Health inspection·November 20, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide evidence an event was thoroughly investigated in a timely manner, when oxygen tubing was found dislodged from the resident, for 1 of 1 resident investigated for respiratory care (Resident #1). Residents Affected - Few The findings included: Resident #1 was admitted to the facility on [DATE]. He was discharged from the facility to the hospital on [DATE]. Resident #1 had a medical history significant for Respiratory Failure, Tracheostomy and Ventilator Dependent, Spina Bifida, Scoliosis, and Failure to Thrive. A Discharge Return Anticipated Minimum Data Set (MDS) was completed on 10/17/23. A Quarterly MDS was done on 07/31/23. This MDS documented Resident #1 had a Brief Interview of Mental Status score of 15, which indicates he was cognitively intact. This MDS documented Resident #1 was verbal and able to make himself understood. This MDS documented he was totally dependent on staff for his activities of daily living. Review of Care Plans revealed a care plan was written regarding ventilator dependent related to quadriplegia, respiratory failure. The written Interventions included the following: assess Level of Consciousness, cyanosis; call bell within reach; maintain spare trach at the bedside; maintain ventilator settings as ordered; observe for indications of tube obstruction; pulse ox readings every shift or more frequently as needed; observe skin color and capillary refill-notify MD of significant abnormalities or changes from baseline. On the evening of 10/17/23, Resident #1 was found unresponsive in his room. Based on witness statements and witness timelines provided by the facility's Administrator, Resident #1's mother called the facility at around 6:19 PM and asked Staff A, Registered Nurse (RN) to check on Resident #1 in his room. Staff A reported to Resident #1's room and found him to be unresponsive. Staff A left the room to request assistance from Staff B, Respiratory Therapist (RT) and Staff E, Licensed Practical Nurse (LPN). According to Staff B's timeline, he had assessed the patient & gave last [breathing] treatment (Sodium Chloride) at 6:15 PM. According to Staff B's witness statement, on Tuesday evening around 6:20 PM, I was notified by [Staff A] to doublecheck [Resident #1] due to some noise it was making. Instantly I rush to the room and found that the vent indicated low minute volume and the patient HR [heart rate] & FIO2 [oxygen level] went down. I quickly assessed the patient and realized that the adaptor Page 1 of 3 106110 106110 11/20/2023 Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060

F 0610 was kind of off the patient trach. Level of Harm - Minimal harm or potential for actual harm Review of Nurses Notes revealed no notes were written by the nursing staff surrounding the event. One Nurses Note was written on 10/17/23 at 7:10 PM which stated Call placed to mother of resident. Voicemail left as there was no response. A Medication Administration Note was written on 10/18/23 at 10:01 AM which stated hospitalized with no additional information documented. Residents Affected - Few An interview was conducted with the facility's Risk Manager on 11/20/23 at 11:23 AM. She stated she was out of town during the week of the event and that she did not begin her investigation until she returned to the facility on [DATE]. When asked if she had reviewed the nursing notes during her investigation, she stated she, as the risk manager, does not review notes during her investigation, that it is the Director of Nursing's responsibility to conduct a clinical investigation. She stated when she returned to work following the event, she received notes and statements that had been collected by the facility's Administrator following the event. She recalled a [NAME] County [NAME] Officer (BSO) notified the facility that Resident #1 had passed away while at the hospital. An interview was conducted with the facility's Administrator on 11/20/23 at 11:29 AM. She stated her investigation included collecting witness statements and timelines from the beginning of the shift on 10/17/23. She said in her investigation, she decided to send the pulse ox machine and ventilator back to the companies for event traces to be downloaded. She said this would assist her in finding out if there was a machine malfunction. However, at the time of this survey, 11/20/23, she had not received this information from either company. She stated this was why her investigation was ongoing. An interview was conducted with the facility's Director of Nursing (DON) on 11/20/23 at 2:27 PM. She stated she was new to the facility and that she started after Resident #1's event. She stated the previous DON had done a partial investigation and that she had continued with her own investigation of the event. She stated that she had conducted in-services with the staff and that a drill had been done with the staff as well. The surveyor asked her if any mock code drills had been done with the staff and she said yes, one mock code had been done. When asked if she felt that one mock code drill in a month since the incident was sufficient for the staff, she stated, no and then also said it's a work in progress. An interview was conducted with the facility's Administrator on 11/20/23 at 2:30 PM. She stated the previous DON had conducted a table-talk type of in-service with the staff the day following the event. She stated they initially were waiting for Resident #1 to return to the facility but that on 10/24/23, a Child Protective Services investigator and a [NAME] County [NAME] arrived at the facility to conduct an investigation. She stated, I wasn't even going to report it to AHCA until they arrived, then I figured AHCA would want to know. She stated the ventilator went with Resident #1 to the hospital and she was unable to retrieve the ventilator from the hospital until 10/27/23. She said that she then contacted the ventilator company to have the data analyzed. When asked if a Root Cause Analysis was completed, she stated the surveyors would have to talk to the Risk Manager who had already left the facility for the day. She stated that herself, the Risk Manager, the current and the previous DONs, and the Medical Director had all performed investigations regarding this event along with the Child Protective Services investigator and the [NAME] County [NAME]. The surveyor explained that the concern was that so many investigations were being conducted but that none had been completed and none had concluded what the root cause of the event was. When asked if she could provide the investigations conducted by the others, she did not respond. A telephone interview was conducted with the facility's Risk Manager on 11/20/23 at 4:14 PM. She 106110 Page 2 of 3 106110 11/20/2023 Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060

F 0610 confirmed that a Root Cause Analysis was not completed and that she was still waiting for the data download information from the ventilator company before she could finalize her investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106110 Page 3 of 3