Health inspection·March 28, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and facility policy and medical record review the facility failed to implement adequate individualized interventions to prevent falls, including fall with major injury for 1 (Resident #43) of 4 residents reviewed for falls. The findings included: Review of the facility Policy titled Incident Management (no initiation date) stated, An incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may involve an injury or damage to property. Incidents/accidents to be recorded, using the incident report form, and reported according to the Reporting Guidelines include but not limited to falls/found on floor. Review of the facility Policy titled Risk Management - Post Incident Evaluation, Root Cause Analysis and Plan (no initiation date) stated, The facility will use a consistent approach for post incident evaluations which will include a thorough investigation to determine how and why the incident occurred. Root Cause Analysis is a process for identifying the basic or contributing causal factors that are responsible for incidents. Root causes will guide changes in systems or processes to reduce the risk of the event recurring. Post Incident Evaluation includes Immediately following any incident - actions to support resident safety will be the priority. For falls, the Fall Risk Reduction Program will be followed to include post fall intervention and care; Incidents will be recorded according to policy; Incidents will be reported according to the reporting guideline. The Risk Manager or designee will be notified per the reporting guidelines and will be responsible for investigating and reporting any allegations of abuse, neglect, exploitation, injuries of unknown origin and or any adverse incidents as defined by State or Federal Regulation according to facility policy. Review of the clinical record for Resident #43 revealed a date of admission of 9/28/2023. Diagnoses included Cerebral Infarction (stroke), Aphasia (language disorder), Dysphagia (swallowing disorder), and Osteoarthritis. Resident #43 shared a room with his wife (Resident #37). Review of the significant change in status Minimum Data Set assessment dated [DATE] noted Resident #43 was cognitively impaired and unable to answer questions with a Brief Interview for Mental Status (BIMS) score of 99. The assessment noted Resident #43 had short term and long term memory problems. A check mark on the assessment noted Resident #43's cognitive skills for daily decision making were moderately impaired-decisions poor, cues/supervision required. Page 1 of 4 106098 106098 03/28/2024 Hawthorne Center for Rehab & Healing of Sarasota 5381 Desoto Road Sarasota, FL 34235

F 0689 The fall risk evaluations completed on 9/28/23, 11/16/23, 11/24/23, 1/2/24 and 1/19/24 noted Resident #43 was at moderate risk for falls. Level of Harm - Actual harm On 1/23/24, 2/17/24 and 3/13/24 the fall risk evaluations noted Resident #43 was at high risk for falls. Residents Affected - Few The care plan created on 9/29/23 noted Resident #43 was at risk for falls due to having decreased mobility with weakness secondary to a CVA. The goal was for the resident not to sustain serious injury. The interventions dated 9/29/23 included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Review of Resident #43's care plan initiated on 10/10/23 noted the resident had impaired cognitive function/dementia or impaired thought process related to disease process, CVA (cerebrovascular accident). Review of Fall Investigations and Incident Log revealed Resident #43 sustained a fall on 11/16/23, 11/24/23, 1/19/24, 2/17/24 and 3/13/24. Review of the nursing progress note dated 11/16/23 noted Resident #43 complained of right side back pain. During assessment Resident #43 was observed to have a big bruise to the right side of the back and the back side of the right upper arm. The resident was nonverbal and not able to explain what happened. The resident's wife said on 11/13/23 Resident #43 was trying to get out of bed by himself and fell from the bed. He hit his back with the bed edge but did not hit his head. She did not call for assistance, she helped him off the floor and did not report the fall to anyone. The fall care plan updated on 11/17/23 noted Resident #43 had a fall on 11/13/23. The interventions listed were laboratory work and therapy to screen. Educate wife to inform if resident has falls and/or injury. Bruise to his back. The care plan did not include the result of the therapy screen or measures to prevent further falls. On 11/24/23 at 12:46 p.m., a nursing progress note documented Resident #43 was sent to the hospital after an unwitnessed fall in his room. The resident's wife said he hit his head. Blood was coming out, from the inside of his right ear. On 11/24/23 at 5:16 p.m., a nursing progress note documented Resident #43 came back from the hospital at approximately 3:00 p.m. with sutures. On 11/25/23 at 11:04 a.m., a nursing progress note documented the resident's right ear continued to 106098 Page 2 of 4 106098 03/28/2024 Hawthorne Center for Rehab & Healing of Sarasota 5381 Desoto Road Sarasota, FL 34235

F 0689 bleed, blood-saturated gauze changed to right ear . Level of Harm - Actual harm The fall care plan was updated on 11/27/23 noting Resident #43 had a fall on 11/24/23. The new intervention was to post environmental cues call don't fall in Spanish. Therapy to screen. Resident #43 was sent to the emergency room due to a laceration to his right ear. Residents Affected - Few On 1/19/24 at 7:23 a.m., a nursing progress note documented at 6:20 a.m., the nurse was called to Resident #43's room. The resident was lying on the floor in front of the clothes closet over the right side of his body, right arm, and right shoulder. The resident denied any pain, was able to move all extremities, no deformity of hip, legs, arm even shoulder. Per the wife Resident #43 got out of bed walking to the door without his walker, shoes and non sole sock. Small laceration was noted to the left eyebrow. The resident was assisted back to bed. On 1/19/24 at 9:08 a.m., a nursing progress note documented the nurse was called to Resident #43's room. The resident was sitting on the toilet, complained of pain to the left hip with the left hip bone protruding. Resident #43 was sent to the emergency room for evaluation and treatment. Review of the hospital progress note dated 1/20/24 revealed Resident #43 was diagnosed with a nondisplaced Acetabular (hip socket) fracture, left shoulder dislocation, and multiple pubic rami (bones that make up the pelvis) fractures. Review of the root cause analysis worksheet for the incident noted the root cause of the fall was the resident did not use his walker, not fully aware of his physical limitations and need for walker, and impaired cognition. On 1/22/24 the fall care plan was updated and noted Resident #43 was readmitted with the multiple fractures and left shoulder dislocation. The goal was for the resident to remain free from complications related to the fracture. The new interventions included floor mats when in bed, modify environment as needed to meet current needs: Non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, adequate glare-free light. On 2/17/24 at 1:37 a.m., a nursing progress note documented Resident #43 was observed lying face down on the floor with his head nearer to the lower quarter of the bed. The resident was barefoot. The outer aspect of right eye sclera (white of the eye) was red. On 2/19/24 the care plan was updated with interventions to obtain a left hip X-ray, toilet the resident upon rising, before or after meals, at bedtime and as needed. On 3/13/24 at 3:36 p.m., a nursing progress note documented per Resident #43's wife, the resident was sitting in a wheelchair close to the bed without his walker. The resident walked to the door of the room and returned. When trying to go back to bed, lost his balance, slid out of the bed over his knee with half of his body over the bed. On 3/14/24 the care plan was updated to obtain laboratory work and neurological checks were 106098 Page 3 of 4 106098 03/28/2024 Hawthorne Center for Rehab & Healing of Sarasota 5381 Desoto Road Sarasota, FL 34235

F 0689 initiated. Level of Harm - Actual harm On 3/25/24 at 11:10 a.m., observed Resident #43 sitting in wheelchair in the common area with other residents monitored by staff. Residents Affected - Few On 3/27/24 at 11:30 a.m., Resident #43 and his wife were observed sitting in their room located down the hall from the nursing station with the call light on. On 3/27/24 at 11:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said Resident #43 has had multiple falls, including a fall with injury. She said she frequently took care of Resident #43 since he only spoke Spanish and she spoke Spanish. She said Resident #43 shares a room with his wife who is wheelchair bound and requires assistance with activities of daily living. She tries to take care of him and help him instead of calling for help. On 3/27/2024 at 3:00 p.m., in an interview the Risk Manager said Resident #43 fell and was a stubborn man. She said the fall was investigated the day of the fall (1/19/24), his wife witnessed the fall. She said the wife told the nurse that the resident got up and walked without his walker with no shoes on. The resident was placed back in bed by two staff members, no pain or sign of injury were noted. She said three hours later the resident was found sitting on the toilet by the CNA (Certified Nursing Assistant) who noticed his left hip protruding. She did not know if the injury was from the original fall or if the resident fell again. The fall investigation did not have documentation of any timed or signed interviews. She said after the facility investigation the IDT (Interdisciplinary Team) met the next morning and decided the accident, was not preventable, was not considered neglect or abuse so was not a reportable incident. She said the resident had his wife (Resident #37) in his room to help look after him. She said the wife was not employed by the facility and was not responsible for his safety. Review of Resident #37's clinical record revealed a Quarterly Minimum Data Set assessment dated [DATE] which noted the resident's cognition was moderately impaired with a BIMS score of 09. On 3/28/2024 at 4:00 p.m., in an interview the Administrator said he did not see falls as abuse or neglect because it was not an injury of unknown origin. When asked if the investigation was thorough, since it was based on the statement from another resident with a BIMS score of 9, he said it could have been better. 106098 Page 4 of 4