Gracewood Inspection Report 5/6/2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/14/2018
CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

OMB NO. 0938-0391
STATEMENT OF (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
DEFICIENCIES / CLIA A. BUILDING ______ COMPLETED
AND PLAN OF IDENNTIFICATION B. WING _____ 05/06/2016
CORRECTION NUMBER
105486
NAME OF PROVIDER OF SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GRACEWOOD REHABILITATION AND NURSING CARE 8600 US HWY 19 N
PINELLAS PARK, FL 33782
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0224 Write and use policies that forbid mistreatment, neglect and abuse of residents and theft
of residents' property.
Level of harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
jeopardy Based on record review and interview, the facility failed to provide goods and services necessary to ensure safety and
prevent neglect for one (Resident #1) of four residents reviewed for accidents and safety. The facility did not provide
Residents Affected - Few supervision or hydration offerings on the patio during non-smoking times and allowed a resident who was assessed as being
at risk for dehydration, with a history of wandering, poor safety awareness, impaired cognition, and a history of falls, to
remain outside & unsupervised on a day with temperatures in excess of 88 F with a Heat Index range of 89.6 F-91 F. Resident
#1, a [AGE] year old long term care resident, had a [DIAGNOSES REDACTED]. Documentation in the latest Minimum Data Set
(MDS), dated [DATE], reflected the resident needed extensive assistance for locomotion off the unit.
On [DATE], the facility failed to ensure the resident had oversight supervision during non-smoking hours on the outdoor
patio. Subsequently at 5:15 p.m., the resident was spotted outside by another resident, slumped in his wheelchair, in the
direct sunlight, and unresponsive. The resident was transferred to the hospital where he was pronounced dead at 7:02 p.m.
The facility ' s failure to honor Resident #1 ' s basic right to be free from neglect by not providing the necessary goods,
oversight and supervision resulted in the findings of immediate jeopardy which was removed on [DATE] at 6:30 p.m.
Findings included
Per the facility ' s Abuse Prevention , policy with an effective date of [DATE], Sub Heading D Definitions; Neglect: Failure
to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.
On [DATE] at 2:37 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the events of [DATE].
When he was asked by the surveyor What was put into place after the event involving (Resident #1)? The NHA said, I will
have to ask the nurse. Communication at first was [MEDICAL CONDITION]. It wasn ' t until after midnight to 1:00 when the
detective spoke to me. The NHA said he had worked at the facility since [DATE]th, 2015 and nothing like the event on [DATE]
had happened at the facility since his hire date. The NHA said, We still don ' t have any confirmation of sunburn,
blisters. We met with everyone to determine what was fact or fiction in this case. We reached out to (Primary Care
Physician) and the (Medical Director). They said they couldn ' t get anything, any information.
Per Weather Underground the weather on, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm temperature was 89.1F.
Dew Point 64.9, Humidity 45%, and Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity 46%,
Heat Index: 89.6%, scattered clouds.
Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. Sheet and
physician '
s progress note of [DATE].
Random staff interviews described the resident as pleasant, quiet, cooperative, and strived to be as independent as
possible.
Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE]. The resident was referred to physical therapy
due to a recent fall with no injury. Short and long term goals had been set for the resident with the long term goal as
follows:
1. Patient will safely perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for
use of side rails and for task segmentation in order to enhance safe functional mobility and increase ability to attend
activities of choice. (Target date: [DATE])
2. Patient will safely perform functional transfers with minimum assistance and 25% verbal cues for correct hand/foot
placement with reduces risk of falls in order to safely maneuver in/out of bed and increase performance skills with
functional tasks. (Target date [DATE])
3. Patient will be able to ambulate using quad-cane 25 feet or more with minimum assistance with steady balance and gait
pattern. (Target date [DATE])
The patient goal was documented as: To get stronger.
A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE].
Per the nurses notes dated [DATE] at 6:30 p.m. the resident was found on the patio sitting next to his wheelchair. The
resident denied hitting his head and there were no apparent injuries.
On [DATE] at 12:30p.m., an interview was conducted with the risk manager regarding Resident # 1 ' s unwitnessed fall on the
patio on [DATE]. She said, at 6:30 p.m. on [DATE], the resident was found sitting outside on the patio in front of his
wheelchair. She said the smoking aide did not witness the fall but turned around and saw him sitting on the ground in front
of his wheelchair. The resident was assessed by the nurse and noted to have no injuries. Per the risk manager the resident
said he slid out of his chair so Dycem was placed in the seat of his wheelchair and a request for therapy to evaluate the
resident for positioning was submitted. The risk manager said the resident had a wheelchair alarm in place. She said the
alarm was in place and sounded when the resident slid out of the wheelchair.
Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed the reason for referral to therapy was due to a
fall. Under the section for area of concern, the form indicated fell while participating in a task/ experienced a fall,
Date of Fall: [DATE]. The screen indicated resident had a fall from wheelchair on outside patio. Would benefit from
positioning. Therapy Evaluation indicated a check mark for Occupational therapy. Review of the record revealed that an
Occupational Therapy Evaluation was conducted on [DATE] and a plan of treatment developed.
Per the nurse ' s notes, dated [DATE] at 2:45 p.m., the resident was found lying on the floor of his room on the left side
of his bed. The resident was lying on his left side on top of the wheel chair cushion. The resident denied pain/discomfort
and the nurse documented mental status intact, range of motion (ROM) exercises performed and intact, skin intact, no
injuries present . Non-skid socks were applied for safety and the fall education was reinforced. The resident verbalized
understanding.
On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m., on [DATE], the resident '
s alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath
him. The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The
wheelchair brakes were locked. The call light was within reach, the floor was dry, and he was wearing regular socks. The
intervention was for non-skid socks and a therapy referral. Physical therapy picked up the resident for skilled services
for bilateral lower extremity strengthening and balance training for transfer safety. She stated the resident sustained
[REDACTED].
Per the nurse ' s notes dated [DATE] at 10:00 p.m. the resident had an alarm to the bed and wheelchair due to poor safety
awareness related to Dementia. The note said the resident checked often. The resident was able to slowly propel himself in
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 105486 If continuation sheet
Previous Versions Obsolete Page 1 of 17
OMB NO. 0938-0391
CORRECTION NUMBER
105486
F 0224 (continued... from page 1)
the wheelchair around the unit.
Level of harm - Immediate Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced
jeopardy a fall, date of fall: [DATE] and Resident would benefit from skilled PT for B LE (Bilateral Lower Extremity) strengthening
and balance training for safety and transfers.
Residents Affected - Few Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine
days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] ,revealed that physical
therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for
[REDACTED].
Review of Resident # 1 ' s care plan for Risk for falls/injury related to h/o falls, poor safety awareness and impaired
mobility with a problem onset date of [DATE] and a next review date of [DATE], revealed [DATE] - fall occurred from w/c -
see nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff
assist with all transfers, Skilled therapy services as indicated, Restorative nursing services as indicated, Up and about
ad lib via w/c, Med review prn and quarterly for need of and or any dose changes (sic), Keep bed in lowest position, Call
light within reach of- encourage to use and staff to answer same asap, Keep area obstruction free as possible, [DATE]
Therapy screen for positioning and Dycem.
Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio.
On [DATE] 1: 45 p.m., an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no
other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were
any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment dated , [DATE], Brief Interview for
Mental Status (BIMS) score of 12 out of 15 (Total score: 8 -12: moderately impaired)).
On [DATE] at 11:00 a.m. Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside
in the patio at times and reads her bible. When asked if she was offered anything to drink when she was out there, she
stated No . When asked, if prior to this past weekend was staff supervising or present on the patio, she stated only when
the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment dated ,
[DATE], BIMS score 12 out of 15).
On [DATE] at 11:15 a.m., Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from
the smokers bothers her. She stated prior to this weekend there was never any staff out there except when the smokers were
out. She emphasized again never. She stated when she was out in the patio; she was never offered anything to drink. (MDS
quarterly assessment dated , [DATE], BIMS score 15. (Total score ,[DATE]: cognitively intact)).
On [DATE] at 11: 30 a.m., Resident #21 was interviewed. The resident was extremely hard of hearing. Stated she goes outside
to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she just got
a new hearing aid and it was crackling and buzzing. When asked if she had asked staff to adjust it for her? She stated no,
they ( .) someone this weekend and they are all very distracted because of it, not sure if I will get the help I need. (MDS
annual assessment dated , [DATE], BIMS score 12 out of 15).
On [DATE] at 1:15 p.m., an interview was conducted Resident #16. The resident stated he only goes outside when it is smoking
time. He stated there was no point going out any other time. He said during smoking time there was staff out there, doesn '
t know other times. He stated there was water out there now but does not recall there being any water before this past
weekend when he would be outside smoking. (MDS annual assessment dated , [DATE], BIMS score 15).
On [DATE] at 1:17 p.m., an interview was conducted with Resident #17. She said she goes out to the patio to smoke and
sometimes goes out there at other times. She confirmed there was staff on the patio only during smoking times. She stated
there was no staff outside in the patio when smokers were not out. She stated she gets her own drinks to bring out with
her. (MDS quarterly assessment dated [DATE], BIMS score 15).
On [DATE] at 1:35 p.m., an interview was conducted with Resident #18. She was seated in the patio using a personal
electronic device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music,
check Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here
in the patio at smoking times prior to this past weekend. (MDS quarterly assessment dated , [DATE], BIMS score 15).
On [DATE] at 1:40 p.m., an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking
times and other times also. He stated there was water available now and also there was the soda machine to get your own
drinks. He stated he sits in the shade and moves to the other side when the shade moves. He stated there was no staff
outside in the patio other than at smoking times until this week and no beverages unless he brought his own. (MDS quarterly
assessment dated , [DATE], BIMS score 15).
On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This was the resident who notified staff of Resident
#1 being in distress. He stated he saw the man who died on the patio. He stated it was nasty and indicated it looked like
he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad as the
man died anyway in spite of trying to get him help. (MDS quarterly assessment [DATE] BIMS score 15).
Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m.,
the resident (Resident #1) was Found on the outside patio unresponsive-[MEDICAL CONDITION] with agonal
respirations-Temperature was 105.7.
Review of the Nursing Evaluation for Resident # 1, dated [DATE], under Section M : Dehydration Risk Analysis : subsection 1
: Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors:
[MEDICAL CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe
Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control
problems
and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue
moist Total score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be
completed. The resident was also on Nectar thickened liquids.
A comprehensive record review revealed an At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical
record.
On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He
said at approximately 5:15 p.m. -5:20p.m., a resident came to him and said You need to go look at this guy he doesn ' t
look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his
wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his
room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident
' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident.
The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator
was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and
took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for
and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the resident ' s
shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The
nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and
gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on
the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident.
On [DATE] at 3:45 p.m. an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and
prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse
(Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a
set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the
resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES
REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES
REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even
anoxia. Reference: Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a
couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and
arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see
[MEDICAL CONDITION] blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his
abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined.
OMB NO. 0938-0391
CORRECTION NUMBER
105486
Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people
Level of harm - Immediate do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical
jeopardy condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the
body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease
Residents Affected - Few Control at http://stacks.cdc.gov/view/cdc/ )
Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to
deal with the heat coming from the environment. Heat fatigue, heat [MEDICAL CONDITION] (sudden dizziness after prolonged
exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for
these conditions can increase with the combination of outside temperature, general health and individual lifestyle.
Health-related factors, some especially common among older people, that may increase risk of hyperthermia include:
· Being dehydrated.
· Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands.
· Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever.
· High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be
at increased risk. However, salt pills should not be used without first consulting a doctor.
Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control
its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees
Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of
sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and
humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness.
(Source: National Institute of Health [DATE])
On [DATE] at 12:15 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant
(CNA) (Staff E) for Resident #1. She said she assisted the resident with his morning care at approximately 10:30 a.m. She
assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo
type shirt, and yellow non-skid socks. She assisted him to transfer to his wheelchair at approximately 11:00 a.m. and took
him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident
to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling
himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA took the
resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling himself toward
the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA said, Ok let ' s
fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident '
s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do
rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be
late.
Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1 on [DATE] at 3:10 p.m.
and [DATE] at 3:30 p.m. She said she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting
under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said, at
approximately 4:15 p.m., the smoking aide told her that the resident did not want to come back inside and was still on the
patio. Staff (F) said at 4:30 p.m., the resident was sitting next to the snack machine and the glass exit/entry door under
the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed
the resident to his table on the far side of the dining room in front of the windows. She said there were no other
residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m.
another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining
room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a
history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his
wheelchair and would try to stand alone and get in another resident ' s bed.
On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the
smoking on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day.
At approximately 4:00 p.m. she said she noticed Resident #1 sitting in his wheelchair near the soda machines in the direct
sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident
was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade.
She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The
resident ' s CNA (Staff F) said, Ok thank you.
On [DATE] at 2:30 p.m., an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on
[DATE]. She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come
down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said
she did not see Resident #1 at 4:30 p.m. or anytime during dinner. She said at approximately 5:10 p.m. another CNA (Staff
G) came into the dining room with Resident #1 ' s tray and said the resident wasn ' t in his room. Staff R told Staff G
that the resident was not in the dining room. Staff R told Staff G to take the tray back to the resident ' s room and go
look for the resident. Staff R said she could not leave the other residents in the dining room and was unable to assist
with locating Resident #1. Staff R verified that at no time during her dining duty did she leave the dining room or see
Resident #1 in the dining room.
An interview was conducted, on [DATE] at 11:00 a.m., with Staff G. He said he left the facility at 3:00 p.m. to get his car
and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out
until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the
dining. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s
room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N)
told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to
interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to
talk to the supervisor. Staff G said the resident moved slow but was able to wheel himself around the facility. Staff G
verified he did not see the resident that day.
On [DATE] at 12:00 p.m., an interview was conducted with unit manager (Staff D). He said the resident was able to
communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio.
On [DATE] at 11:30 a.m., an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse
(Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in
bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m., the resident was in
the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She
said at about 1:50 p.m. the CNA took the resident to his room for afternoon care. That was the last time she saw the
resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the
handrail.
A tour of the facility, on [DATE], found that the building was a 120 bed nursing home, rectangular in shape, with a middle
enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and
had glass panels with a glass automatic door which was accessible by an automatic door push to open button at wheelchair
height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or call system
observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the
left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently
throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio
had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was
conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between
,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the outside walls under
the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation).
Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N '
s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass
OMB NO. 0938-0391
CORRECTION NUMBER
105486
door to the patio.
Level of harm - Immediate The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the
jeopardy facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining
room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location
Residents Affected - Few from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in
the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Yet, Staff R said she
was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the dining
room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15
p.m. He said the resident was not in the dining at that time, nor was the resident in his room when staff G took the tray
to the resident ' s room.
Record review of the nurse ' s notes dated, [DATE] (no time), revealed the nurse was called out to the patio by another
resident. The nurse found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room
and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The
resident was transferred to the hospital.
A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400: Recall:
the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long
term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900:
Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not
know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded
as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of
[MEDICAL CONDITION]: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present,
fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and
frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date
of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns
from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor,
how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The
resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Under subsection
GO400- Functional Limitation in Range of Motion: The resident was coded as a 1 for the upper and lower extremities on one
side of the body. The resident was unable to walk and used a wheelchair for mobility.
A review of the care plan, with problem onset date of [DATE] and next review date of [DATE], found Resident #1 needed
extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to
dementia and left [MEDICAL CONDITION].
A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE] (date of death ), did not indicate that he received
breakfast, lunch, or dinner and
F 0226 Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of
resident property.
jeopardy Based on interview and record review the facility failed to develop and implement policies and procedures to ensure
residents who utilized the outdoor patio area were not neglected for one (Resident #1) of four residents reviewed for
Residents Affected - Few safety. Resident #1 was permitted to go outside unsupervised even though he was at risk for dehydration, wandering, poor
safety awareness, impaired cognition, and had a history of [REDACTED].#1 was outside and did not look good or sound good.
No one in the facility had seen the resident from 4:30 p.m. until 5:15 p.m. when he was found outside on the patio,
unsupervised, slumped in his wheelchair, in the direct sun and unresponsive.
The facility ' s failure to implement policies and procedures to ensure residents are not neglected and are provided
oversight supervision during non-smoking times on the patio resulted in the findings of immediate jeopardy which was
removed on [DATE] at 6:30 p.m.
Findings included
Per the facility ' s Abuse Prevention , policy with an effective date of [DATE], The facility prohibits the mistreatment,
neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc.
The facility has implemented and designed processes, which strive to ensure the prevention and reporting of suspected or
alleged abuse, neglect, mistreatment, and/or misappropriation of property.
Under the heading ' Process ' :
Sub heading B. The Administration and Director of Nursing are responsible for the investigation and reporting. They are
also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property
standards and procedures:
Implementation
Ongoing monitoring
Reporting
Investigation
Tracking and trending
Sub heading C. Implementation and ongoing monitoring consist of the following:
Screening
Training
Prevention
Identification
Protection
Investigation
Reporting
Sub Heading D Definitions:
Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness
Sub Heading G Prevention:
1. Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of
employees through visual observation of care delivery and recognition of signs of burnout, frustration and stress.
2. Identify, correct and intervene in situations where abuse, neglect and /or mistreatment are more likely to occur. This
includes, but is not limited to, identification and analysis of:
a. Secluded areas of the facility
b. Sufficient staffing on each shift to meet the needs of the individual resident ' s needs
c. Sufficient and appropriate supervisory staff to identify inappropriate behaviors
d. Residents with needs and behaviors which might lead to conflict or neglect.
Review of a policy entitled Policy: Routine Resident Checks : 2001 Med-Pass, Inc. (revised [DATE]):
Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being.
Policy Interpretation and Implementation:
1. To ensure the safety and well- being of our residents, nursing staff shall make a routine resident check on each unit at
least once per each 8 hour shift.
2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to
determine if the resident ' s needs are being met, identify any change in the resident ' s condition, identify whether the
resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.
3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the
resident ' s condition and medical needs.
4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time,
identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and
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provide it to Nurse Supervisor/Charge Nurses.)
Level of harm - Immediate This policy was reviewed with the Administrator, Assistant Director of Nursing (ADON), Regional Clinical Nurse, and Director
jeopardy of Nursing, on [DATE] at 3: 17 p.m. The Regional Clinical Nurse Regional nurse stated that residents are to be checked at
least once every 8 hours but the standard of practice is every couple of hours check. She stated that there was no other
Residents Affected - Few policy for resident checks, just the one you have there and stated there is no documentation recorded of resident checks.
Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED].
An interview was conducted with the ADON, on [DATE] at 2: 45 PM. She stated that prior to finding Resident #1 unresponsive
on [DATE], there was no staff in the patio to monitor residents and offer hydration except during smoking times.
Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio.
On [DATE] 1: 45 p.m. an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other
times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any
beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental
Status (BIMS) score of 12. (Total score: 8 -12: moderately impaired)).
in the patio at times and reads her bible. When asked if she is offered anything to drink when she is out there, she stated
No . When asked if prior to this past weekend were there staff supervising or present in the patio, she stated only when
the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE] BIMS
score 12).
On [DATE] at 11:15 a.m. Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from
out. She emphasized again never . She stated when she was out in the patio; she was never offered anything to drink. (MDS
quarterly assessment [DATE] BIMS score 15. Total score ,[DATE]: cognitively intact).
On [DATE] at 11: 30 a.m. Resident #21 was interviewed. The resident was extremely hard of hearing. Stated she goes outside
to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she just got
a new hearing aid and it is crackling and buzzing. Asked if she had asked staff to adjust it for her? She stated no, they (
.) someone this weekend and they are all very distracted because of it, not sure if I will get the help I need. (MDS annual
Assessment [DATE] BIMS score 12).
On [DATE] at 1:15 p.m. an interview was conducted Resident #16. The resident stated he only goes outside when it is smoking
time. He stated there was no point going out any other time. He said during smoking time there is staff out there, doesn '
t know other times. He stated there is water out there now but does not recall there being any water before this past
weekend when he would be outside smoking. ([DATE] MDS annual assessment BIMS score 15).
On [DATE] at 1:17 p.m. an interview was conducted with Resident #17. She said she goes out to the patio to smoke and
her. ([DATE] MDS quarterly assessment BIMS score 15).
On [DATE] at 1:35 p.m. an interview was conducted with Resident #18. She was seated in the patio using a personal electronic
device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music, check
Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here in
the patio at smoking times prior to this past weekend. ([DATE] MDS quarterly assessment BIMS score 15).
On [DATE] at 1:40 p.m. an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking
times and other times also. He stated there is water available now and also there is the soda machine to get your own
outside in the patio other than at smoking times until this week and no beverages unless he brought his own. ([DATE] MDS
quarterly assessment BIMS score 15).
On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This is the resident who notified staff of Resident
#1 being in distress. He stated he saw the man who died , in the courtyard, he stated it was nasty and indicated it looked
like he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad
as the man died anyway in spite of trying to get him help. ([DATE] Quarterly MDS assessment BIMS score 15).
Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm temperature was
89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity 46%,
Heat Index: 89.6%, scattered clouds.
do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical
condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the
Control at <http://stacks.cdc.gov/view/cdc/ >
A tour of the facility, on [DATE], found that the facility is a 120 bed nursing home, rectangular in shape, with a middle
had glass panels with a glass automatic door which was accessible by an automatic door push to open button, accessible at
wheelchair height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or
call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine
to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded
differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded
portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An
interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new
(put up between ,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the
outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the
time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the
door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the
facility through the glass door to the patio.
Review of the Nursing Evaluation dated [DATE] under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/
Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: [MEDICAL
CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision
Making
and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand
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dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist Total
Level of harm - Immediate score: 9. Score of 8 or more indicates at risk for dehydration. At Risk Dehydration Care Plan must be completed. The
jeopardy resident was also on Nectar thickened liquids. The comprehensive record review revealed an At Risk Dehydration Care Plan
could not be located in Resident # 1 ' s clinical record.
Residents Affected - Few On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He
prepare Resident #1 for transport to the hospital. He said on, [DATE] between 5:25 p.m. and 5:30p.m., the other nurse
REDACTED] (muscle spasms or jerking. Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even
anoxia.) Reference: Wikipedia, the free encyclopedia) Staff Q asked the CNA in the room to get cold wet wash cloths and a
On [DATE] at 12:15 p.m. an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant
(CNA) (Staff E) for Resident #1 .She said she assisted the resident with his morning care at approximately 10:30 a.m. She
type shirt, and yellow non-skid socks. She assisted him to transfer him to his wheelchair at approximately 11:00 a.m. and
took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the
resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift
propelling himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA
took the resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling
himself toward the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA
said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button
and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said
she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA
was going to be late .
Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1, on [DATE] at 3: 10 p.m.
and [DATE] at 3: 30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was
sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at
approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the
patio. Staff (F) said at 4:30 p.m. the resident was sitting next to the snack machine and the glass exit/entry door under
On [DATE] at 3:40 p.m. an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the
At approximately 4:00 p.m. she said she noticed Resident #1 sitting in wheelchair near the soda machines in the direct sun.
She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was
sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She
said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The
On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on
An interview was conducted on [DATE] at 11:00 a.m. with Staff G. He said he left the facility at 3:00 p.m. to get his car
talk to the supervisor. Staff (G) said the resident moved slow but was able to wheel himself around the facility. Staff G
On [DATE] at 12:00 p.m. an interview was conducted with unit manager (Staff D). He said the resident was able to communicate
his needs. The resident could propel himself around the unit and throughout the facility including to the patio.
On [DATE] at 11:30 a.m. an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse
bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m. the resident was in
handrail.
On [DATE] at 1:20 p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding
Resident #1. He said he saw, The man on the patio who died , and stated it was nasty and indicated it looked like he had
vomit all over his face and said, He didn ' t look good . He went and told the nurse and said he felt bad as the man died
anyway in spite of him trying to get him help.
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The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE].Per the time line the
Level of harm - Immediate facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining
jeopardy room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location
from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in
Residents Affected - Few the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. yet Staff R said she
p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the tray to
the resident ' s room.
Record review of the nurse ' s notes, dated [DATE] (no time), revealed the nurse was called out to the patio by another
A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]:
understanding.
On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m. on [DATE] the resident ' s
alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath him.
The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The
[REDACTED].
awareness related to Dementia. The noted said the resident checked often The resident was able to slowly propel himself in
Review of a Multidisciplinary Rehabilitation Screen , dated [DATE] ,revealed fell while participating in a task/experienced
a fall, Date of Fall: [DATE] and Resident would benefit from skilled PT for B LE ( Bilateral Lower Extremity) strengthing
and balance training for safety and tran(TRUNCATED)
F 0323 Make sure that the nursing home area is free from accident hazards and risks and provides
supervision to prevent avoidable accidents
jeopardy Based on interview, observation of an enclosed outdoor patio and record review, the facility failed to provide the
supervision needed for one (Resident #1) of four sampled residents who were identified as needing closer supervision.
Residents Affected - Few Resident #1 was on the facility outdoor patio in 88 degree weather in direct Florida sunlight for an undetermined amount of
time without consistent supervision and monitoring and without evidence of hydration and sun protection. Resident # 1 was
determined to be at risk for dehydration, had a history of [REDACTED]. The resident was found on the outside patio and was
assessed as being unresponsive, tachycardic with agonal respirations and an internal body temperature of 105.7. The
resident was transported to the hospital emergency room where he subsequently died .
All residents who utilized the patio were at risk for neglect/ illness injury and even death as a result of the facility
failing to have a system in place to supervise and monitor residents at all times while outside on the patio.
This failure created a situation that resulted in serious injury and harm to Resident # 1 and resulted in the determination
of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 6:30 p.m.
and the severity and scope was reduced to a D.
Findings Included:
Record review of the nurse ' s notes, dated [DATE] (no time), revealed the nurse was called out to the patio by another
deal with the heat coming from the environment. Heat fatigue, heat syncope (sudden dizziness after prolonged exposure to
the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions
can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors,
some especially common among older people, that may increase risk of hyperthermia include:
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Level of harm - Immediate its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees
jeopardy Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of
Residents Affected - Few humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness.
Control at <http://stacks.cdc.gov/view/cdc/ >
Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53 p.m. temperature
was 89.1F. Dew Point 64.9, Humidity 45%, and Heat Index: 91%, skies were clear. At 4:53 p.m. Temp. 88 F, Dew Point 64.9,
Humidity 46%, Heat Index: 89.6%, scattered clouds.
the resident (Resident #1) was Found on the outside patio unresponsive-tachycardic with agonal respirations-Temperature was
105.7.
Review of the Nursing Evaluation dated [DATE] under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/
Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: Renal
Insufficiency/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision
Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and
Hand
score: 9. Score of 8 or more indicates at risk for dehydration. At Risk Dehydration Care Plan must be completed. The
resident was also on Nectar thickened liquids. The comprehensive record review revealed an At Risk Dehydration Care Plan
could not be located in Resident #1 ' s clinical record.
On [DATE] at 3:45 p.m., an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N).
He said at approximately 5:15 p.m. -5:20 p.m., a resident came to him and said You need to go look at this guy he doesn ' t
and the nurse said it was an Exelon patch for the Dementia. The nurse then pulled the patch off the resident ' s shoulder
and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse
said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and
REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme hypoxia or even anoxia Reference:
Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice.
Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency
Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see any burns or
blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a
dull black color about ¼ inches wide and the length was undetermined.
On [DATE] at 12:15 p.m. an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant
(CNA) (Staff E) for Resident #1.She said she assisted the resident with his morning care at approximately 10:30 a.m. She
himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA took the
resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m., she saw the resident propelling himself toward
late .
Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1, on [DATE] at 3: 10 p.m.
and on [DATE] at 3: 30 p.m. She said she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was
[DATE].She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come
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Level of harm - Immediate until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the
jeopardy dining room. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident '
s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N)
Residents Affected - Few told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to
handrail.
The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE].Per the time line; the
facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining
room for evening meal. However, the staff interviews revealed conflicting information regarding the resident ' s location
the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Yet, Staff R said she
was in the dining room between 4:25 p.m. and 4:30 p.m., until approximately 5:10 p.m., and did not see the resident in the
dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about
5:15 p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the
tray to the resident ' s room.
A tour of the facility, on [DATE], found that the facility was a 120 bed nursing home, rectangular in shape, with a middle
had glass panels with a glass automatic door which was accessible by an automatic door push to open button accessible at
to the left. The alcove led to a large rectangular unshaded area. Due to sun movement, the alcove area was shaded
A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400:
Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800:
long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection
CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces,
did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was
coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms
of Delirium: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present,
A review of the care plan (Onset date [DATE] with a revision date of [DATE]) for Resident #1 indicated the resident needed
extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to
dementia and left hemiparesis.
A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE] (date of death ), did not indicate that he received
breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner.
Per the physician's order [REDACTED].
A review of the resident ' s latest laboratory results, dated [DATE], revealed Sodium, Potassium, Chloride and Calcium were
all within normal limits. Per a physician's order [REDACTED].
On [DATE], at 2:27 p.m., an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the
facility called him to inform him that the resident was on his way to the hospital. He said he was not aware of any
concerns related to being outside until the next day when he heard it on the news. He said he was not sure of the exact
time he was called but said he went on call at 6:00 p.m. He said he received a call from the emergency room doctor later in
the evening after the resident had expired. He said initially he agreed to sign the death certificate but the case was
referred to the medical examiner. He said the ER MD did not mention anything about the resident ' s skin condition i.e.
blisters, sunburn. He said he had recently seen the resident at the facility ([DATE]). The resident was medically stable
and he had no concerns about the resident. He said the resident did not have any conditions that made him more sensitive to
the sun or the heat.
On [DATE] at 2:00 p.m., an interview was conducted with the pharmacist. The pharmacist reviewed the medications that the
resident was receiving prior to his death to see if any of the medications would cause photosensitivity or heat
sensitivity. The review revealed that none of the medications would cause photosensitivity or heat sensitivity.
At 11:30 a.m. on [DATE], an interview was conducted with the facility ' s Medical Director. He said he was notified by the
facility on, Monday ([DATE]), that the resident had been found outside unresponsive, sent to the hospital, and that there
was concern by the EMTs regarding sun exposure. He said he had not spoken with the facility regarding the corrective plan
or root cause analysis as of yet but would expect to be included in the process.
Per the Physician ' s progress note, dated [DATE], the resident was a [AGE] year old with [DIAGNOSES REDACTED].
Per the physician ' s progress note, dated [DATE], the physician documented that the resident had been stable since his
last physician ' s visit with no cough or dyspnea reported, no new pain or discomfort, no tremors or convulsions, no
palpitations, stable reports of elimination and stable nutrition. Physical examination revealed: General appearance:
appears stated age. Heart rate: Regular. Heart sounds: Normal: S1S2. Lungs: no wheezing/rhonchi/rales. Abdomen: Soft.
Extremities: No clubbing or cyanosis.
Per review of the Routine Resident Checks policy (Nursing Services Policy and Procedure Manual, 2001 MED-PASS, Inc., Revised
[DATE]), the policy was as follows; Policy Statement : Staff shall make routine resident checks to help maintain resident
safety and well-being.
Policy Interpretation and Implementation :
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CORRECTION NUMBER
105486
Level of harm - Immediate least once per each 8 hour shift.
jeopardy 2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to
Residents Affected - Few resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.
4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time,
identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and
provide it to Nurse Supervisor/Charge Nurses.)
This policy was reviewed with the Administrator, Assistant Director of Nursing (ADON), Regional Clinical Nurse, and Director
of Nursing, on [DATE] at 3: 17 p.m. The Regional Clinical Nurse Regional nurse stated that residents are to be checked at
least once every 8 hours but the standard of practice was every couple of hours check. She stated that there was no other
policy for resident checks, just the one you have there and stated there was no documentation recorded of resident checks.
A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]:
Per the nurse ' s notes, dated [DATE] at 6:30 p.m., the resident was found on the patio sitting next to his wheelchair. The
understanding.
On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m. on [DATE] the resident ' s
[REDACTED].
awareness related to Dementia. The noted said the resident checked often The resident was able to slowly propel himself in
Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced
a fall, Date of Fall: [DATE] and Resident would benefit from skilled PT for B LE ( Bilateral Lower Extremity) strengthening
and balance training for safety and transfers.
Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine
days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] ,revealed that physical
therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for
[REDACTED].
mobility with a problem onset date of [DATE] and a next review date of [DATE], revealed [DATE] - fall occurred from w/c -
see nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff
Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio and were as
follows:
On [DATE] 1: 45 p.m. an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other
times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any
beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental
Status (BIMS) score of 12 out of 15. (Total score: 8 -12: moderately impaired)).
in the patio at times and reads her bible. When asked if she was offered anything to drink when she was out there, she
stated No . When asked if prior to this past weekend were there staff supervising or present in the patio, she stated only
when the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE]
BIMS score 12 out of 15).
On [DATE] at 11:15 a.m. Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from
out. She emphasized again never . She stated when she was out in the patio; she was never offered anything to drink. (MDS
quarterly assessment [DATE] BIMS score 15.
F 0327 Give each resident enough fluids to keep them healthy and prevent dehydration.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Immediate Based on interview, and record review and observation of the facility and outside patio area, the facility failed to ensure
jeopardy that fluid needs were identified and met for one (Resident #1) of two residents identified at risk of dehydration of four
sampled residents who used the patio during non-smoking times. Resident #1, a [AGE] year old resident, was described as
Residents Affected - Few having poor safety awareness which put the resident at risk when allowed to remain outdoors. Resident #1 was on the
facility patio in 88 degree weather in direct sunlight in Florida without sunscreen, for an undetermined amount of time
without consistent supervision nor evidence that hydration needs were assessed and met. Resident # 1 was determined to be
at risk for dehydration, was identified with impaired cognition, and left [MEDICAL CONDITION], along with [DIAGNOSES
REDACTED]. The resident was found unresponsive on the outdoor patio, [MEDICAL CONDITION] with agonal respirations and an
internal body temperature of 105.7. The resident was transported to the hospital emergency room where he subsequently died
.
All residents who utilized the patio were at risk for neglect/ illness injury and even death as a result of the facility
failing to have a system in place to ensure sufficient fluids for hydration throughout the day and while outside on the
patio.
OMB NO. 0938-0391
CORRECTION NUMBER
105486
Findings Included:
Level of harm - Immediate Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. note of [DATE].
jeopardy At 11:30 a.m. on [DATE] an interview was conducted with the facility ' s Medical Director. He said he was notified by the
facility on, Monday ([DATE]), that the resident had been found outside unresponsive, sent to the hospital, and that there
Residents Affected - Few was concern by the EMTs regarding sun exposure. He said he had not spoken with the facility regarding the corrective plan
or root cause analysis as of yet but would expect to be included in the process.
Review of the Nursing Evaluation, dated [DATE], under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/
Making
dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist.
Total score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be completed. The
resident was also on Nectar thickened liquids.
A comprehensive record review revealed an At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical
record.
A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section G -Functional Status: subsection H - Eating-how
resident eats and drinks, regardless of skill. The resident was coded as a ,[DATE] indicating he needed limited assistance
with one person physical assist. Under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for
Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident
was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident
was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing
home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately
impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of [MEDICAL CONDITION]: the
resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and
goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident
was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the
section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit
locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident
moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was
coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist.
Review of the care plan with Problem onset, dated [DATE], and the next review date of [DATE] indicated the resident was over
his ideal body weight and received a mechanical soft/no added salt diet with thickened liquids. A Problem onset dated
[DATE] and the next review date of [DATE] found the resident was at risk for aspiration related to dysphasia treatment for
[REDACTED].
A review of the care plan for resident #1 indicated Problem onset , dated [DATE] with the next review date of [DATE],
resident needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene
needs related to dementia and left [MEDICAL CONDITION].
A review of the CNA ADL Flow Sheet for Resident #1 dated [DATE] did not indicate for [DATE] (day of death) that he received
breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner. In addition, out of 29 possible
offerings for a snack, 26 opportunities were left blank. There was no documentation on the Activities of Daily Living (ADL)
flow sheet that indicated the resident received a bedtime snack as per the physician's order [REDACTED].>Per the
physician's order [REDACTED].
possible.
Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE],the resident was referred to physical therapy
follows:
1. Patient will safety perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for
On [DATE] at 3:00 p.m. an interview was conducted with the Director of Nurses (DON). Regarding documentation of the resident
' s daily fluid intake, she said there was no documentation of offerings or intake of fluids other than at meals.
And On [DATE] at 3:45 p.m. an interview was conducted with the Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse
(Staff N). He said at approximately 5:15 p.m. -5:20 p.m., a resident came to him and said You need to go look at this guy
he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped
in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident
to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the
resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the
resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911
operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics
arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the
patch was for and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the
resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked
sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to
the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a
raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident.
anoxia
Reference: Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a couple
bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms.
The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see
Record review the nurse ' s notes dated, [DATE] (no time), revealed the nurse was called out to the patio by another
OMB NO. 0938-0391
CORRECTION NUMBER
105486
Level of harm - Immediate respirations-Temperature was 105.7.
jeopardy On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on
Residents Affected - Few down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said
all the other fluids i.e. juice, water, milk, etc. come with the meal. She said did not see Resident #1 at 4:30 p.m. or
anytime during dinner.
Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida, was as follows: At 3:53 p.m. temperature
was 89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53 p.m. Temp. 88 F, Dew Point 64.9,
Humidity 46%, Heat Index: 89.6%, scattered clouds.
Control at http://stacks.cdc.gov/view/cdc/
Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio and were as
follows:
On [DATE] 1: 45 p.m., an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no
other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were
any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental
Status (BIMS) score of 12 out of 15(Total Score ,[DATE]: Moderately Impaired).)
On [DATE] at 11:00 a.m., Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside
in the patio at times and reads her bible. When asked if she is offered anything to drink when she is out there, she stated
No . When asked if prior to this past weekend were there staff supervising or present in the patio? She stated, only when
the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE] BIMS
score 12 out of 15).
On [DATE] at 11:15 a.m., Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from
out. She emphasized again never. She stated when she was out in the patio; she was never offered anything to drink. (MDS
quarterly assessment [DATE] BIMS score 15 (Total score: ,[DATE] Cognitively Intact)).
On [DATE] at 11: 30 a.m., Resident #21 was interviewed. The resident was extremely hard of hearing. She stated she goes
outside to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she
just got a new hearing aid and it was crackling and buzzing. She was asked if she had asked staff to adjust it for her? She
stated no, they ( .) someone this weekend and they are all very distracted because of it, not sure if I will get the help I
need. (MDS annual Assessment [DATE] BIMS score 12 out of 15).
On [DATE] at 1:15 p.m., an interview was conducted Resident #16. The resident stated he only goes outside when it was
smoking time. He stated there was no point going out any other time. He said during smoking time there was staff out there,
doesn ' t know other times. He stated there was water out there now but does not recall there being any water before this
past weekend when he would be outside smoking. (MDS annual assessment [DATE] BIMS score 15).
On [DATE] at 1:17 p.m., an interview was conducted with Resident #17. She said she goes out to the patio to smoke and
her. (MDS quarterly assessment [DATE] BIMS score 15).
On [DATE] at 1:35 p.m., an interview was conducted with Resident #18. She was seated in the patio using a personal
electronic device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music,
check Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here
in the patio at smoking times prior to this past weekend. (MDS quarterly assessment BIMS score 15)
On [DATE] at 1:40 p.m., an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking
time and other times also. He stated there was water available now and also there was the soda machine to get your own
outside in the patio other than at smoking times until this week and no beverages unless he brought his own. (MDS quarterly
assessment BIMS score 15).
On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This was the resident who notified staff of Resident
#1 being in distress. He stated he saw the man who died , in the patio. He stated it was nasty and indicated it looked like
he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad as the
man died anyway in spite of trying to get him help. (MDS quarterly assessment [DATE] BIMS score 15).
(CNA) (Staff E) for Resident #1 .She said she assisted the resident with his morning care at approximately 10:30 a.m. She
himself around the TV room and in front of the north wing nurse ' s station. Between 2:15 p.m. -2:30 p.m., the CNA took the
resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling himself toward
late.
and on [DATE] at 3:30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was
OMB NO. 0938-0391
CORRECTION NUMBER
105486
Level of harm - Immediate room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a
jeopardy history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his
Residents Affected - Few On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the
On [DATE] at 12:00 p.m., an interview was conducted with unit manager (Staff D). He said the resident was able to
communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio.
bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m., the resident was in
said at about 1:50 p.m., the CNA took the resident to his room for afternoon care. That was the last time she saw the
handrail.
On [DATE] at 1:20p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding
The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the
the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m., yet, Staff R said she
p.m. He said the resident was not in the dining at that time, nor was the resident in his room when Staff G took the tray
to the resident ' s room.
had glass panels with a glass automatic door which was accessible by an automatic door push to open button accessible at
to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded
On [DATE], at 2:27 p.m., an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the
concerns related to being outside until the next day when he heard it on the news. He said he was not sure of the exact
time he was called but said he went on call at 6:00p.m. He said he received a call from the emergency room doctor later in
the evening after the resident had expired. He said initially he agreed to sign the death certificate but the case was
referred to the medical examiner. He said the ER MD did not mention anything about the resident ' s skin condition i.e.
blisters, sunburn. He said he had recently seen the resident at the facility ([DATE]). The resident was medically stable
and he had no concerns about the resident. He said the resident did not have any conditions that made him more sensitive to
the sun or the heat.
On [DATE] at 2:00 p.m., an interview was conducted with the pharmacist. The pharmacist reviewed the medications that the
resident was receiving prior to his death to see if any of the medications would cause photosensitivity or heat
sensitivity. The review revealed that none of the medications would cause photosensitivity or heat sensitivity.
Per the Physician ' s progress note, dated [DATE], the resident was a [AGE] year old with [DIAGNOSES REDACTED].
Per the physician ' s progress note, dated [DATE], the physician documented that the resident had been stable since his
last physician ' s visit with no cough or dyspnea reported, no new pain or discomfort, no tremors or convulsions, no
palpitations, stable reports of elimination and stable nutrition. Physical examination revealed: General appearance:
appears stated age. Heart rate: Regular. Heart sounds: Normal: S1S2. Lungs: no wheezing/rhonchi/rales. Abdomen: Soft.
Extremities: No clubbing or cyanosis.
Per review of the Routine Resident Checks policy, the policy is as follow; Policy Statement : Staff shall make routine
resident checks to help maintain resident safety and well-being.
Policy Interpretation and Implementation :
least once per each 8 hour shift.
2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to
resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.
4. The Nursing Supervisor/Charge Nurse shall keep documentation rela(TRUNCATED)
F 0490 Be administered in an acceptable way that maintains the well-being of each resident .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Level of harm - Immediate Based on record review, policy and procedure review, staff and administrative interview, and job description review, it was
jeopardy determined that the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain
the highest practicable physical well-being for one (Resident #1) of four sampled residents who was identified as needing
Residents Affected - Few closer supervision. The administrator did not ensure that the direct functions and operations of the facility were in
OMB NO. 0938-0391
CORRECTION NUMBER
105486
accordance with current regulations governing long term care facilities and the facility ' s policies for supervision and
Level of harm - Immediate neglect as evidenced by the following: Resident #1 was on a facility patio in 88 degree weather in direct sunlight for an
jeopardy undetermined amount of time, without consistent supervision and monitoring and without evidence of hydration and sun
protection. Resident # 1 had a history of [REDACTED].V.A.) was determined to be at risk for dehydration, wandering, poor
Residents Affected - Few safety awareness, impaired cognition, and a history of falls with [DIAGNOSES REDACTED]. The resident was found on the
outside patio and was assessed as being unresponsive, [MEDICAL CONDITION] with agonal respirations and an internal body
temperature of 105.7. The resident was transported to the hospital emergency room where he subsequently died .
All residents who utilized the patio were at risk for neglect/illness injury and even death as a result of the facility
failing to have a system in place to supervise and monitor residents at all times while outside on the patio.
Findings Included:
Review of the job description provided by the facility (unsigned and undated) for the Nursing Home Administrator (2003
Med-Pass, Inc.) revealed the following relevant information;
Purpose of Your Job Position : The primary purpose of you job position is to direct the day-to-day functions of the
facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing
facilities to assure that the highest degree of quality care can be provided to our residents at all times.
Administrative Functions : Plan, develop, organize, implement, and direct the facility ' s programs and activities in
accordance with guidelines issued by the governing board.
Develop and maintain written policies and procedures and professional standards of practice that govern the operations of
the facility.
Assist department directors in the development, use, and implementation of departmental policies and procedures and
professional standards of practice.
Ensure that all employees, residents, visitors, and the general public follow the facility ' s established policies and
procedures.
Make routine inspections of the facility to assure that established policies and procedures are being implemented and
followed.
Personnel Functions : Assist in the recruitment and selection of competent department directors, supervision, facility non-
licensed staff, consultants, etc.
Delegate administrative authority, responsibility, and accountability to other staff personnel as deemed necessary to
perform their assigned duties.
Staff Development : Assist department directors in the topic selection, planning, conducting, and scheduling of in-service
training classes and on-the-job training and orientation programs to assure that current material and programs are
continuously provided.
Safety and Sanitation : Review accident/incident reports (e.g., falls, injuries of an unknown source, abuse, etc.). Monitor
to determine the effectiveness of the facility ' s risk management program.
Equipment and Supply Functions : Ensure that the facility is maintained in a clean and safe manner for resident comfort and
convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services.
On [DATE] at 2:37 p.m. an interview was conducted with the Nursing Home Administrator NHA regarding the events of [DATE].
When he was asked by the surveyor What was put into place after the event involving (Resident #1)? The NHA said, I will
have to ask the nurse. Communication at first was [MEDICAL CONDITION]. It wasn ' t until after midnight to 1:00 when the
detective spoke to me. The NHA said he had worked at the facility since [DATE]th, 2015 and nothing like the event on [DATE]
had happened at the facility since his hire date. The NHA said, We still don ' t have any confirmation of sunburn,
blisters. We met with everyone to determine what was fact or fiction in this case. We reached out to (Primary Care
Physician) and the (Medical Director). They said they couldn ' t get anything, any information.
Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. Sheet and
physician
progress notes [REDACTED].
possible.
Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE],the resident was referred to physical therapy
follows:
1. Patient will safely perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for
A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE].
understanding.
On [DATE] at 12:30 p.m., an interview was conducted with the Risk Manager. She said at 2:45 p.m. on [DATE], the resident ' s
[REDACTED].
Per the nurse ' s notes, dated [DATE] at 10:00 p.m., the resident had an alarm to the bed and wheelchair due to poor safety
awareness related to Dementia. The noted said the resident checked often. The resident was able to slowly propel himself in
Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced
OMB NO. 0938-0391
CORRECTION NUMBER
105486
a fall, date of fall: [DATE] and Resident would benefit from skilled PT for B LE (Bilateral Lower Extremity) strengthening
Level of harm - Immediate and balance training for safety and transfers.
jeopardy Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine
days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] , revealed that physical
Residents Affected - Few therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for
[REDACTED].
mobility with a problem onset date of [DATE] and a next review date of [DATE], found [DATE] - fall occurred from w/c - see
nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff
Continued record review of the nurse ' s notes, dated, [DATE] (no time), found that a nurse was called out to the patio by
another resident. The nurse (Staff N) found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken
back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911
was called. The resident was transferred to the hospital.
(Source: National Institute of Health [DATE]).
Control at http://stacks.cdc.gov/view/cdc/ ).
Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm the temperature
was 89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity
46%, Heat Index: 89.6%, scattered clouds.
On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He
On [DATE] at 3:45 p.m., an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess
and prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse
anoxia. Reference: Wikipedia, the free encyclopedia) Staff Q asked the CNA in the room to get cold wet wash cloths and a
Review of the Nursing Evaluation dated, [DATE], under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/
Making
score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be completed. The
resident was also on Nectar thickened liquids.
A comprehensive record review revealed no At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical
record.
(CNA) (Staff E) for Resident #1. She said she assisted the resident with his morning care at approximately 10:30 a.m. She
himself around the TV room and in front of the north wing nurses ' station. Between 2:15 p.m. -2:30 p.m., the CNA took the
resident to his room to provide care. She said, between 2:45 p.m. -3:00 p.m., she saw the resident propelling himself
toward the patio door. She stopped him and said, Where are you going? The resident responded, Outside . The CNA said, Ok
let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the
resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did
not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going
to be late .
OMB NO. 0938-0391
CORRECTION NUMBER
105486
and on [DATE] at 3:30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was
Level of harm - Immediate sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at
jeopardy approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the
Residents Affected - Few the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed
smoking patio on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before
that day. At approximately 4:00 p.m., she said she noticed Resident #1 sitting in his wheelchair near the soda machines in
the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the
resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into
the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come
inside. The resident ' s CNA (Staff F) said, Ok thank you.
with locating Resident #1. Staff R verified that, at no time during her dining duty, did she leave the dining room or see
dining room. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident '
s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N)
handrail.
Resident #1. He said he saw, The man on the patio that died , and stated it was nasty and indicated it looked like he had
The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the
the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Staff R said, however,
she was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the
dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about
5:15 p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the
tray to the resident ' s room.
had glass panels with a glass automatic door which was accessible by an automatic door push to open button at wheelchair
height. The patio was not within line of sight from the North Unit nurses ' station and there was no phone or call system
observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the
left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently
throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio
had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was
conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between
,[DATE] and [DATE]). She said prior to the new canopy, there was no other shaded areas except along the outside walls under
the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation).
Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N '
s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass
door to the patio.
A review of the care plan for Resident #1 found Problem onset, dated [DATE], with the next review date of [DATE], for
resident needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene
needs related to dementia and left [MEDICAL CONDITION].
Review of the care plan with Problem onset dated [DATE] and the next review date of [DATE] indicated the resident was over
his ideal body weight and received a mechanical soft/no added salt diet with thickened liquids. For Problem onset dated
[DATE], and the next review date of [DATE], the resident was at risk for aspiration related to dysphasia treatment for
OMB NO. 0938-0391
CORRECTION NUMBER
105486
[REDACTED].
Level of harm - Immediate A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE], did not indicate for [DATE] (day of death) that he
jeopardy received breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner. In addition, out of 29
possible offerings for a snack, 26 opportunities were left blank. There was no documentation on the Activities of Daily
Residents Affected - Few Living (ADL) flow sheet that indicated the resident received a bedtime snack as per the physician's order [REDACTED].>Per
the physician's order [REDACTED].
On 2:27 p.m. [DATE] an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the
concerns related to being o(TRUNCATED)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED:2/14/2018

CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

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