Health inspection·November 17, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to timely address a resident change in condition. This affected one resident (Resident #65) of three residents reviewed for notification of changes. The facility census was 62. Findings include: Review of Resident #65's closed medical record revealed an admission date of 01/13/23 and diagnoses including anemia, failure to thrive, type two diabetes, hypertension, chronic kidney disease, congestive heart failure, mild cognitive impairment, cardiomegaly, COVID-19, heart disease and hypokalemia. Resident #65 was his own responsible party. Resident #65 discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #65's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired and required minimal assistance to supervision with activities of daily living. Resident #65 was coded as receiving a diuretic six out of seven days in the seven-day look back period. Resident #65 admitted to the facility from the hospital. Review of Resident #65's physician's orders revealed orders to monitor vital signs every shift. Resident #65 was a full code. Review of treatment administration records (TARs) from February 2023 revealed the last set of vitals recorded was on 02/03/23 in the evening (7:00 P.M. to 7:00 A.M.). Review of a nurses' note dated 02/04/23 at 8:15 A.M. authored by Licensed Practical Nurse (LPN) #104 revealed the following information: This nurse went into Resident #65's room to give morning mediations, resident was noted to have facial, bilateral upper extremity and bilateral lower extremity edema. Vitals as follows: blood pressure 197/129 millimeters mercury (mmHg), heart rate 67 beats per minute (bpm), temperature 98.1 degrees Fahrenheit (F), pulse oximetry (SpO2) 95% on room air and respirations 20 (breaths per minute). Message left for provider [not specified], awaiting call back. Review of the next available nurses' note dated 02/04/23 at 10:30 A.M. authored by LPN #104 revealed the following information: Resident #65's daughter in facility, wants this nurse to send resident to [hospital name], 9-1-1 (emergency medical services) called and in building. Resident #65 states he goes not want to go to [hospital name] he wants to go to [different hospital name]. Resident transferred to [different hospital name] at 10:10 A.M. Page 1 of 3 365707 365707 11/17/2023 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #65's assessments revealed no transfer assessment or other documentation from 02/04/23 regarding Resident #65's change in condition. Interview on 11/17/23 at 8:58 A.M. with Resident #65's daughter revealed on 02/04/23 the nurse (name not known) never called 9-1-1 after Resident #65 had a change in condition. Resident #65's daughter stated Resident #65 called her to come to the facility and once she was at the facility she made the nurse call 9-1-1. Resident #65's daughter said the nurse told her the doctor ordered labs relative to Resident #65's change in condition. Resident #65 was hospitalized from [DATE] onwards and did not return to this facility. Interview on 11/17/23 at 10:53 A.M. with LPN #100 revealed for high blood pressures over 190 mmHg (systolic)/100 mmHg (diastolic) she would send residents out to the hospital as she did not mess around with changes in condition. Interviews were attempted with LPN #104 on 11/17/23 at 11:32 A.M. and 1:14 P.M. but were not successful. Interview on 11/17/23 at 11:35 A.M. with Certified Nurse Practitioner (CNP) #103 revealed she was a contracted provider thus was not on-call for the facility. CNP #103 indicated she had seen Resident #65 during his stay at the facility and shared he had significant blood pressure readings. CNP #103 stated that this facility did not have a threshold for blood pressure readings to determine if residents should be kept at the facility or sent to the hospital for further evaluation. CNP #103 stated if blood pressures were out of range for the resident, nursing staff should have called the primary care provider (PCP) for further instructions. Interview on 11/17/23 at 11:54 A.M. with the Director of Nursing (DON) revealed LPN #104 had called her after Resident #65 was sent to the hospital on [DATE] and shared while Resident #65 had facial edema he was still breathing, talking and acting normally and she had contacted Physician #109 but did not get a response. The DON was asked if there was a protocol for staff to follow if physicians did not respond to calls timely and she confirmed there was no protocol and stated staff were to continue to try to contact the doctor. The DON did not recall Physician #109 having a nurse practitioner or other staff that covered for him in his absence. The DON could not state if Resident #65 should have been sent to the hospital prior to his family requesting him to be sent as she was not present in the facility on 02/04/23 to make that clinical judgement. The DON indicated she kept in contact with Resident #65's family after he was discharged from the facility and it was thought Resident #65 may have had an allergic reaction which caused him to be hospitalized . Interview on 11/17/23 at 12:34 P.M. with Registered Nurse (RN) #108 revealed she cared for Resident #65 during his admission to the facility and recalled his blood pressure was consistently high. At times she would have to call the doctor for new orders and elaborated this would occur if Resident #65's systolic blood pressure was in the 200 mmHg range and his diastolic blood pressure was in the 100 mmHg range. When asked who staff were to call if the physician was not available, RN #108 stated staff would call the on-call physician and if that person was not available they would send the resident to the hospital. Follow-up interview on 11/17/23 at 1:49 P.M. with the DON revealed if Physician #109 was out of the country his nurse practitioner would take calls but that person would not be on-call. The DON stated Physician #109 was not out of the country on 02/04/23 so staff would have called him and only him, there was no one else they would have called. The DON reiterated nursing staff were to use their 365707 Page 2 of 3 365707 11/17/2023 Phoenix of Fairlawn 120 Brookmont Rd Akron, OH 44333

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical judgement and indicated Resident #65's blood pressure of 197/129 mmHg was not abnormal for him. The DON stated LPN #104 had called the physician multiple times on 02/04/23 but was made aware during the interview this was not documented in the medical record. The DON verified there was no protocol in place in the event a resident's physician could not be reached. During the interview the DON was made aware after LPN #104's progress note on 02/04/23 at 8:15 A.M. there were no additional blood pressure readings to check Resident #65's status, there were no other notes indicating that the physician was contacted additional times and the record lacked a change in condition/transfer assessment and DON did not disagree. Review of a policy, Change in a Resident's Condition, dated 12/16/20 revealed the facility would notify the resident, their physician and their sponsor of changes in the residents' medical/mental condition. Except in medical emergencies, notifications will be made timely of a change occurring in the residents' medical/mental condition or status. The nurse supervisor/charge nurse would record in the residents' medical record information relative to changes in the residents' medical/mental condition or status. The policy lacked guidance for staff to follow in the event the physician was not available. This deficiency represents non-compliance investigated under Complaint Number OH00147933. 365707 Page 3 of 3