59A-36.014(3) FAC Physical Plant – Safe Living Environ/Other
(3) OTHER REQUIREMENTS.
(a) All facilities must:
1. Provide a safe living environment pursuant to section 429.28(1ya), F.S.;
2. Be maintained free of hazards; and,
3. Ensure that all existing architectural, mechanical, electrical and structural systems,
and appurtenances are maintained in good Working order.
(b) Pursuant to section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings:
1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable to ensure easy access by the resident,
2. A closet or wardrobe space for hanging clothes,
3. A dresser, or other furniture designed for storage of clothing or personal effects,
4. A table or nightstand, bedside lamp or floor tamp, and waste basket; and,
5. A comfortable chair, if requested.
(c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency.
(d) Residents who use portable bedside commodes must be provided with privacy during
use.
(e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be. –…
This Statute or Rule is not met as evidenced by: Based on observation and interview the facility failed to ensure all existing architectural, electrical and structural systems are maintain in good working order.
Findings included:
On. .. at 8:20 AM observed tarps on buildings 410 and 418.
On……………… at 8:21 AM the Administrator stated that there was no leaking, but they had to put the tarps because they were on the process of a claim to replace the roof because the roof was from 1997
Uncorrected Class III
429.23 & FS; 59A-36.016 FAC Risk Mgmt & QA; Adverse Incident Report
429.23 Internal risk management and quality assurance program, adverse incidents and reporting requirements-
(1) Every facility licensed under this part may, as part of its administrative functions, voluntarily establish a risk management and quality assurance program, the purpose of which is to assess resident care practices, facility incident reports, deficiencies cited by the agency, adverse incident reports, and resident grievances and develop plans of action to correct and respond quickly to identify quality differences.
(2) Every facility licensed under this part is required to maintain adverse incident reports. For purposes of this section, the term, “adverse Incident” means: (a) An event over which facility personnel could exercise control rather than as a result of the resident’s condition and results in:
1. …….
2 or damage:
3. Permanent…
4…………… Or………….. of bones or joints;
5. Any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives;
6. Any condition that requires the transfer of the resident from the facility to a unit providing more acute care due to the incident rather than the resident’s condition before the incident; or
7. An event that is reported to law enforcement or its personnel for investigation; or
(b) Resident elopement, if the elopement places the resident at risk of harm or injury.
(3) Licensed facilities shall provide within 1 business day after the occurrence of an adverse Incident, through the agency’s online portal, or if the portal is offline, by electronic mail, a preliminary report to the agency on all adverse incidents specified under this section. The report must include information regarding the identity of the affected resident, the type of adverse incident, and the status of the facility’s investigation of the incident.
(4) Licensed facilities shall provide within 15 days, through the agency’s online portal, or if the portal is offline, by electronic mail, a full report to the agency on all adverse incidents specified in this section. The report must include the results of the facility’s investigation into the adverse incident.
(6) ……………….., neglect, or , must be reported to the Department of Children and Families as required under chapter 415.
(7) The information reported to the agency pursuant to subsection (3) which relates to persons licensed under chapter 458, chapter 459, chapter 461, chapter 464, or chapter 465 shall be reviewed by the agency. The agency shall determine whether any of the incidents potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of $. 456.073 apply. The agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken in response to the incident.
The agency shall review each incident and determine whether it potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of $. 456.073 apply.
(8) If the agency, through its receipt of the adverse incident reports prescribed in this part or through any investigation, has reasonable belief that conduct by a staff member or employee of a licensed facility is grounds for disciplinary action by the appropriate board, the agency shall report this fact to such regulatory board.
(9) The adverse incident reports and preliminary adverse incident reports required under this section are confidential as provided by law and are not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or appropriate regulatory board.
(10) The agency may adopt rules necessary to administer this section.
59A-36.016 Adverse Incident Report.
(1) INITIAL ADVERSE INCIDENT REPORT. The preliminary adverse incident report required by section 429.23(3), F.S., must be submitted within 1 business day after the incident pursuant to rule 59A-35. 110, F.A.C., which requires online reporting.
(2) FULL ADVERSE INCIDENT REPORT. For each adverse incident reported in subsection (1), above, the facility must submit a full report within 15 days of the incident. The full report must be submitted pursuant to rule 59A-35.110, F.A.C., which requires online reporting.
This Statute or Rule is not met as evidenced by: Based on record review and interview the facility failed to file an adverse incident report with the agency for healthcare after 1 business day and within 15 business days after the occurrence of an onsite for one out of 17 sampled residents (Resident # 10).
Findings Included:
A facility record review revealed that Resident #10 at the facility on . ……….. . Further review showed no documentation of an incident report.
On………….. at 9:30 AM the Administrator stated that the facility did not file a complaint with the agency because the resident, natural causes. An internal incident report was filed. She stated that the doctor had told the officers that it had probably been a sudden …..
Uncorrected Class III