Health inspection·January 16, 2020

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide vision services in a timely manner for 1 (Resident #22) of 1 resident sampled for vision. Residents Affected - Few The findings included: During the initial screening process, on 1/13/20 at 10:37 a.m., Resident #22 revealed, he did not have his glasses, and he did not have money to go to an eye doctor. He said he had told everybody he had blurry vision and stated, I'm not going to say who I told. On 1/15/20 at 4:31 p.m., during an interview with Resident #22 he said he had no trouble seeing the television but, he needed glasses for reading. He said he had left eye cataract surgery years ago but couldn't recall how long ago he had the surgery. He said he never went back for treatment for the right eye because of cost. Resident #22 said his sight was blurred because he had fallen many times and hit his head. Observed a pair of reading glasses in a case on his bedside table. He said the glasses were given to him by the facility staff. He said the glasses helped him a little, but he still couldn't see clearly with them, and still had blurry vision. When asked if staff knew he was having trouble with his vision, he said he thought he told the Social Worker, but he didn't want to discuss further. In an interview on 1/15/20 at 4:34 p.m., the Social Worker said she was not aware the patient had blurry vision and needed prescription glasses but would discuss that with him to arrange services. In an interview conducted on 1/15/20 at 4:41 p.m., Speech Language Pathologist, (SLP), Staff B revealed Resident #22 received services two times per week. She also said she discussed the patient vision issue with the Rehabilitation Manager (RM). Staff B also said she had done the initial assessment of Resident #22. She provided copies of Speech Therapist (SP) Treatment Note records that detailed the patient's visual limitations. In an interview conducted on 1/15/20 at 5:00 p.m., the RM, said she personally discussed Resident #22 blurry vision with the Interdisciplinary Team, (IDT) during a meeting on 12/5/19. She said she believed the Medical Director (MD), spoke with resident regarding his vision issue. The RM said she thought this issue was resolved and the resident was capable of reading and signing forms. The resident was offered vision reading glasses on 12/13/19, but she did not have a record of the outcome. Record review revealed, from the SLP Preadmission Screening Form dated on 12/04/19, Resident #22 reported blurry vision and listed for impaired vision. Record review from the SP Daily Treatment Note dated on 12/10/19. The resident could read a medium Page 1 of 4 106122 106122 01/16/2020 Gulf Coast Medical Center Skilled Nursing Unit 13960 Plantation Road Fort Myers, FL 33912

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few size bold print font. The resident could use a calendar 70% with accommodations (likely due to impaired vision). The patient was encouraged to continue using personalized visual aids and call button for safety and fall prevention. Record review revealed a physician order dated on 12/10/19, to set up appointment for Optometry to evaluate vision and make recommendation. The Physician listed as a Special Instruction; resident complained of blurry vision, had history of cataracts, but he thought this happened when he hit his head before admission. Record review, from the SP Daily Treatment Note dated on 12/12/19 written by SLP Staff E stated PT (patient) unable to benefit from visual aids d/t (due to) low vision. On 12/16/19 SLP Staff C wrote SLP read short stories aloud given poor vision. Dated on 12/17/19 written by Staff E said Pt (patient) shares he will need an eye appointment once he does have some income to enhance vision as he cannot reading pertinent and functional info at this time (medication labels, nutrition labels, menus etc.) Same SLP note written on 12/19/19 said Pt (patient) able to complete calendar reading tasks (large print) with 90% with acc (accommodations) w/o (without) cues. Note dated on 12/28/19 written by SLP Staff D. She said the patient tries to write notes to self, but said his vision makes it difficult to see (cannot read medicine bottle 'my eyes done gone blurry'). Pt (patient) has readers and reported they help if 'I hold up close'. Pt (patient) said he does not have time to get an appointment with eye doctor. Noted by therapist during this session; Pt (patient) given real life scenarios to apply strategies and due to vision problems visual and written strategies are not ideal. The Minimum Data Set (MDS), dated on 12/7/19 revealed: * Section-B, Hearing, Speech, Vision. Adequate-sees fine detail, such as regular print in newspapers/books, Corrective lenses indicated (No) * Section-C, Cognitive Patterns Brief Interview for Mental Status. (BIMS) Summary Score 15. The total possible BIMS score ranges from 00. To 15. 13-15: cognitively intact. 08-12: moderately impaired. Progress note dated 1/16/20 noted the resident had a future scheduled appointment on 1/21/20 at 3:30 p.m. foe an eye exam with an Optometrist. The vision was not addressed in the revised care plan on 12/16/19 On 1/16/20 at 1:33 p.m., in an interview Register Nurse (RN)/MDS Nurse Staff G said she looked at the nursing admission observations to write and code the resident's MDS. She said she reviewed the admission assessment by the nurse, and it was documented no vision issues. The admitting nurse enters the care plan information. The MDS nurse adds more information into the care plans. Staff G produced an order for vision testing on the 10th. She said the care plan should have been revised on the 12/16/19. In an interview on 1/16/20 at 2:00 p.m., the DON verified it was a problem the order was written and the appointment was scheduled so long ago. She said the resident was a charity case and it was 106122 Page 2 of 4 106122 01/16/2020 Gulf Coast Medical Center Skilled Nursing Unit 13960 Plantation Road Fort Myers, FL 33912

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few difficult to find provider that the resident would follow-up with. She said they made accommodations within the building for the patient to read. In an Interview on 1/16/19 at 2:16 p.m., with the RM and Staff E, Staff E explained the external visual aids used for the patient were use of white board, large magnifying glass, large and bold print, and an iPad application that uses auditory stories. Staff E said she had communicated with the nursing staff regarding the patient's vision problems but not with the social worker. She was aware the resident's vision was discussed at the IDT meeting. In an interview on 1/16/20 at 5:41 p.m., the DON said the doctors orders should have been followed. 106122 Page 3 of 4 106122 01/16/2020 Gulf Coast Medical Center Skilled Nursing Unit 13960 Plantation Road Fort Myers, FL 33912

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to ensure physician orders were transcribed correctly for 1 (Resident #149) of 5 residents reviewed for unnecessary medications, which caused the resident to receive medications every 6 hours for 3 days instead of as the resident needed as ordered by physician. Residents Affected - Few The findings included: Policy review of Medication Administration and Documentation (policy #371) last revised on 8/19 records that the purpose is to provide safe and accurate medication administration. Item A-5 records As-needed (PRN) medications are to be administered for their specified indication(s). Clinical record review for Resident #149 on 1/15/20 at 10:37 a.m., showed the resident had an order written 1/12/20 for Motrin IB (ibuprofen) over the counter (OTC) tablet: 200 mg give two tablets every six hours as needed for severe pain. On review of Resident's Medication Administrator Record (MAR) showed the physician order was place on the record to be given by nurses every six hours around the clock at midnight, 6:00 a.m., 12:00 p.m., and 6:00 p.m. This medication was given to the resident as routine and not as resident needed it or asked for it. Black Box Warnings for Ibuprofen out lines that medication has cardiovascular risk, Gastrointestinal risk if taken on a regular basis. This medication should be avoided or withdrawn whenever possible. On 1/15/20 at 10:30 a.m., in interview withthe nurse, Staff F said Resident #149 was admitted with back pain. She said there was no pain evaluation in the MAR. She said that it appeared that the order in the computer did not have the option to monitor for pain with the medication and the 2-tablet order for Motrin IB was put in as every 6 hours even though the order was for it to be given as needed. On 1/16/20 at 2:05 p.m., the Director of Nursing acknowledged that the order for Motrin IB (ibuprofen) had been transcribed wrong on the MAR and the Resident was receiving the medication every six hours. She said because it was scheduled and not as needed it did not give nurse opportunity to evaluate the pain level. She said that the nurse who took off the medication order did not insure the as needed button PRN was marked and that is why it was put on the MAR as scheduled to be given every six hours. On 1/16/19 at 2:22 p.m., Medical Director acknowledged that resident #149 should not have been receiving the Motrin IB every six hours 106122 Page 4 of 4