Life Care Center of Altamonte Springs

In the surveyor’s words

From the most serious findings on record at Life Care Center of Altamonte Springs, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 18, 2023

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide post fall neurologic assessment and monitoring, failure to immediately notify the physician of changes in condition post fall, (#4); failure to implement fall management protocols to ensure residents received necessary care, equipment, and services to prevent falls and avoid major injuries; and failure to maintain processes that supported effective interdisciplinary team (IDT) functions to meet the safety and care needs for 6 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). […]

• Immediate jeopardy, patternF689Aug 18, 2023

  Based on observation, interview, and record review, the facility failed to identify and implement effective fall prevention approaches including equipment, adequate assistance, and increased supervision for vulnerable, physically and cognitively impaired residents, to avoid falls and falls with injuries for 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). This failure contributed to numerous unwitnessed falls which resulted in injuries such as fractures, head injuries, and lacerations. […]

• Immediate jeopardy, patternF835Aug 18, 2023

  Based on observation, interview, and record review, the facility's administration failed to recognize and address trends related to repeated unwitnessed falls and fall-related injuries; and failed to direct its resources to provide adequate clinical oversight of the fall incident review process and implementation of fall management protocols to ensure the safety and well-being of 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). These failures contributed to falls with major injuries for residents #1 and #9, who required hospitalization , surgical intervention, and rehabilitation for hip fractures. […]

• Immediate jeopardy, isolatedF684Aug 18, 2023

  Based on interview, and record review, the facility failed to ensure licensed nurses provided neurological assessments after an unwitnessed fall and failed to ensure licensed nurses notified a physician of changes in condition post-fall per professional standards of practice for post fall monitoring for 1 of 8 residents reviewed for falls, of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found her notified assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injuries, no change in range of motion and was to have continued monitoring. […]

• Immediate jeopardy, isolatedF726Aug 18, 2023

  Based on interview, and record review, the facility failed to ensure licensed and agency nurses were knowledgeable and competent in initiating and performing neurological assessments after an unwitnessed fall, and in notifying the physician and oncoming staff of a resident's fall and changes in condition for 1 of 8 residents reviewed for falls of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found resident #4 notified assigned Registered Nurse (RN) H of resident #4's fall. […]