Health inspection·April 11, 2024

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident met criteria for admission to the facility's secure unit and was in the least restrictive environment available. This affected one (#6) of three residents reviewed who resided in the secure or locked unit. The census was 173. Residents Affected - Few Findings include: Review of Resident #6's closed medical record revealed an admission date of 02/09/24. Diagnoses listed include anxiety disorder, major depressive disorder, hypokalemia, and hypertension. Resident #6 was transferred to a local hospital on [DATE] for stroke like symptoms and had not returned to the facility. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of a possible 15. Resident #6 was not having hallucinations or delusions, was not verbally of physically aggressive towards others, and had not wandered. Review of behavioral hospital documentation revealed Resident #6 was admitted from a local hospital on [DATE] after being found laying face down on her floor by neighbors. Resident #6 was psychotic and having delusions. Resident #6 was treated for nontraumatic rhabdomyolysis, severe hypokalemia, and starvation ketosis while at the local hospital. Review of discharge instructions dated 02/09/24 revealed Resident #6 was at her baseline as evidenced by decrease in psychotic and delusional behaviors. Resident #6 had been cooperative with care and denies any paranoid ideation's or delusional thoughts and has been medication compliant. Further review of Resident #6's closed medical record revealed she was admitted to a secured unit of the facility on 02/09/24 and remained there during her stay until transfer 04/06/24. Resident #6 was documented as being her own representative. Review of physician orders revealed and order dated 02/13/24 for may be on secured unit related to poor safety awareness and impaired cognition. Further review of Resident #6's closed medical record revealed no documentation of any hallucinations, delusions, wandering, or exit seeking behavior while at the facility from 02/09/24 to 04/06/24. Resident #6 was documented as being pleasant and cooperative with care and medications. There was no documentation by a physician of Resident #6's benefit from a secured unit environment. No Page 1 of 2 365877 365877 04/11/2024 Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405

F 0603 documentation of Resident #6 signing a consent to be in the facility's secured unit was found. Level of Harm - Minimal harm or potential for actual harm Review of a psychiatric consult dated 04/04/24 revealed Resident #6 was alert and oriented, engaged, and cooperative. Resident #6 denied any hallucinations, suicidal ideation's, or homicidal ideation's. Nursing staff deny any concerns and state resident is compliant with care and medications. Nursing staff state patient is at baseline. Resident #6 was documented as not having any psychosis or disturbance of perception. Resident #6's insight and judgment was fair. Residents Affected - Few Interview with the Administrator and Registered Nurse (RN) #120 on 04/10/24 at 12:45 P.M. confirmed Resident #6 did not have an assigned guardian and the resident was alert and oriented. The Administrator and RN #120 confirmed that Resident #6 had not displayed any behaviors that would warrant residing in the secure unit. The Administrator and RN #120 confirmed a physician had not documented a benefit to Resident #6 residing in the secure unit. RN #120 confirmed Resident #6's psychiatric consult dated 04/04/24 was negative for any acute psychosis. RN #120 confirmed a psychiatric consult was not conducted when Resident #6 was first admitted to the secure unit. Review of the facility's undated policy titled Secured (Locked) Unit the secured of locked unit is a unit that is separated form the other units without free access to move between unit by residents and used for those residents with limited cognitive or reasoning abilities who lack the capacity for re-direction, re-learning including those with late stage Alzheimer's, related dementia's, and mental illness. Confused or wandering does not meet criteria for placing a resident on a secured unit. A resident will be admitted to a locked or secured unit based on a mental and physical assessment that has documentation that the resident would benefit from such an environment. The interdisciplinary team (IDT) will provide documentation the secure unit is the least restrictive approach that is reasonable to protect the resident and assure his/her safety. The physician is aware and had provided documentation and order that the resident would benefit from such an environment. This deficiency represents non-compliance investigated under Complaint Number OH00152759. 365877 Page 2 of 2