Health inspection·February 27, 2020

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of election of Hospice Services for 5 (Residents #168, #118, #135, #146, and #20) of 6 residents reviewed for significant changes. This has potential to delay assessment of the decline in function and changing needs for care. Residents Affected - Some The findings included: 1. On 2/27/20 record review revealed the representative for Resident #168 elected Hospice Services on 8/14/19. The significant change MDS was not completed until 10/22/19, 69 days after election of Hospice Services. 2. On 2/27/20 record review revealed the representative for Resident #118 elected Hospice Services on 1/13/20. The significant change MDS was not completed until 1/30/20, 17 days after election of Hospice Services. 3. On 2/27/20 record review revealed the representative for Resident #135 elected Hospice Services on 1/17/20. The significant change MDS was not completed until 2/6/20, 19 days after election of Hospice Services. 4. On 2/27/20 record review revealed the representative for Resident #146 elected Hospice Services on 1/31/20. The significant change MDS was not completed until 2/20/20, 20 days after election of Hospice Services. 5. On 2/27/20 record review revealed the representative for Resident #20 elected Hospice Services on 2/6/20. The significant change MDS was not completed until 2/25/20, 19 days after election of Hospice Services. In an interview on 2/27/20 at 8:21 a.m., MDS Coordinator Staff S confirmed the significant change MDS for Residents #168, #118, #135, #146, and #20 was not completed within 14 days of election of Hospice Services. Page 1 of 10 105859 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review the facility failed to ensure 6 (Residents #60, #121, #114, #374, #75 and #117) of 101 residents with bed rails/grab bars were assessed for alternative interventions prior to the use of bed rails/grab bars. The facility failed to ensure informed consent was obtained prior to the use of the bed rails/grab rails and to conduct periodic maintenance of the bed rails to ensure they remained safe for residents' use. The term bed rails includes: side rails, bed side rails, safety rails, grab bars, or assist bars. The findings included: 1. Observations on 2/24/20 at 9:30 a.m., and on 2/25/20 at 10:27 a.m., found Resident #60 in her bed with bilateral upper bed rails in the up position and bilateral body pillows in place. Review of Resident #60's record revealed she was first admitted to the facility on [DATE]. A physician's order dated 9/11/19 for body pillows to each side of the bed was noted. There was no documentation the facility had assessed the resident for the use of bed rails, which included a review of the risk for entrapment. There was no documentation of attempts to use alternatives prior to the use of the bed rails nor did the facility obtain an informed consent for the use of the bed rails prior to their use. 2. On 2/24/20 at 11:25 a.m., and 2/25/20 at 10:17 a.m., Resident #121 was observed in his bed with bilateral upper padded bed rails in the up position. Review of Resident #121's record revealed he was admitted to the facility 6/26/17 with a readmission on [DATE]. The record included a Siderails Utilization assessment form dated 9/8/19 had been completed. There was no documentation the facility explained the risk and benefits for the use of bed rails/grab bars nor documentation of attempts to use alternatives prior to instillation of bed rails on Resident #121's bed. In an interview on 2/26/20 at 8:43 a.m., Certified Nursing Assistant (CNA) Staff T said she had been working at the facility for several years. She said they get a Pocket Care Plan (PCP) which tells them everything about a resident and included if they had grab bars on their bed. She said when Resident #60 and #121 were in bed both upper bed rails/grab bars were always in the up position. She reviewed her PCP for Resident #60 and #121 and said neither resident should have bed rails/grab bars on their bed. She said she was unaware the PCP stated the bed rails/grab bars were not to be used for Residents #60 and #121. Review of the policy Proper Use of Side Rails (revised 2/10/19) included: 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . 9. Consent for side rail use will be obtained from the resident or legal representative, after presented potential benefits and risks . 10. The resident will be checked periodically for safety relative to the side rail use . In an interview on 2/26/20 at 9:50 a.m., Assistant Director of Nursing (ADON) said the facility's policy prior to the use of bed rails/grab bars, was they were required to complete the Siderails 105859 Page 2 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Utilization form, have the resident or representative sign the consent form for the bed rails/grab bar, get a physician order for the bed rails/grab bars, and made sure the bed rails/grab bars were noted in the care plan and PCP. She said Resident #60 and #121 had bilateral bed rails/grab bar on their bed which they used when they were in their bed. After she reviewed Resident #60's record, the ADON confirmed they did not do the Siderails Utilization form as required nor obtain consent for the use of bed rails/grab bars prior to their installation. She said there was no documentation of attempts of alternatives prior to the bed rails/grab bar use. She acknowledged there was no documentation the facility staff informed the residents or their representative of the risk and benefits of bed rails/grab bars for Resident #60 and Resident #121. In an interview on 2/26/20 at 10:30 a.m., Plant Operations Director said he had been there since November 2018. As the Director he was responsible for all the maintenance in the facility which included attaching and removing the bed rails/grab bars in the facility. He said the facility had multiple different style of beds and bed rails/grab bars. He said he did not do routine maintenance checks on any of the bed rails/grab bars in use in the facility. He also did not know the manufactures specification for the use of the bed rails/grab bars for the different types of bed in the facility. In an interview on 2/26/20 at 12:00 p.m., the Director of Nursing (DON) confirmed they did not obtain the bed rail consent form and they did not complete the Siderails Utilization form prior to the use of the bilateral bed rails/grab bars. She said there was no documentation they had attempted an alternative prior to the use of the bed rails/grab bar. She said there was no documentation the facility staff had informed the residents or their representative of the risk and benefits of bed rails/grab bars for Resident #60 and Resident #121. In an interview on 2/26/20 at 12:30 p.m., the Administrator said he was unaware the Plant Operations Director was not conducting and documenting routine maintenance checks after the instillation of bed rails/grab bars to ensure they remain within manufactures specification to ensure the continued safety of the residents. *********************** 6. On 2/24/20 at 10:20 a.m., Resident #117 was observed lying in bed with bilateral affixed swing-type bed rails (can be swung into different locations on the top half of the bed). Both rails were raised and, in a position, parallel to the resident's shoulders. The resident was confused and unable to be interviewed. In an interview on 2/26/20 at 1:40 p.m., Resident #117's wife said he would not have been able to sign anything as he has dementia. She did not recall anyone going over the bed rails with her or offering any alternatives to them when he was admitted . She said Resident #117's daughter was the Power of Attorney and made all the decisions. Resident #117's clinical record included an admission Siderails Utilization form completed on 10/12/19 at 12:04 a.m. by an LPN. The form indicated the resident had expressed desire to have the siderails while in bed and was correctly using the siderails to enable positioning. A physician's order was received on 10/12/19 at 1:51 a.m., for bilateral grab bars for bed mobility and transfers. There was no documentation of any alternatives being attempted or informed consent prior to the use of bed rails. An admission Minimum Data Set 3.0 assessment was completed on 10/17/19 and indicated Resident #117 had severe cognitive impairment. On 10/24/19, an Incapacity to Give Informed Consent And/Or Make 105859 Page 3 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Medical Decisions form was completed by Resident #117's physician and the resident's daughter was appointed as Health Care Proxy (HCP). Resident #117 was transferred to the hospital on 1/7/20 and readmitted to the facility on [DATE]. An admission Siderails Utilization form was completed on 1/15/20 at 9:21 p.m. by a Registered Nurse which indicated the resident had expressed desire to have the siderails while in bed and was correctly using the siderails to enable positioning. There was no documentation of any alternatives being attempted or informed consent prior to the use of bed rails. In an interview on 2/26/20 at 2:48 p.m., ADON reviewed the Siderails Utilization form completed on 1/15/20 for Resident #117 and provided a paper dated 1/15/20 at 9:24 p.m. with an X in the center of the otherwise blank page. The ADON said this was the resident's acknowledgement of informed consent (the resident had been deemed to lack capacity to making informed consent on 10/24/19). The ADON confirmed there was no documentation of alternatives being attempted for Resident #117 or any discussion with the resident's HCP in regard to the risks associated with the use of bed rails to obtain informed consent. 3. On 2/24/20 at 9:55 a.m., bilateral bed rails/grab bars were observed in the up position on the bed of Resident #114. In an interview on 2/24/20 at 9:57 a.m., Resident #114 could not recall if he was informed of the risks and benefits of bed rails or if alternatives were offered. On 2/25/20 record review of Resident #114's records revealed no evidence the risks and benefits of bed rails were discussed with the resident or if any alternatives were offered. On 2/26/20 at 1:28 p.m., Unit Manager/Licensed Practitioner Nurse (LPN) Staff R provided a copy of an assessment for entrapment and said this was all the documentation she had for the use of bed rails. 4. On 2/24/20 at 10:22 a.m., bilateral bed rails/grab bars were observed in the up position on the bed of Resident #374. In an interview on 2/24/20 at 10:23 a.m., Resident #374 said she did not sign a consent form and could not recall if she was informed of the risks and benefits of bed rails or if alternatives were offered. On 2/25/20 record review of Resident #374's records revealed no evidence of informed consent or that the risks and benefits of bed rails were discussed with the resident or if any alternatives were offered. On 2/26/20 at 1:28 p.m., LPN Staff R provided a copy of an assessment for entrapment and said this was all the documentation she had for the use of bed rails 5. On 2/24/20 at 12:17 p.m., bilateral bed rails/grab bars were observed in the up position on Resident #75's bed. In an interview on 2/24/20 at 12:18 p.m., Resident #75 said the facility explained the risks and benefits. She thought she signed a consent but no alternatives to the bed rails were offered. 105859 Page 4 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0700 Level of Harm - Minimal harm or potential for actual harm On 2/25/20, record review of Resident #75's records revealed no evidence any alternatives were offered prior to the use of bed rails. On 2/26/20 at 1:28 p.m., LPN Staff R provided a copy of an assessment for entrapment and said this was all the documentation she had for the use of bed rails. Residents Affected - Some 105859 Page 5 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to notify the physician of significant weight loss for 1 (Resident #125) of 3 residents reviewed for nutrition. Residents Affected - Few The findings included: Record review on 2/26/20 at 9:30 a.m., showed Resident #125 had a 10.7% weight loss over 30 days. There was no documentation of the physician being notified of the weight loss. In an interview on 2/26/20 at 10:54 a.m., the Dietician said he was oat the weekly risk meeting and the physician was not notified of the weight loss. In an interview on 2/26/20 11:09 a.m., Licensed Practical Nurse (LPN) Staff K said the physician was not notified of weight loss and usually dietary notified the physician. In an interview on 2/26/20 at 11:10 a.m., LPN Staff R said there was no notification to the physician. He was on the risk team and they meet weekly. The physician did not attend those meetings. 105859 Page 6 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview the facility failed to ensure the attending physician responded to pharmacy recommendations regarding psychoactive medications for 3 (Residents #171, #135, and #52) of 9 residents reviewed for medications. The findings included: The facility's Policy IIIA2: Documentation and Communication of Consultant Pharmacist Recommendations (revised January 2018) indicated recommendations were to be acted upon and documented by the facility staff and/or the prescriber. If the prescriber did not respond to recommendations directed to him/her within 30 days, the Director of Nursing (DON) and/or consultant pharmacist may contact the Medical Director. 1. Review of Resident #52's clinical record revealed the use of antianxiety, antipsychotic, and antidepressant medications. A consultant pharmacist recommendation was made to the resident's attending physician on 8/31/19 to discontinue the PRN (as needed) antianxiety medication Alprazolam which had been in place for greater than 14 days without a stop date. The physician did not indicate if he agreed or disagreed with the recommendation. The report was signed by both the physician and DON on 9/5/19. The resident continued to receive the PRN Alprazolam until 1/16/20. In an interview on 2/27/20 at 2:06 p.m., the DON said Resident #52's physician continued to write scripts for the Alprazolam so they must had wanted to continue the medication. The DON acknowledged the lack of documentation as to the physician response to the pharmacist's recommendation and the lack of rationale for continuing the medication past the 14 days. 2. Review of Resident #135's clinical record revealed the use the antidepressant medication Citalopram 10 milligrams (mg) daily and mood stabilizing medication Depakote 500 mg twice a day. A consultant pharmacist recommendation was made to the resident's attending physician on 10/31/19 to please attempt a gradual dose reduction (GDR) to decrease the Depakote to 375 mg twice a day with Citalopram 10 mg daily. The box next to other was checked and maintain current medication was written next to it. There was no signature on the report. In an interview on 2/27/20 at 9:23 a.m., the DON said she reviewed Resident #135's clinical record and wrote to maintain current medication, not the prescribing physician. There was no indication the attending physician responded to the request for a GDR. 3. Review of Resident #171's clinical record revealed the use of the antipsychotic medication Risperidone. A consultant pharmacist recommendation on 10/30/19 indicated Resident #117 had received the Risperidone 0.25 mg three times a day since 11/20/18. A request was made to the resident's attending physician to please attempt a GDR to decrease the Risperidone to twice a day. There was no indication the attending physician responded to the request for a GDR. In an interview on 2/27/20 at 12:12 p.m., the DON said the request for a GDR was addressed in a note by the psychiatric nurse practitioner on 11/27/19. The DON confirmed there was no documentation of the physician response to the pharmacist recommendation. 105859 Page 7 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and staff interview the facility failed to have an end dates for as needed (PRN) psychotropic medication orders for 2 (Residents #15 and #75) of 9 residents reviewed for medications. PRN orders for psychotropic drugs are limited to 14 days unless the rationale and duration are noted. The findings included: On 2/27/20, review of facility policy IB3: Stop Orders (revised January 2018) noted, The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. Included in those classes were PRN psychotropic medication orders [14 days] 1. Record review showed Resident #15 was admitted to the facility 2/7/20. On admission Resident #15 was ordered antianxiety medication Alprazolam 0.25 milligrams (mg) by mouth three times a day as needed. There was no end date for this medication. The January 2020 pharmacy recommendations were reviewed by the pharmacist and did not note any irregularities including the fact the Alprazolam was open ended. In an interview on 2/27/20 at 8:29 a.m., Licensed Practical Nurse (LPN) Staff R confirmed the resident's medication was open ended. There were no physician orders addressing rationale or duration for the Alprazolam. 2. On 2/27/20 record review of resident #75 revealed an order for antianxiety medication Xanax 0.5 mg every twelve hours as needed. The order was dated 1/23/20 and was extended beyond 14 days without being reordered and documenting the rationale and determined duration. In an interview on 2/28/20 at 8:22 a.m., LPN Staff R confirmed the PRN Xanax order for Resident #75 was dated 1/23/20 and also confirmed the order was noted as Open Ended, meaning no determined duration. In an interview on 2/28/20 at 2:27 p.m., the Director of Nursing confirmed the PRN Xanax order for Resident # 75 was extended beyond 14 days without being reordered and documenting the rationale and determined duration. She also was unable to answer why the Xanax had not been automatically stopped after 14 days. 105859 Page 8 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and staff interview the facility failed to ensure medical records were completed and contained the irregularities identified from the monthly consultant pharmacist medication regime review for 5 (Residents #135, #76, #168, #171 and #52) of 9 residents reviewed for medications. The findings included: The facility's policy IA2: Consultant Pharmacist Services Provider Requirements (revised January 2018), indicated in section F, the consultant pharmacist was to document the monthly findings from the medication regimen review in the resident's medical record or in a readily retrievable format if electronic documentation used. 1. Review of Resident #168's clinical record revealed the use of the antianxiety medication Lorazepam twice a day. There was no evidence of the consultant pharmacist conducting a monthly medication review to identify any irregularities for August, October, November, and December 2019, or January 2020. In an interview on 2/25/20 at 10:37 a.m., Licensed Practical Nurse (LPN) Staff L said the residents' records were all electronic and the consultant pharmacist reports were scanned into the computer. LPN Staff L said there were no consultant pharmacist recommendations in a paper chart. In an interview on 2/25/20 at 10:49 a.m., the Assistant Director of Nursing Staff M reviewed Resident #168's record and confirmed the last pharmacist consultant report was in September 2019. 2. Review of Resident #52's clinical record revealed the use of antianxiety, antipsychotic, and antidepressant medications. There was no evidence of the consultant pharmacist conducting a monthly medication review for August, October, and December 2019, or January 2020. 3. Review of Resident #135's clinical record revealed the use of antidepressant and anticonvulsant medications. There was no evidence of the consultant pharmacist conducting a monthly medication review for August, October, and December 2019, or January 2020. 4. Review of Resident #76's clinical record revealed the use of antipsychotic and antidepressant medications. There was no evidence of the consultant pharmacist conducting a monthly medication review for August and October 2019, or January 2020. 5. Review of Resident #171's clinical record revealed the use of an antipsychotic medication. There was no evidence of the consultant pharmacist conducting a monthly medication review for August, October, and December 2019, or January 2020. In an interview on 2/27/20 at 11:50 a.m., the Director of Nursing said she did keep a copy of the consultant pharmacist recommendations in her office and found recommendations made in August for Residents #168, #52, #76, and #171; October for Residents #135 and #171; 105859 Page 9 of 10 105859 02/27/2020 Solaris Healthcare Charlotte Harbor 4000 Kings Hwy Port Charlotte, FL 33980

F 0842 and November for Resident #168. Level of Harm - Minimal harm or potential for actual harm The DON acknowledged the consultant pharmacist recommendations and physician responses should be part of the resident's clinical record. Residents Affected - Some 105859 Page 10 of 10