Health inspection·December 18, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 1 of 3 residents reviewed for Dialysis received timely care and services to mitigate the risk for development of serious complications, from a total sample of 5 residents, (#3). Residents Affected - Few Findings: Review of the medical record revealed resident #3, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included end stage renal (kidney) disease, dependence on renal dialysis, myocardial infarction, congestive heart failure, severe cardiomyopathy, atrial fibrillation, chronic pulmonary edema, and type 2 diabetes mellitus. On 12/08/23, four days after admission, the resident required re-hospitalization, and was readmitted back to the facility on [DATE] with additional diagnoses that included metabolic encephalopathy (biochemical brain dysfunction), and hyperkalemia (high Potassium). The Minimum Data Set (MDS) 5-day/Discharge Return Not Anticipated Assessment with Assessment Reference Date (ARD) 12/08/23 noted the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively intact. The assessment showed there were no behavioral symptoms or rejections of evaluation or care. The assessment noted the resident required partial assistance from staff for mobility and to complete Activities of Daily Living (ADLs), was frequently incontinent of bladder and bowel functions, and he received hemodialysis during the look back period. The Care Plan showed there were Focus items for altered cardiovascular status, defibrillation/life vest, and ADL self-care performance. The plan of care did not include a focus item for Dialysis. The Order Summary Report showed physician's orders were entered on 12/04/23 for dialysis treatments with an 8:15 AM pick up time every Tuesday, Thursday, and Saturday, a specialized dialysis diet, fluid limits, and included the medications, Sevelamer HCI 3200 Milligrams (MG) with meals for hyperphosphatemia (electrolyte disorder), and Allopurinol 100 MG once daily for gout. On 12/05/23, the physician ordered STAT (immediate) laboratory tests of the resident's blood potassium level that read, high potassium level before dialysis. On 12/18/23 at 9:48 AM, resident #3 was observed lying awake and lying in bed. He recalled he experienced problems with getting dialysis approximately 2 weeks prior because his ride didn't show up and he had to go to the hospital. Review of a Nurses Progress Note completed by Licensed Practical Nurse (LPN) D on 12/05/23 at 3:30 PM read, Resident lab results reviewed Potassium 6.3 and BUN (blood, urea, nitrogen) 80. NP (Nurse Page 1 of 4 105987 105987 12/18/2023 Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837

F 0698 Level of Harm - Minimal harm or potential for actual harm Practitioner) (Advanced Practice Registered Nurse (APRN) I) notified and order to repeat labs when the resident return (returns) back from dialysis. Resident currently at dialysis. A Nurses Progress Note completed by the LPN on 12/07/23 at 5:39 PM read, Resident did not go to dialysis this morning because of transportation cancellation, dialysis center notified, NP (APRN I) notified and order to send patient to hospital for dialysis, resident and family member notified. Residents Affected - Few In an interview on 12/18/23 at 12:50 PM, LPN D recalled resident #3 had unstable Potassium levels, and he had missed dialysis on 12/7/23. She explained there had been problems with the resident's transportation arrangements and he wasn't picked up. She said she reported the incident to APRN I who was concerned because the resident had a history of high potassium, and she told her she wanted the resident to go to the hospital to ensure he received treatment. The LPN said APRN I told her, This cannot wait until tomorrow. Review of the SNF (Skilled Nursing Facility) / NF (Nursing Facility) to Hospital Transfer Form noted on 12/07/23 at 2:00 PM, LPN D contacted the hospital emergency room to report resident #3's expected arrival. On 12/18/23 at 1:29 PM, the Assistant Director of Nursing (ADON) recalled she assisted nurses with resident #3's missed dialysis incident on 12/07/23. She said on 12/07/23, she arranged non-emergency transportation via telephone and email with the ambulance service. She explained when she left the same day at approximately 6:00 PM, she expected the resident would be picked up by 11:00 PM. Review of a Skilled Nursing Note completed by LPN C on 12/07/23 at 5:38 PM did not note the resident was awaiting transportation to the hospital for dialysis. On 12/18/23 at 3:15 PM, an unsuccessful attempt was made to interview LPN C by telephone. In a telephone interview on 12/18/23 at 1:50 PM, LPN F recalled she had resident #3 on her assignment during the 3:00 PM to 11:00 PM shift on 12/07/23. She explained by the end of her shift, the resident had not been picked up and she was concerned because the nurse from the previous shift reported the APRN expressed urgency and didn't want the resident to wait because he was high risk with unstable potassium. She said she reported to the oncoming 11:00 PM to 7:00 AM nurse, Registered Nurse (RN) G that she needed to call and check on the transportation status and notify the provider if the resident did not get transported to the hospital soon. On 12/18/23 at 2:00 PM, the ADON explained RN G was not available for an interview as she was out of the country and could not be reached. On 12/18/23 at 1:29 PM, the ADON explained when she returned to work on 12/08/23, the next morning she found that resident #3 had not been transported and was still at the facility. She stated she was concerned because she knew APRN I was concerned about the resident's unstable potassium level, and she didn't want him to wait that long. She explained nurses contacted APRN H and obtained orders to send the resident by emergency/911 to the hospital. On 12/18/23 at 4:15 PM, in a telephone interview with the non-emergency ambulance provider, the Supervisor checked their records for resident #3's service request on 12/07/23. The Supervisor explained the record showed there was a request made at 1:30 PM and the service was placed in a pending status that the facility was supposed to call with further information and at that time, a pickup time would have been provided. He said their records indicated they were not contacted by the facility 105987 Page 2 of 4 105987 12/18/2023 Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837

F 0698 again until 10:00 AM on 12/08/23. Level of Harm - Minimal harm or potential for actual harm Review of a Nurses Progress Note completed by LPN C on 12/08/23 at 11:00 AM read, Resident transferred to (name) hospital for dialysis via 3 (county name) fire rescue/911. Residents Affected - Few The hospital's (provider name) Kidney Specialists physician report dated 12/08/23 documented the resident missed dialysis while at the facility due to transportation issues with treatment plans for rehospitalization with diagnoses that included acute hyperkalemia with treatment plans that read, . arrange for hemodialysis to correct electrolyte abnormalities and to mobilize fluid. The Order Summary Report noted on 12/11/23, after the resident returned from the hospital, physicians ordered the additional medications, Metoprolol Succinate ER 25 Milligrams (MG) once daily for high blood pressure, and Apixaban 5 MG twice daily for clot prevention. On 12/18/23 at 1:29 PM, the ADON explained she expected nurses to contact the provider when there was a delay with physician's order implementation. She was informed that a review of resident #3's medical record had not revealed evidence that the 3:00 PM to 11:00 PM nor 11:00 PM to 7:00 AM nurses checked on the resident's transportation status or contacted the physician. She stated she did not know why nurses had not followed up, and said, they should have called. On 12/18/23 at 3:48 PM, the Director of Nursing (DON) explained she remembered on 12/07/23 at approximately 10:00 PM, she noticed resident #3's medical record showed he had not been transported to the hospital after his missed dialysis visit. She said she spoke to APRN H on the telephone, who told her the resident could wait until the following morning because dialysis wasn't done overnight in the emergency room. On 12/18/23 at 4:10 PM during a telephone interview, APRN H recalled the morning of 12/08/23, she received a telephone call from the DON who reported resident #3 had missed dialysis the prior day, was still at the facility, and they were still awaiting non-emergency transportation. She said she knew the resident's history and was concerned because dialysis had already been delayed by over 24 hours, and the emergency department process typically took several hours. She explained dialysis treatments were further delayed overnight which placed the resident at risk for serious complications. She said she was certain her conversation with the DON occurred the morning of 12/08/23. She stated she gave orders for the resident to be transported by 911 to ensure he arrived at the hospital timely. On 12/18/23 at 2:09 PM, during a joint telephone interview with APRN I and resident #3's Primary Care Physician (PCP), the APRN said she was familiar with resident #3. She recalled on 12/07/23 she was contacted by a nurse who informed her the resident had missed dialysis. She explained she told the nurse the resident could not wait until the next day because his Potassium level was elevated. She said she expected the resident would go to the hospital the same day, and she was not informed of the delay and need for 911 intervention. The PCP explained, nurses waited a few hours, the ambulance hadn't arrived, and the resident required emergency hospital services. He added, We can't make the nurses do what they are supposed to do. On 12/18/23 at 5:00 PM, the Regional Clinical Director said the facility did not have standards and guidelines related to provision of care and services to ensure dialysis treatments and/or transportation services were provided. Review of the facility's standards and guidelines titled Dialysis revised 6/23/15 read, PURPOSE To 105987 Page 3 of 4 105987 12/18/2023 Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitor and care for Hemodialysis Residents in the skilled nursing facility. The standards and guidelines titled Physician Orders revised 10/24/17 read, PURPOSE Physician orders are obtained to provide a clear direction in the care of the resident. The Facility Assessment Tool reviewed 10/17/23 read, . 3.7 Standards and Protocols The Management and staff familiarize and review what is expected from the medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and types of support and care need for the resident population . 105987 Page 4 of 4