Lehigh Acres Healthcare & Rehab Center
LEHIGH ACRES HEALTHCARE & REHAB CENTER in LEHIGH ACRES, FL — inspection on August 24, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the clinical record revealed Resident #1 was a vulnerable [AGE] year-old male admitted to the facility from an acute care hospital on 8/7/24.
Diagnoses included Dementia and Alzheimer's disease.
On 8/7/24 the Licensed Practical Nurse documented in an elopement risk evaluation Resident #1 scored a 6 on the elopement risk evaluation indicating he was not at risk for elopement.
The resident was alert and oriented X 1 (Oriented to person) or had periodic confusion. Resident #1 wandered but has never eloped. Resident #1 was discontent but agreeable to facility placement.
The Admission Comprehensive Nursing Evaluation with an effective date of 8/7/24 noted Resident #1 was alert with some confusion.
The resident's balance while standing, sitting and during transitions was not steady but Resident #1 was able to stabilize self without assistance.
The baseline care plan initiated on 8/8/24 documented Resident #1 had decreased cognitive skills related to cognitive/linguistic deficits and a potential for alteration in thought process related to diagnosis of dementia, Alzheimer's disease and altered mental status.
The baseline care plan specified to observe Resident #1 for changes in cognitive function and notify the physician if noted.
On 8/8/24 the Speech Language Pathologist (SLP) checked the boxes in a therapy screen form indicating Resident #1 had a change in cognitive function, and safety awareness/judgment.
The SLP noted the resident's cognition was severely impaired with a score of 03 on the Brief Interview for Mental Status assessment (used to evaluate a resident's cognition, behavior and mood).
On 8/8/24 the Physical Therapist (PT) documented in an evaluation Resident #1 was able to ambulate 150 feet with minimal assistance. Resident #1's goal was, I want to go home.
The PT documented the potential for achieving the goal was fair, limited by the resident's impaired cognition and safety awareness.
Review of the progress notes revealed the Attending Physician assessed Resident #1 on 8/8/24, 8/9/24, 8/15/24, and 8/16/24.
The physician documented during each visit the resident's cognition was impaired and, Monitor for worsening symptoms or changes in mental status.
On 8/15/24 the Psychiatrist documented Resident #1 was referred for an evaluation for Depression and anxiety.
The resident's daughter reported he has been showing sundowning behavior (confusion that occurs in the late afternoon and lasts into the night) with more anxiety specially at nighttime.
The psychiatrist documented, Cognitive impairment, Confusion. Resident #1's insight, judgment, short-term, and long-term memory were poor.
105522
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105522 B.
Wing 08/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936
Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] from an acute care hospital.
Diagnoses included Alzheimer's disease and Dementia.
The Admission Nursing Comprehensive evaluation dated 8/7/24 at 6:56 p.m., noted Resident #1 scored a 6 on the elopement risk evaluation indicating the resident was not at risk for elopement.
The Licensed Nurse completing the assessment noted in History of elopement/wandering, Wanders, but has NEVER eloped. Resident #1 was totally or mostly dependent in locomotion, was discontent but agreeable to facility placement.
The baseline care plan initiated on 8/8/24 documented Resident #1 had decreased cognitive skills related to cognitive/linguistic deficits and a potential for alteration in thought process related to diagnosis of dementia, Alzheimer's disease and altered mental status.
The baseline care plan specified to observe Resident #1 for changes in cognitive function and notify the physician if noted.
105522
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105522 B.
Wing 08/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lehigh Acres Healthcare & Rehab Center 1550 Lee Boulevard Lehigh Acres, FL 33936