Aviata at Palma Sola Bay

In the surveyor’s words

From the most serious findings on record at Aviata at Palma Sola Bay, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 29, 2024

  Cross Reference F842 Based on observation, interview, and record review, the facility failed to ensure a newly admitted resident (#6) out of five newly admitted residents reviewed was free from significant medication errors as evidenced by not receiving physician ordered medications for a period of seven days resulting in a readmission to a local hospital due to a hematoma and exacerbation of her medical diagnoses to include a flare-up of Multiple Sclerosis (MS) symptoms to include paralysis in her hands, confusion, and a low hemoglobin requiring a transfusion of packed red blood cells (PRBCs) . On 8/9/24, Resident #6 was admitted to the facility with medication orders from the acute facility. Resident #6's ordered medications were not entered into the electronic medical record. […]

• Immediate jeopardy, isolatedF842Aug 29, 2024

  Cross Reference F760 Based on observation, review of medical records, policy and procedure review, interviews with residents, resident representative, nursing staff, key management staff, the residents' physician and pharmacist, it was determined the facility failed to ensure the medical records were complete and accurate in accordance to accepted professional standards and practices for two residents (#3, and #6) out of 9 residents reviewed. This failure contributed to the lack of communication amongst staff in delivering care and services for Resident #3 and Resident #6 resulting in the residents not receiving physician ordered medications. The facility staff did not ensure documentation was completed upon admission for Resident #6 related to medication reconciliation. […]

• Immediate jeopardy, isolatedF600Jul 12, 2024

  Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse/neglect by 1) failing to respond to a serious change in condition in a timely manner for one resident (#404) out of seven residents sampled for abuse/neglect and, 2) use of a Geri-chair as a restraint to limit a residents movement for one resident (#248) out of seven sampled for abuse/neglect. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. The bleeding required four dressing changes to the upper extremities and two dressing changes to the lower extremities due to bleeding through the dressings over the course of 17 hours. On [DATE] at 7:25 a.m. […]

• Immediate jeopardy, isolatedF684Jul 12, 2024

  Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1) a failure to communicate a significant change of condition to other licensed nurses and the physician, resulting in a delay of treatment for one resident (#404) out of seven residents sampled; 2) a failure to implement physician orders related to vital signs monitoring for one resident (#94) out of seven residents sampled and, 3) a failure to recognize and respond to a change in condition related to hypotension for one resident (#401) out of seven residents sampled. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. […]

• Immediate jeopardy, isolatedF726Jul 12, 2024

  Based on interviews and record reviews, the facility failed to ensure there were competent staff to provide nursing services in order to assure resident safety and well-being for three residents (#404, #94, and #401) out of seven residents sampled. Findings included: 1. A review of the medical record revealed Resident #404 was admitted on [DATE] with diagnoses, including but not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, chronic pancreatitis, unspecified open wounds to left ankle, neck, right lower leg, right thigh, left hip, left lower leg, lower back, and pelvis without penetration to retroperitoneum, unspecified atrial fibrillation, gastrostomy status, unspecified gastrointestinal hemorrhage, unspecified anemia, and unspecified coagulation… […]