Orlando Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Orlando Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 8, 2024

  Based on observation, interview and record review, the facility neglected to provide adequate oversight of staff to provide appropriate admission orders and skin assessments; and neglected to provide maintenance care and services for a peripherally inserted central line intravenous catheter (PICC) per standards of care for 1 of 1 resident reviewed for PICC lines, of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. The 3008 Agency for Healthcare Administration Transfer and Discharge form dated 1/10/24 detailed the double lumen PICC, but the form did not give the date it was inserted, the date the dressing was last changed or the location. […]

• Immediate jeopardy, isolatedF684Mar 8, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate care and services in accordance with accepted professional standards to identify, obtain and implement physician orders for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, (#72), failed to change intravenous line dressings as per orders for 1 of 6 residents reviewed for medication administration (#435), and failed to monitor blood glucose levels as per physician orders for 1 of 3 residents reviewed for (#584) insulin use out of a total sample of 109 residents, (#72). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. […]

• Immediate jeopardy, isolatedF726Mar 8, 2024

  Based on observation, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a peripherally inserted intravenous central line catheter (PICC) for 1 of 1 resident reviewed for PICC lines, out of a total sample of 109 residents (#72) and failed to ensure licensed nurses were competent to follow physician orders for medication parameters, topical ointments and diabetes management for 4 of 102 licensed nurses, (Registered Nurses D, K, E and GG). Resident #72 was readmitted to the facility from the hospital on 1/10/24 with a peripherally inserted central line catheter in his left upper arm. […]

• Immediate jeopardy, isolatedF600Oct 24, 2022

  Based on observation, interview and record review, the facility neglected to provide adequate supervision and a secure environment, neglected to administer scheduled tube feedings and perform regular and change of shift rounds to monitor resident status and activities to prevent resident from exiting the facility unsupervised for 1 of 18 residents reviewed for elopement out of 25 residents identified at risk for elopement, (resident #1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility for 7 hours, unsupervised, there was likelihood he could have become dehydrated, fallen, been accosted by unknown persons, drowned or been hit by a car. […]

• Immediate jeopardy, isolatedF689Oct 24, 2022

  Based on observation, interview and record review, the facility failed to maintain a secure environment and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility unsupervised for 1 of 18 residents reviewed for elopement out of 25 residents identified at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility for 7 hours, unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, drowned or been hit by a car. On 10/15/22, four days after admission, at approximately 10:45 AM, resident #1 left his room and walked to the lobby of the main entrance door. […]