Solaris Healthcare Bayonet Point

Inspectors wroteBased on record review, interview, and policy and procedure review the facility failed to ensure the residents rights were honored by failing to implement/follow formulated advance directives for one resident (#209) of one resident reviewed. Resident #209 had an Advanced Directive for Do Not Resuscitate (DNR) formulated, which staff did not follow. The DNR was not honored by the facility when they failed to obtain clarification of code status during the admission process, per facility policy. This failure resulted in the resident experiencing sternal and anterior chest wall pain, serious psychosocial harm by not honoring the resident's wishes for a natural, dignified death.

Inspectors wroteBased on interview, record review and policy and procedure review the facility failed to honor a resident's expressed Advanced Directive for end of life for one resident (#209) of one resident reviewed, by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were not performed when Resident #209 was found unresponsive and absent of vital signs. Resident #209 was admitted to the facility on [DATE] with a fully executed State of Florida Do NOT RESUSCITATE ORDER (DNR) DH (Department of Health) form 1896,Revised [DATE] dated [DATE]. Resident #209's representative provided a copy to the facility on [DATE] at 12:40 PM. The facility's unlicensed staff did not provide the DNR order to a licensed staff member for processing. Resident #209 was found unresponsive and absent of vital signs on [DATE] at 2:12 PM. The resident's wishes were not honored, and CPR was initiated. [...]

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to ensure food was stored safely and properly labeled in one reach-in cooler out of one reach-in cooler observed in the kitchen.

Inspectors wroteBased on observation, interview, and record review and policy and procedure review, the facility failed to prevent the possible spread of infection and communicable diseases by failing to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions for (Resident # 194), and contact precautions for (Resident #188) and did not perform hand hygiene upon entering and exiting resident's rooms during five observations of ten observations of medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident a minimum data set assessment was transmitted within 14 days after completion for one resident (#12) of two residents reviewed for resident assessment.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin according to professional standards of practice for two residents (#152 and #5) of four residents reviewed for insulin administration and failed to administer cardiovascular medications according to professional standards of practice for one resident (#185) of four residents reviewed for cardiovascular medication administration.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered parameters were followed for blood pressure medications resulting in the administration of unnecessary medications for three residents (#157, #10 and #91) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to properly store medications for two residents (#212 and #213) in one unit (200) out of 3 units observed.

Inspectors wroteBased on interview and record review the facility failed to accurately and adequately document medication administration for antidiabetic and cardiovascular medications for three residents (#35, #85 and #185) of seven residents reviewed for medication management.

Inspectors wroteBased on review of pharmacy recommendations and interviews, the facility failed to ensure the attending physician documented in the residents medical records the rationale for not acting on and following pharmacy recommendation for two (#2 and #19) of three residents reviewed for pharmacy recommendations.

Inspectors wroteBased on observation, interview, and policy and procedure review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by failing to perform hand hygiene during medication administration for three (Residents #12,#13 and #14) of six residents observed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner to limit unauthorized access to medications for one (#14) of three residents reviewed for medication storage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain privacy and dignity related to 1. one (Unit D) of three units, with a constant loud high pitch noise coming from the call light system, and throughout the halls during four of four days observed (9/11/2023, 9/12/2023, 9/13/2023, and 9/14/2023); and 2. two (Residents #33 and #136) of two sampled residents observed from the hallway, lying in bed disrobed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess one (Resident #95) of forty-three sampled residents for the ability to self-administer medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately follow up on a pharmacy recommendation for one (Resident #85) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed, and four errors were identified for four (Residents #356, #456, #97, and #95) of seven residents observed. These errors constituted a 15.38% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. have personal protective equipment (PPE) immediately available for staff use to protect residents who were on enhanced barrier precautions for one (Residents #407) of two residents reviewed and 2. failed to ensure staff cleaned their multi-use mask after each use for one (Resident #127) of two residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a dignified dining experience during two (8/24 - 8/25/2021) of two dining observations. Fifty-eight residents were identified as living on one of three wings (B wing) where staff were observed standing over two (#100 and #44) residents while assisting with eating. The Staff delivered meal trays to four roommates (#57, 51, 14, and 67) at different times, and left one meal out of reach but within sight of one dependent diner (#97).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care plan interventions for one (Resident #137) of four residents sampled for falls related to placement of floor mats for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitation services related to physical therapy, for one (Resident #418) of 32 residents sampled. Findings Included: On 08/24/21 at 11:34 a.m. an interview was conducted with Resident #418. She stated she was admitted to the facility about six weeks ago. Resident #418 had a goal of completing physical therapy and being discharged home. Resident #418 stated her therapy services ended over three weeks ago. Staff informed her that it was due to her insurance coverage ending. Resident #418 stated she asked staff to speak to the facility social worker, to no avail. Resident #418 stated her son would not allow her to come back home until she was able to transfer safely to the bathroom. Resident #418 stated since she was not receiving physical therapy, she was unable to achieve that goal. [...]