Health inspection·May 16, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and staff interviews, the facility failed to have processes in place to ensure an accurate evaluation of cognitively impaired residents upon admission to accurately reflect smoking status and implement adequate interventions to prevent avoidable accidents related to smoking for 1(Resident #999) of 4 newly admitted residents. The findings included: A review of Resident #999's clinical record documented an initial admission to the facility on 3/4/23. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, alcohol abuse and schizoaffective disorder. The smoking evaluation completed on 3/4/23 noted the resident was not able to light the cigarette safely, smoke safely, or utilize ashtray safely and properly. The resident was not able to extinguish the cigarette safely and completely. The evaluation documented in comments, Resident chooses not to smoke at this time due to respiratory condition and use of oxygen. Declines patch at this time. The rest of the evaluation was not completed since the resident chose not to smoke at this time. Resident #999 was discharged from the facility on 3/27/23, return not anticipated. The hospital history and physical dated 4/5/23 noted Resident #999 was admitted to the hospital on [DATE], and noted the resident had a 50-year smoking history and almost daily alcohol however unknown amount. Reports he is still smoking. The facility record showed the resident was admitted to the facility on [DATE] from the acute care hospital. The clinical record revealed an admission Data Collection signed on 4/14/23 at 9:56 p.m. The nurse completing the admission data collection noted the resident's level of consciousness as lethargic. The resident was oriented to person and place. The data collection form also noted the Resident was on continuous use of 4 Liters(L) of oxygen via nasal cannula. In the hot liquid risk indicators section, the nurse checked Yes noting the resident had severe cognitive impairment or no safety awareness or Brief Interview for Mental Status score of less than 8. Page 1 of 3 105983 105983 05/16/2023 Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232

F 0689 In the elopement risk evaluation section of the form, the nurse checked Yes to the following questions: Level of Harm - Minimal harm or potential for actual harm 1. Is the resident cognitively impaired? Residents Affected - Few 2. Does the resident have poor decision-making skills? In the safety section of the form, the nurse entered No to the question: 1. Does the resident smoke (including electronic cigarettes)? The clinical record contained a copy of the facility policy/procedure, Resident Smoking dated and signed by Resident #999 on 4/14/23. The progress note dated 4/15/23 at 8:41 p.m., documented Education not provided. Resident is sleeping and does not interact . Oxygen is used via nasal cannula 4L (liters). The progress note dated 4/15/23 at 11:36 p.m., noted the resident was lethargic but pleasant and cooperative early in the shift, but became increasingly angry when they administered his intravenous antibiotic at 10:00 p.m. On 4/16/23 at 4:42 p.m., the nurse documented, Resident #999 was observed in his room by his Certified Nursing Assistant standing by the bathroom door with a lit cigarette in his mouth. The resident was using oxygen via nasal cannula. The cigarette and lighter were taken from the resident and he was advised that smoking was not allowed in the room. A review of the incident note dated 4/17/23 at 7:45 a.m., documented the nurse and the Administrator in Training spoke to Resident #999 regarding the incident on 4/16/23 and his noncompliance following the facility's smoking policy. Verbal consent was obtained from the resident to search his room/person and belongings for any smoking material, and none was found. They specifically discussed safety issues related to smoking in the facility and the immediate danger it poses to himself other residents and staff especially with the use of oxygen. The smoking policy was resigned by the resident and a new smoking evaluation completed. On 5/15/23 at 9:50 a.m., the Director of Nursing (DON) said Resident #999 was a smoker who used oxygen but was forgetful and did not understand the smoking rules. The DON said we had the resident sign the smoking policy at admission and he signed another one on 4/17/23. On 5/15/23 at 11:05 a.m., the DON said, when Resident #999 was admitted the nurse asked if he was a smoker and he said no. He came from the hospital, and they did not search the resident or his belongings. They did not know he had cigarettes on him. The DON was not able to locate an inventory of the resident's possessions at the time of admission 105983 Page 2 of 3 105983 05/16/2023 Harborview Sarasota 4783 Fruitville Road Sarasota, FL 34232

F 0689 which could have identified the smoking materials. Level of Harm - Minimal harm or potential for actual harm On 5/15/23 at 2:00 p.m., the DON said the facility's process for identifying smokers was to ask the resident or family upon admission. She said the nurse was responsible for reviewing all the information from the hospital if available when the resident is admitted . The DON confirmed the facility had no policy for completion and accuracy of the admission assessment when a resident is cognitively impaired and said the admitting nurse should have read the hospital's record and use the information in the admission evaluation. The DON said Resident #999 denied smoking at admission on [DATE] but the admitting nurse failed to read the hospital history and physical identifying the Resident was still smoking. Residents Affected - Few 105983 Page 3 of 3