resuscitation (full code) if he was unresponsive. Resident #9's wife said she signed the DNR form before he was admitted to the facility and sent the form to the facility within a few weeks of his admission in September. Review of resident #9's medical record revealed a State of Florida Do Not Resuscitate form was scanned into the electronic file on 11/01/21 at 11:06 AM. It was signed by the physician on 6/23/21 and by resident #9's POA on 6/7/21. Review of the Order Summary Report dated 1/11/22 revealed a physician's order dated 12/20/21 for Full Code. An additional physician's order for Full Code was in place from the date of resident #9's admission on [DATE] until 12/20/21. On 1/11/22 at 11:24 AM, resident #9's nurse, Registered Nurse (RN) A explained that knowing a resident's code status was important because, You need to know what they want, either full code or DNR, you don't want to do something that is against their wishes. On 1/11/22 at 11:53 AM, RN A confirmed resident #9 had a DNR form in the North wing DNR notebook, but her report sheet and the physician's order in the medical record showed he was a Full Code. She stated the conflicting information could be confusing for staff. On 1/11/22 at 11:55 AM, during a review of the North wing DNR notebook with the North wing Unit Manager (UM), she validated resident #9 had a State of Florida Do Not Resuscitate form signed on 105839 Page 2 of 3 105839 01/13/2022 Terrace of Kissimmee, The 221 Park Place Blvd Kissimmee, FL 34741

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 6/23/21 by the physician. She then acknowledged resident #9 had a physician's order for Full Code dated 12/20/21. On 1/11/22 at 11:59 AM, the Social Service Director stated there was an admission note on 9/24/21 written by the Social Service Assistant that showed resident #9 was a full code. She said the Social Service readmission note on 12/17/21 also showed him as a full code. She stated that when the Social Services department received a DNR form, they would notify the UM and the nurse who were responsible to change the orders immediately. She was unable to say if the UM or nurse were notified when Social Services received resident #9's DNR form. On 1/13/22 at 9:35 AM, the Social Service Director stated having a full code order when a resident had a signed DNR allowed for confusion and agreed there was potential for a grave error to be made because the orders did not match the wishes of the resident. She confirmed it would be very serious if a staff member misunderstood the code status and the wishes of the resident were not honored. Review of the Transfer Form dated 12/11/21 used to provide information about the resident when transferred outside the facility, revealed resident #9 was sent to an acute care hospital on [DATE] at 12:40 AM to rule out bleeding. The code status on the form was marked as full code by the nurse who called the report to the hospital. Review of the Social Services Quarterly Assessment dated 12/29/21, revealed the summary, Advance directives were reviewed, no changes at this time and he continues to be a full code status. On 1/13/22 at approximately 9:55 AM, the Social Services Director was asked to provide a copy of the Social Services Quarterly Assessment dated 12/29/21. Review of the electronic medical record revealed changes were made to the form a few minutes ago, on 1/13/22 at 10:01 AM, by the Social Services Assistant. On 1/13/22 at 10:25 AM, the Social Service Assistant stated when she went to print the Social Services Quarterly Assessment dated 12/29/21, she reviewed the information and realized the summary was wrong because she wrote resident #9 was a full code. She explained she then changed the form to read DNR and printed it for the surveyor. She further explained she did not understand how she had documented resident #9 was a full code in the summary so she changed it. On 1/13/22 at approximately 10:28 AM, the Regional Nurse acknowledged the change made in the documentation by the Social Service Assistant and stated that documents should not be changed by staff when surveyors ask for copies. Review of the document Advance Directives revised December 2016, revealed, The Director of Nursing or designee will notify the Attending Physician of the resident's advance directives so that appropriate orders can be documented in the resident's medical record . 105839 Page 3 of 3