Health inspection·April 20, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders, for 1 (Resident #251) of 1 resident reviewed. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or an increased risk of respiratory complications. Residents Affected - Few The findings included : Facility policy titled Oxygen Administration, Revised October 2010, stated the purpose of the procedure was to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. A review of the medical record revealed Resident #251 was admitted to the facility on [DATE] with diagnoses including Asthma, and Chronic Obstructive Pulmonary Disease. The physician's orders dated 4/6/23 included to administer oxygen at three liters via nasal cannula every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's cognition was severely impaired. Resident #251 required extensive assistance of staff for all activities of daily living, including bed mobility and transfer. On 4/18/23 at 3:50 p.m., Resident #251 was observed sitting in a recliner. The oxygen concentrator was set on two liters and the nasal cannula was draped across the bed. Resident #251's wife said the oxygen was new since being in the hospital and Resident #251 was to wear it all the time. On 4/19/23 at 10:07 a.m., Resident #251 was observed in bed wearing the nasal cannula. The oxygen concentrator was set at two liters. On 4/19/23 at 1:21 p.m., resident #251 was observed sitting in his recliner wearing his oxygen. The oxygen concentrator was set at two liters. Page 1 of 4 106108 106108 04/20/2023 Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113

F 0695 Level of Harm - Minimal harm or potential for actual harm The Director of Nursing (DON) confirmed the concentrator was set on two liters. She said the concentrator should be set at three liters as ordered by the physician. On 4/19/23 at 4:24 p.m., Registered Nurse (RN) Staff C, stated the nurse is to check the residents oxygen level/setting at the start of each shift. She did not realize the oxygen was at two liters. Residents Affected - Few 106108 Page 2 of 4 106108 04/20/2023 Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, record review, staff and resident interviews, the facility failed to ensure 1 ( Resident #22), of 2 residents with bed rails were assessed for alternative interventions prior to the use of bed rails. The facility failed to provide documentation they had informed the resident and/or their representative of the risks and benefits of bed rails, obtain an informed consent prior to use of the bed rails and to conduct periodic maintenance of the bed rails to ensure they remained safe for residents use. The findings included: The facility's policy titled Bed Safety and Bed Rails, Revised August 2022 policy stated, Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The Facility Policy interpretation and implementation further describes the circumstances for bed rail use. In total, 11 items are identified prior to use of bed rails. The residents sleeping environment is evaluated by the interdisciplinary team; Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; Regardless of the mattress type, width, length and or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a residents head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; The use of bed rails or side rails, including temporarily raising the side rails for episodic use during care is prohibited unless the criteria for use of bedrails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include, roll guards, foam bumpers, lowering the bed or the use of concave mattresses to reduce rolling off the bed. On 4/17/23 at 3:08 p.m., Resident #22 was noted to have quarter side rails elevated on both sides of the bed. On 4/18/23 at 3:59 p.m., Resident #22 stated she did not request side rails, they were on the bed when she was admitted . Both side rails were noted in the up position. Resident #22 stated she was not asked if she wanted them, no alternatives were attempted and did not sign any paperwork requesting side or bed rails. On 4/19/23 at 10:13 a.m., The Rehabilitation Director stated over the past three weeks, they began to assess new admissions to see if the resident would benefit from the use of side rails. Residents 106108 Page 3 of 4 106108 04/20/2023 Oakton Place Health and Rehabilitation at the Arli 8000 Arlington Circle Naples, FL 34113

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few are not assessed for any interventions prior to requesting maintenance install the side rails. Resident #22 had not been assessed. On 4/19/23 at 10:44 a.m., the Director of Facility and Property Management stated the maintenance department does not check for entrapment or assess beds for side rails. Their only role is to put the rails on or take them off. The nursing department will make a maintenance request through the TELS system ( a system designed to enter and track maintenance requests) to either install or remove the bed rails. If there is not a nursing request entered through TELS, we do not touch them. On 4/19/23 at 1:35 p.m., the Director of Nursing (DON) stated the therapy department would complete an evaluation and indicate if the resident would benefit from side rails. If so then the nursing department will obtain a physician order, provide education to the resident and family to obtain their consent for the use of rails and understanding the risks associated with side rail use. The nurse will assess the mobility, purpose of the rails and make a determination if the side rails were indicated for the resident. It is therapy that determines what interventions would be attempted prior to side rails. The Director of Nursing confirmed Resident #22 did not have a consent or education regarding the safety and risks associated with bed rails until 4/19/2023. Alternative interventions had not been attempted and the resident bed had not been assessed for areas of entrapment. On 4/19/23 at 2:12 p.m., During a follow up interview, the facility Maintenance Director stated his department is only responsible for getting the work order and either installing or removing the bed rails. Maintenance does not do any assessment, evaluation or periodic inspection of the rail once installed. The maintenance director stated he did not have any history of requesting the side rails be installed or removed from the bed for Resident #22. Reviewed bed rail policy, which stated maintenance staff routinely inspect all bed and related equipment to identify risks and problems including potential entrapment risks. Maintenance director stated we do not do that. On 4/20/23 at 10:52 a.m., Licensed Practical Nurse (LPN) Staff A, stated we used to get consents signed for everyone when a resident was admitted . Recently side rail use has been decreased so we don't offer siderails. The rails used to stay in place when a resident was discharged , but since the new company has taken over the process has been changed. On 4/20/23 at 10:57 a.m., Certified Nursing Assistant (CNA) Staff D, stated if a resident is assisted back to bed the side rails are placed in the up position. On 4/20/23 at 11:03 a.m., Certified Nursing Assistant (CNA) Staff G, stated when a resident is in bed the side rails are placed in the up position. On 4/20/23 at 12:39 p.m., the Assistant Maintenance Director stated an outside provided the facility with an annual assessment of facility equipment completed in October 2022, which included the beds for safety. The audit does not address specific resident needs or interventions for side rail use. The beds are assessed for safety and function but are not assessed for side rails, fit, gaps or compatibility with different mattresses. On 4/20/23 at 12:51 p.m., the Director of Nursing confirmed Resident #22 did not have a consent or education regarding the safety and risks associated with bed rails until 4/19/2023. Alternative interventions had not been attempted and the resident bed had not been assessed for areas of entrapment. 106108 Page 4 of 4