Health inspection·May 18, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who was actively dying received necessary medication for pain and comfort based on the comprehensive assessment and in accordance with professional standards of practice for 1 of 3 residents reviewed for hospice care out of 8 sampled residents, (#1). Residents Affected - Few The facility's failure to ensure the assigned nurse gave necessary medication to a terminally ill, actively dying resident resulted in psychosocial harm to resident #1. Based on the resident's severe cognitive impairment and inability to express her response and using the reasonable person concept, the resident would have experienced pain, anxiety, agitation, distress, and depressed mood due to not receiving necessary narcotic analgesic medication for 10 ½ hours that was ordered to be given every 4 hours by the physician. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] under the care of hospice. Her diagnoses included Alzheimer's disease, cerebral ischemia, cardiac arrhythmia, spinal stenosis, lower back pain, protein calorie malnutrition, altered mental status, pelvic and perineal pain, pain in right foot, anxiety, insomnia, history of falls, cerebral atherosclerosis, atrial fibrillation, and muscle weakness. The resident's hospice initial certification of terminal illness began on [DATE] with terminal diagnosis of end stage cerebral atherosclerosis and secondary diagnosis of vascular dementia. Cerebral atherosclerosis is a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain. (https://www.ninds.nih.gov/health-information/disorders/cerebral-arteriosclerosis). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 5 out of 10 which indicated severe cognitive impairment. She had disorganized thinking and altered level of consciousness. The assessment noted the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of resident #1's individualized plan of care documented the resident was dependent on staff to meet emotional, intellectual, physical, and social needs. The care plan noted the resident had mood/behavior problems related to anxiety, impaired cognitive function related to dementia and memory recall. The care plan for pain related to decreased mobility and chronic back pain included Page 1 of 6 105888 105888 05/18/2023 Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769

F 0684 Level of Harm - Actual harm interventions to administer analgesic medications as ordered by the physician with the goal that she will have adequate pain relief. The care plan for terminal prognosis related to cerebral atherosclerosis had the goal to maintain her comfort and interventions included admitted to hospice service, observe resident closely for signs of pain and administer pain medications as ordered. Residents Affected - Few The physician orders for Morphine dated [DATE] to [DATE] read 100 milligrams (mg) per 5 milliliters (ml) solution give 0.25 ml every 4 hours for pain and increase on [DATE] to 0.5 ml every 4 hours for pain. Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath. Successfully reducing pain and addressing concerns about breathing can provide needed comfort to someone who is close to dying (https://www.nia.nih.gov/health/providing-comfort-end-life). On [DATE] 2:06 PM, in a telephone interview, resident #1's daughter stated her mother did not receive her scheduled dose of Morphine at 8 AM or 12 PM on [DATE] when she was dying. She said she and her family were in the resident's room the entire time and the nurse, Registered Nurse (RN) A did not come into the room to administer the Morphine. Review of the facility AHCA (Agency for Healthcare Administration) Immediate Report #181527 read, On [DATE] .resident representative .complained to .Unit Manager that the resident did not receive her scheduled morphine at 12 noon .nurse was suspended pending investigation .Resident is under crisis care due to imminent death Review of the Controlled Medication Utilization Record for resident #1's Morphine 100 mg/5 ml showed the nurses signed for 0.25 ml on [DATE] at 2 PM and 8 PM and on [DATE] at 12 AM, 4 AM, 8 AM, and 12 PM. The doses in question were documented by RN A as given on [DATE] at 8 AM and 12 PM. The Medication Administration Record showed that on [DATE] At 8 AM and 12 PM, RN A signed for giving Morphine Sulfate 100 mg/5 ml 0.5 ml by mouth for pain. Review of the Administration History report dated [DATE] showed a time stamp by RN A that he administered 0.5 ml of Morphine at 9:27 AM and 11 AM. This conflicted with what he logged on the Controlled Medication Record of only 0.25 ml of morphine at 8 AM and 12 PM. On [DATE] at 10:16 AM, the Director of Nursing (DON) said according to the Medication Administration Record (MAR), RN A gave Morphine to resident #1 on [DATE] at exactly 9:27 AM and 11 AM. Review of facility's investigation for misappropriation and RN A's statement dated [DATE] read, Give medication morphine 7-8 and 11-12 the room empty at the moment. The time stamp of 9:27 AM was contrary to RN A's time of giving medication between 7-8 AM. The statements/interviews obtained from nurses Hospice Licensed Practical Nurse (LPN) C, Hospice LPN D, Hospice RN Case Manager, and family of resident #1 noted they did not see RN A in the resident's room except for Hospice LPN D who indicated he only saw him after 7 AM to do an assessment and not give Morphine. During their investigation, the facility obtained a witness statement dated [DATE] by the crisis care Hospice LPN C. The statement revealed she arrived at the bedside at 8 AM and the Hospice Night LPN D was still present and remained in the room with her until 8:30 AM. Hospice LPN C documented I 105888 Page 2 of 6 105888 05/18/2023 Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769

F 0684 Level of Harm - Actual harm Residents Affected - Few was with patient continuously never left bedside .facility unit manager asked about the morphine dose from 8 AM and 12 PM she asked [nurse A] he stated he gave it, which he did not .the Director of Nursing states she spoke with [nurse A] .counted the medications to discover the two doses were not there so the count reflected he gave the morphine but I know the patient in my care and she did not get any and I had never left her bedside .(Advanced Practice Registered Nurse [APRN] G) from facility came to patient and assessed her to report she reacted to testing thought she had not received any medications and will get her morphine now 2:30 PM Director of Nursing gave morphine 1 ml as ordered. The patient rested quietly after that dose and (APRN G) returned in 45 minutes to reassess her. Family remains with patient . On [DATE] at 11:50 AM, the Unit Manager (UM) said resident #1 received crisis care from hospice who was providing around the clock nurse at the bedside. The UM explained crisis care was for pain or symptom management. She stated resident #1 was moaning, grimacing, and tensing up when staff tried to reposition her or provide care. The UM verified the hospice nurses did not administer the medications, it was the responsibility of the facility nurses. The hospice nurses provided repositioning and incontinence care but relied on the facility nurse to administer medications. The UM recalled that on [DATE] at about 1 PM to 2 PM, the Hospice Case Manager reported to her that resident #1's family was concerned as the resident was in pain and looked uncomfortable. The family did not believe the nurse had administered her Morphine. The UM said she spoke to the resident's daughter who told her she did not believe her mother was given Morphine. The daughter's husband and brother were in the room at the time along with Hospice LPN C. The daughter conveyed she had been in the resident's room since 10:00 AM and the assigned nurse, RN A had not been in the room. The daughter explained she had not stepped out of the room or used the restroom and had remained at her mother's bedside the entire time. She added that her brother arrived at 12:00 PM. Hospice LPN C verified the daughter's statement and reported she had been in the room since 8:00 AM and had never left the resident's bedside. The UM said she then spoke to the assigned nurse, RN A and he reported that he gave the resident Morphine twice on his shift. The UM noted she verified the narcotic sign out count was correct. The UM explained she then informed the family and Hospice LPN C that the Morphine narcotic count was correct. She said the Hospice LPN C and the resident's daughter stated, RN A did not give medication, and something has to be done. The UM reported her concerns to the DON. The DON then re-checked the Morphine bottle to ensure the count was correct and sent RN A home. The UM noted the family and Hospice LPN C reported to the DON that the resident looked uncomfortable and was in pain if they moved her. She validated the importance of keeping someone on hospice comfortable when providing end of life care. The UM added the daughter was furious and stated, he [RN A] absolutely did not go in the room since she had been at beside since 10 AM. Hospice LPN C also stated that she had not seen RN A since she had been at bedside since 8 AM. The UM said the daughter was very upset and did not deserve to go through that when her mom was dying and the Certified Nursing Assistants (CNAs) on the unit did not see RN A go into the room either. The UM indicated that it was not possible for someone to go into the resident's room and not been seen. She noted she could not understand how RN A could say he went in the resident's room and nobody saw him. On [DATE] at 12:44 PM, during a telephone interview, Hospice LPN C said she provided bedside hospice care to patients who were dying and in need of symptom/pain management at end of life. She verified she worked at the facility on [DATE] and cared for resident #1 from 7:50 AM to 7 PM. She recalled when she arrived at the facility, resident #1 was not agitated or fidgeting and she was informed by the Hospice Night LPN D that the last dose of Morphine was given at 4 AM. She noted that when she and LPN D repositioned the resident close to 8:20 AM, the resident was not comfortable, was fidgeting, moaning and moving her 105888 Page 3 of 6 105888 05/18/2023 Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769

F 0684 Level of Harm - Actual harm Residents Affected - Few legs. She remembered Hospice Night LPN D stayed in the room until 8:20 AM and reiterated that resident #1 received Morphine last at 4 AM by the facility nurse. She said the resident seemed more uncomfortable at 10 AM and was moving around more. She recalled the resident's daughter spoke to RN A who told her he gave Morphine to her mother at 8 AM. Hospice LPN C said the resident did not receive Morphine at 8 AM as she and Night LPN D were in the room and did not see RN A come in the room. When we asked RN A to give the Morphine at 12 PM he said to me and the family that he could not give it again until 4 PM as he already gave the 12 PM dose. He swore up/down he gave it, and the facility said the counts were correct, but nobody saw him. She said the daughter was very upset and APRN G got involved. She recalled APRN G assessed the resident and indicated the resident had not had any medication. She noted the APRN made sure the DON administered medication to make the resident comfortable. Hospice LPN C said the resident was more comfortable after the DON gave Morphine. She recalled APRN G also came back after Morphine was given and noted the resident was more comfortable. Hospice LPN C verified the daughter arrived in the resident's room a little after 10 AM and the rest of the family arrived after 12 PM. She noted the daughter did not leave the bedside except to talk with the DON in the hall and then left around 5:30 PM. Hospice LPN C verified she never left the room except to use the bathroom in the resident's room when the family were present. She verbalized that she and the family were very upset as RN A was adamant that he gave the resident's Morphine but they were always in the room and never saw him. During a telephone interview on [DATE] at 1:45 PM, Hospice Night LPN D stated he was assigned to resident #1 on the night shift from 7 PM to 8 AM on [DATE]-[DATE]. He said the resident was comfortable during his shift and the last time he saw the facility nurse give Morphine was at 4 AM. She was declining and her breathing was shallow. He explained that he stayed in the room until approximately 8:30 AM with Hospice LPN C and the Hospice Case Manager arrived at approximately 7:45 AM. He said he only saw facility RN A once after 7 AM when he assessed the resident but he did not administer any Morphine. A telephone interview was conducted on [DATE] at 1:30 PM, with Hospice Case Manager who verified she saw resident #1 on [DATE] from 7:45 AM to 8:10 AM. She said the resident was imminent which indicated she was close to death. She was moaning a little at that time and the Hospice Night LPN D said she received her last dose of Morphine at 4 AM from the facility nurse. At that time, she was getting Morphine routinely every 4 hours and could have breakthrough medication every 2 hours if needed. She recalled she came back around 11:45 AM and wrote more orders to increase the Morphine dose because the resident showed signs of increased pain. She recalled the UM had reported RN A gave her the Morphine at 8 AM so she did a virtual call to the hospice physician so he could visualize resident #1. She said the hospice physician gave orders to increase her Morphine dose from 0.5 ml to 1.0 ml. I reported the dosage change to RN A and gave him the new order to update the facility orders. She said RN A told her he would and she left to visit another resident in the facility. The Hospice Case Manager stated she then received a text at about 12:45 PM that RN A had not given the Morphine yet. I came over and she was still uncomfortable and ready for a dose. I went to the UM and told her the Hospice LPN C reported that (resident #1) .missed a 2nd dose and the family at beside are very upset. She recalled the DON intervened, and she was not aware of what transpired. She said she informed the Hospice Physician and documented an incident report. She added that the resident's family at bedside were visibly upset. On [DATE] at 1:55 PM, during a telephone interview, the Hospice Physician said he did a virtual visit and resident #1 looked very agitated and in pain but died in peace after we adjusted her medications. He added, the facility is not consistent when giving medications and I did not realize at the time when I ordered to increase her Morphine that the nurse may not have given the 8 AM and 12 PM 105888 Page 4 of 6 105888 05/18/2023 Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769

F 0684 doses. Level of Harm - Actual harm On [DATE] at 4:38 PM, APRN G remembered he assessed resident #1 on [DATE] around 1-2 PM per the family's request. He recalled there were 2 family members and a Hospice Nurse present at the bedside. He said the resident was uncomfortable and restless probably due to not getting her prescribed Morphine. He said he heart rate was irregular at 110 beats per minute and blood pressure was okay. When he assessed her for pain, he did a mild chest rub and she really grimaced and that was enough to tell that she did not have pain medication in her system. He explained he also did [NAME] test where the heel was rubbed from the foot up the toes and she withdrew and kicked her legs up immediately and I could tell there was no pain medication in her. He stated he told the nurse to change the pain medication schedule and to give a dose now and continue the same schedule. He noted when he came back 45 minutes later after she received Morphine, she was calmer, and the [NAME] response was very soft. He reported the family members at the bedside were upset as they were confident the nurse did not give the medication. He said he was familiar with the family as they recently had 2 other family members that died in the facility under hospice care. He said they should not have had the added stress regarding mom not getting needed medications prior to her death. Residents Affected - Few On [DATE] at 12:10 PM, a telephone interview was conducted with RN A and the Business Office Manager (BOM) assisted with translation as per RN A's request who spoke Spanish. RN A said he had been a nurse for 15 years and worked for the facility initially as an agency nurse and then was hired by the facility last year. He verified he was the assigned nurse for resident #1 on [DATE] from 7 AM to 7 PM. He recalled he went to the resident's room to assess her prior to 8 AM and there was a nurse from hospice in the room. He then immediately went back to give the Morphine and the hospice nurse was in the hall at approximately 8 AM and resident #1 was alone. He said he went back to give a second dose of Morphine between 11-11:30 AM and there was no one in the room. He then went on break at 11:45 AM. RN A was persistent that he gave Morphine to resident #1 and said he gave the drops under the tongue. When asked why he did not return the facility phone calls, he stated he did not call them back because he was upset. He said,I never took drugs before and it is just ridiculous. On [DATE] at 8:25 AM, during a telephone interview, the resident's daughter said she went to the facility on [DATE] because the Hospice Nurse called her and said her mom was close to passing. She recalled she arrived at the facility between 9 -9:30 AM and found her mom in bed moaning, grimacing and raising her legs due to spasms. She explained her mom never complained of pain and was very stoic. She stated she did not leave the room until approximately 1:30 PM to inform the DON that no one had come in the room to give her Morphine. She indicated the facility staff did not believe her and the DON and UM both said the narcotic counts were correct. They did not believe us that RN A never came into the room. I asked him (RN A) while he was out at the medication cart around 2 PM if he was going to give mom her medications and he said that he already gave Morphine and then left to speak to a supervisor. She said the experience added to her family's stress and if they had known this was going to happen, they would have kept her at home. The Hospice Services Agreement dated [DATE] read, Facility Interdisciplinary Group means a team of Facility employees will monitor the deliver of the Hospice Services to a Hospice Patient in order to assure that professional standards and principles are followed in the provision of the Hospice Services within the Facility Hospice Plan of Care means with respect to each Hospice Patient, a written care plan .including management of discomfort and symptom relief, appropriate to meet the Hospice Patient's needs and the related needs of the Hospice Patient's family Responsibilities and Services To Be Furnished By Facility. Facility Plan of Care and Facility services .Facility will furnish Facility Services to each Hospice Patient in accordance with the Hospice Patient Facility Plan of Care 105888 Page 5 of 6 105888 05/18/2023 Aviata at St Cloud 4641 Old Canoe Creek Road Saint Cloud, FL 34769

F 0684 Level of Harm - Actual harm .must receive all nursing services as prescribe and must be kept comfortable .shall provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and Facility Plan of Care . Residents Affected - Few 105888 Page 6 of 6