Health inspection·August 3, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to follow the Person-Centered Comprehensive Care Plan for one resident (#2) out of four sampled residents related to performing weights as ordered and medication administration as ordered. Findings included: Resident #2 was admitted on [DATE] and discharged on 06/16/2023. Record review showed diagnoses, included but were not limited to, urinary tract infection, diabetes hypertension, hypertension with chronic kidney disease with Congestive Heart Failure (CHF), atrial fibrillation (A-fib), hypothyroidism, pulmonary hypertension, and metabolic encephalopathy. Review of the admission Minimum Data Set (MDS), dated [DATE], showed he had Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). He required extensive assistance of two for bed mobility, transfers and toileting. Section J showed he had shortness of breath on exertion. A record review of the care plans showed risk for decreased cardiac output related to CHF, Coronary Artery Disease (CAD), A-fib, and hypertension. Interventions included but were not limited to medications as ordered as of 03/31/23. Nutrition care plan showed he was at nutrition and / or hydration risk as evidenced by impaired skin, diagnosis of metabolic encephalopathy, diabetes, hypertension, and CHF. Interventions included but not limited to weigh and monitor results: on admission weekly times 4, as ordered and as needed as of 03/31/23. A review of the physician orders showed: Torsemide 100 milligrams (mg) 0.5 tablet or 50 mg daily for heart failure as of 05/07/23 to 05/11/23 Torsemide 100 mg bid 0.5 tablet or 50 mg for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 5/21/23 to 05/25/23 Torsemide 100 mg bid 0.5 tablet or 50 mg bid for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 05/25/23 to 05/27/23 at 9 a.m. and 9 p.m. Torsemide 100 mg BID 0.5 tablet or 50 mg for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 05/27/23 to 06/15/23 7 a.m. and 7 p.m. Weights for 3 days upon admission, record on clipboard for Unit Manager (UM) to review on 05/07/23 Page 1 of 5 106150 106150 08/03/2023 Pruitthealth-North Tampa, LLC 18940 Sunlake Blvd Lutz, FL 33558

F 0656 to 05/09/23 Level of Harm - Minimal harm or potential for actual harm Weekly weights times 4 weeks, record on clipboard for Unit Manager (UM) to review as of 05/08/23 to 05/29/23 Residents Affected - Few Daily weights starting 05/10/23 to 05/28/23 Daily weights in a.m. before breakfast as of 05/25/23 to 06/15/23 Handwritten orders from the nephrologist showed the following: Date 05/11/23 1. Torsemide 50 mg BID 2. Metolazone 10 mg 30 minutes before Torsemide, 3 times a week, Monday, Wednesday, Friday 3. Left arm, no IV, no blood draw A record review of the Medication Administration Record (MAR) for June 2023 shows Torsemide 100 mg 0.5 tablet or 50 mg not given between 05/12/23 and 05/21/23. An Event Report showed on 05/11/23 a medication error occurred. The error was found on 05/20/23. ON 05/11/23 an order was received to increase the Torsemide to 100 mg BID. Order was not transcribed. Torsemide 100 mg daily was discontinued. Resulting in the resident missing dose of Torsemide from 05/12/23 to 05/19/23. The type of error was incorrect transcription. Resident experienced weight gain likely due to decrease in receiving diuretics. Weight gain can also be caused by the resident's overall condition/ comorbidities, Stage III CKD. Interventions included the correct order was entered and Torsemide was administered per physician orders. Audit of all residents written physician orders was completed to ensure no further transcription errors. The nurse responsible was educated. The Medical Records Director was educated on monitoring paper records for notation by the nurse that the order was properly noted. The nurses were educated on the process for order transcription and appropriate documentation A record review of the weights and documented in the resident's medical record were as follows: 05/06/23-234 pounds 05/19/23-245 05/25/23-241 05/26/23-240 05/27/23-241 05/28/23-240 05/29/23-240 106150 Page 2 of 5 106150 08/03/2023 Pruitthealth-North Tampa, LLC 18940 Sunlake Blvd Lutz, FL 33558

F 0656 05/30/23---239 Level of Harm - Minimal harm or potential for actual harm Additional weights found on the clip board but not documented in the medical record were as follows: 05/15/23-240 Residents Affected - Few 05/17/23---241 05/18/23---246 05/22/23---242 05/24/23---242 Both showing weights were not performed daily as per the order. A review of the Progress Notes showed the following : On 05/08/23: the physician wrote the resident had a CHF exacerbation with worsening respiratory failure and was now on a CPAP. He started declining 5 days after he was discharged . He has been confused. He has confusion, weakness, shortness of Breath (SOB) on exertion, gait impairment, lower extremities edema and decreased breath sounds in posterior bases. The plan included monitor for changes, daily weight. On 05/11/23 the physician documented the lower extremities edema was better. He denies SOB and oxygen saturation at room air at 97%. He has SOB on exertion. On 05/19/23 the nurse noted he was alert and oriented. No SOB noted. On 05/20/23 the nurse noted he had a decreased urine output since yesterday. Approximately 250 cc over 12 hours period. He has increased fluid retention in abdomen, legs and arms over the last few weeks, with a noted weight gain. Kidney functions severely compromised per lab results, which has been ongoing since prior to admission. Call was placed to the on-call physician, with orders to monitor output and weight at this time. On 05/20/23 at 6:47 p.m., the resident's wife asked this writer about the orders from the nephrologist when the resident visited on 05/11/23. This writer looked back on uploaded order that stated to give Torsemide 50 mg BID and give 30 minutes apart from Metolazone 10 mg every Monday, Wednesday, Friday. Order was placed to reflect. On 05/21/23, at 4:09 p.m. resident with increased urine output this shift since correction of ordered medications. On 05/24/23 the physician noted resident gained 9 pounds in one week and lower extremities edema was marked. No acute distress at this time, oxygen saturation at 99% on room air. Resident has bilateral Lower extremity edema. Monitor for changes and perform daily weights. On 05/26/23 the physician noted he had lost 4.2 pounds this week. His lower extremity edema was 106150 Page 3 of 5 106150 08/03/2023 Pruitthealth-North Tampa, LLC 18940 Sunlake Blvd Lutz, FL 33558

F 0656 improving. He denies SOB. No acute distress. The oxygen saturation was at 94% on room air. Level of Harm - Minimal harm or potential for actual harm On 05/30/23 physician noted family was at bedside today. He lost 4.8 pounds over the week, and he gained one pound today. His lower extremities are swollen. He denies SOB. No acute distress. Perform daily weights. Residents Affected - Few During an interview on 08/03/23 at 1:17 p.m. with the Director of Nursing (DON) she stated the resident was admitted for short-term rehabilitation. He had been in the hospital for CHF exacerbation. There was a medication error involving the resident. He returned from the nephrologist office with a written order for a change in medication. That order was not transcribed properly. The Torsemide 50 mg was supposed to be twice a day. The resident did not receive the medication from 05/12/23 through 05/19/23. The physician was notified and there were no further orders (except to restart the Torsemide). He had some weight gain. His physician assessed him. The physician was not overly concerned, no negative effect to him, due to all other things going on with the resident. He did return to the hospital on [DATE] but it was unrelated to the medication error, it was due to his declining condition. The DON reviewed the weight orders and verified them. She stated that they should have been performed daily. Based on the orders he should have had daily weights the whole time he was here. She stated that the weights were performed daily between 05/25/23 and 05/30/23 only, prior to that they were not daily. The DON reviewed the MAR for weights and verified there were missing documentation regarding weights. She stated they were documented on a clip board and then inputted into the computer. During interview on 08/03/23 at 1:56 p.m., with the resident's physician and the DON, the physician stated sometimes the sister would weight him. If a weight was not documented in the chart, it was not done. She stated she did not know what happened with the weights. The DON stated the weights were not in the chart. The physician verified she had ordered the weights to be performed. The medication error she was aware of, and a Plan of Correction and education was put into place. It was due to a transcribing problem. She got a call from the nurse regarding the medication error. She stated without the diuretics he would have an increase in swelling, gain weight and his congestion would get worse. He had baseline kidney disease and CHF. She stated after he was given the diuretic, he did improve but it did not improve his kidney functions. She stated she spoke with the family every time she was at the facility. The DON stated he had to have pads on the floor for his leg edema leakage. The DON stated his weight gain of 5 pounds, may not have been noticeable. The physician stated they were trying to balance his diuretics; he was struggling with fluid. The physician stated he was in a very chronic state. She stated they were watching the resident. The physician stated they kept increasing his diuretics (Torsemide). She stated either her or the Nephrologist was changing his diuretics. The kidney function was not getting any better, he was in kidney failure. She stated she and the nephrologist were adjusting the diuretics due to edema and the kidneys not functioning well. He was the same when he was at the facility before (in March). He was 234 pounds on 05/06/23 and in March he was 224 pounds. He left and came back 10 pounds heavier. The physician stated the diuretics were not effective. The medication error caused him to have some weight gain, but it was only part of the chronic problem going on. A record review of the facility's policy, Care Plans, revised 07/27/2023 showed it is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment to the Resident Assessment Instrument (RAI) Manual and the patient / resident choice. 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient/resident within seven days after the completion of the comprehensive assessment. 3. The comprehensive person-centered care plan is 106150 Page 4 of 5 106150 08/03/2023 Pruitthealth-North Tampa, LLC 18940 Sunlake Blvd Lutz, FL 33558

F 0656 Level of Harm - Minimal harm or potential for actual harm developed to include measurable goals and time frames to meet a patient' / resident medical, nursing, and psychosocial needs, the services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following: the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Residents Affected - Few 106150 Page 5 of 5