Every finding on record at Baptist Village of Enid

Based on record review and interview, the facility failed to complete quarterly fall risk evaluations for 1 (#3) of 5 sampled residents reviewed for falls.The ADON identified 70 residents resided in the facility. Findings:A Fall Prevention Policy and Procedure policy, revised 02/2014, read in part, A fall risk evaluation will be completed quarterly, annually, on re-admission and with significant change in condition.A FALL RISK EVALUATION for Resident #3, dated 08/22/24, showed the resident had a fall risk score of 11, indicating a high risk for falls.There was no documentation a fall risk evaluation was completed for Resident #3 between September 2024 through February 2025. A quarterly resident assessment for Resident #3, dated 02/11/25, showed the resident had diagnoses which included heart failure and hypertension. It showed the resident's cognition was severely impaired, with a BIMS of 06.A care plan for Resident #3, revised 02/12/25, showed the resident was at risk for falls related to weakness, knee buckling, and hypertension.A Fall Investigation Form for Resident #3, dated 02/12/25, showed the resident had a fall during transfer.On 03/05/26 at 10:39 a.m., the DON stated the process for fall risk evaluations was to evaluate the resident at admission, quarterly, and upon any significant change. They stated fall risk evaluations could be completed by the charge nurse or the MDS coordinator.On 03/05/26 at 12:21 p.m., the ADON and vice president were interviewed. The ADON stated a quarterly fall risk evaluation was completed for Resident #3 on 8/22/24. The vice president stated the resident should have had the next evaluation completed in 11/2024.

Based on record review and interview, the facility failed to obtain lab as ordered for 1 (#5) of 5 sampled residents reviewed for falls.The ADON identified 70 residents resided in the facility.Findings:Resident #5's physician's order, dated 09/01/25, showeda. Dilantin 100 mg (an anticonvulsant medication) one capsule one time daily in the morning for seizure prevention.b. Dilantin 100 mg two capsules one time daily in the evening for seizure prevention.Resident #5's nursing note, dated 11/24/25, read in part, Dilantin level 44.4. Notified PCP new order to hold Dilantin and redraw labs on Wednesday.Resident #5's laboratory results were reviewed for November 2025, there was no documentation the lab was obtained.On 03/04/26 at 10:39 a.m., LPN #1 stated the lab should have been obtained on 11/26/25. They stated there was no record the lab was obtained.On 03/04/26 at 10:50 a.m., the DON stated the lab should have been obtained on 11/26/25.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#53) of five sampled residents who was reviewed for unnecessary medications. Corporate Nurse #1 stated 53 residents received blood pressure medications. Findings: A Preparation for Medication Administration policy, dated 06/2021, documented medications were administered as prescribed. Resident #53 had diagnoses which included hypertension. A medication order form, dated 06/14/24, documented Resident #53 was to receive metoprolol succinate ER (beta blocker) 50 mg every day and 100 mg every night. It documented to hold the medication if systolic blood pressure was less than 100 and diastolic blood pressure was less than 50. A medication order form, dated 08/12/24, documented Resident #53 was to receive lisinopril (blood pressure medication)10 mg every day. A September 2024 Medications form, documented on 09/27/24 Resident #53's morning diastolic blood pressure was 49. It documented the resident received metoprolol succinate ER 50 mg and Lisinopril 10 mg. A November 2024 Medications form, documented on 11/10/24 Resident #53's evening systolic blood pressure was 81. It documented the resident received Metoprolol Succinate ER 100 mg. On 12/04/24 at 9:52 a.m., CMA #2 stated blood pressure medications usually had parameters instructing when not to administer the medication. They stated if the systolic was below 100 and if the diastolic was below 50, staff were not to administer the medication and they were to notify the nurse. CMA #2 was shown Resident #53's medications forms from September and November 2024. They stated they would not have administered the medications. On 12/04/24 at 9:57 a.m., LPN #3 was shown Resident #53's medication forms from September and November 2024. They stated the medications should not have been given.

Based on observation, record review and interview, the facility failed to ensure a medication was labeled for one of two medication carts observed. The DON identified 63 residents resided in the facility. Findings: A Medication Ordering and Receiving from Provider Pharmacy policy, dated 06/2021, read in part, Medication containers having soiled, damaged, incomplete, illegible or makeshift labels are returned to the issuing pharmacy for relabeling or destroyed in accordance with the medication destruction policy. On 12/02/24 at 1:10 p.m., a box of ipratropium bromide (broncodilator) 0.5 mg and albuterol sulfate 3 mg Inhalation solution was observed to be in a medication cart. There was a common nickname handwritten on the top of the medication box. The medication did not have a label with a resident name, medication name, strength, directions for use, fill date, quantity dispensed, prescriber name or expiration. LPN #1 stated, That's for [resident name deleted]. LPN #1 was asked how staff knew who the medication was for since it did not have a label. They stated, It says [name deleted] on it. LPN #1 stated the medication had been there since they returned to work in August 2024. On 12/02/24 at 1:35 p.m., CMA #1 was asked how they knew they were giving a resident the correct medications. They stated, It has a label on it. CMA #1 was asked what they would do if the medication did not have a label on it. They stated, Then you don't give it. 41318

Based on record review and interview, the facility failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The administrator identified 63 residents resided in facility. Findings: A Legionella policy, dated August 20 2024, read in part, is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The policy did not identify a system to prevent or detect water borne contaminants. On 12/04/24 at 10:30 a.m., the administrator was asked what system does the facility have in place to prevent and detect the water borne pathogens such as Legionella in the facility water system. They stated there was a policy, but not a system for testing.

Based on record review and interview the facility failed: a. to notify the physician for one (#5) of three sampled residents reviewed for physician notification, and b. notify the resident representative for one (#2) of three residents reviewed for a change in condition. The administrator identified 65 residents resided in the facility. Findings: 1. Resident #5 had diagnoses which included renal insufficiency, and diabetes mellitus. Resident #5 had a physician order for Eliquis 5 mg tablet two times per day. A nurse's Change in Condition note, dated 04/21/24 at 5:19 a.m., read in part Res was noted with milky thick urine with foul oder [sic]. Encouraged res to drink more water . There was no documentation the physician had been notified. A nursing progress note, dated 05/05/24 at 11:13 p.m., read in part staff reported to this nurse res had bright red blood in brief and toilet x2 this shift res explained past experience r/t bladder and blood transfusion res has no s/s of weakness noted states also f/u in am r/t condition call light et fluids within reach A Change in Condition nurse note, dated 05/06/24 at 6:47 a.m., read in part Res is noted with blood in her brief and in toilet when [they] urinates. Denies pain or discomfort [at] this time. A nursing Daily Note, dated 5/6/24 at 12:48 p.m., read in part blood in urine no blood noted in urine today, res states this happens sometimes, eliquis initially held this AM, until nurse able to assess urine. no blood noted. A nurse's Daily Note, dated 05/07/24 at 12:49 p.m., read in part staff reported res urine is dark, cloudy and foul odor. UA collected and sent to lab with pending results. There was not documentation the physician had been notified of the blood in the brief on 05/05/24, 05/06/24 and 05/07/24. On 07/17/24 at 8:31 a.m., the DON was asked if the cloudy thick urine and blood in the urine should have been reported to the physician. They stated, Yes. 2. Resident #2 had diagnoses which included Alzheimer's, and dysphagia. A Physician order, dated 07/29/23, documented mechanical soft with ground meat and nectar thick liquids. A quarterly assessment, dated 06/09/24, documented the resident had a memory problem and was moderately impaired regarding decisions for tasks of daily life. A Radiology Interpretation, dated 06/24/24, documented a chest xray was completed and the impression was congestive heart failure. A East Hall 24 hour communication log, dated 06/26/24, read in part, 11-7 shift . [Residents name] educate staff check lungs Hospice will call .7-3 shift .wont Keep [oxygen] NC on RA sat 90%-92% .3-11 shift .[oxygen] cannula refusal nasty cough nose bleed . A nursing hospice communication note, dated 07/01/24, read in part Received call back from hospice director of nursing on concern about resident being given thin liquids There was no documentation Resident #2's family had been notified of the change in condition. On 07/15/24 at 1:58 p.m., Resident #2's family member was asked if they were notified when there was a change in the residents health. They stated, No, they usually find out some other way. On 07/16/24 at 9:58 a.m., the DON was asked to review a progress note dated 06/24/24 that documented the resident was coughing and their pulse ox had dropped. The resident had been started on Mucinex and a chest xray had been ordered. They were asked if the family had been notified. They stated No. On 07/16/24 at 10:51 a.m., the DON was asked if the family was notified when the resident may have been given thin liquids. They stated, they did not find out about the incident until 07/01/24 then spoke with Hospice. There was no documentation the family had been notified.

Based on observation, record review, and interview the facility failed to ensure residents and resident representatives were able to file a grievance form anonymously, and post information regarding the name of the grievance official. The Administrator identified 65 residents resided in the facility. Findings: A Grievance Procedure, revised 03/2018, read in part Whenever the Guest has a need or request that is not being met, the Guest or his/her Representative should .Report it to the person in charge .Additional notices of health care center grievance process will be displayed in prominent locations throughout the health center .Grievance may be given to any friends' team member who will forward the grievance to the Grievance Office or they may file the grievances anonymously in the designated box located . Ombudsman contact name, resident rights, and OSDH complaint poster was observed in a box with a glass cover on the wall near the front entrance. There was no signage to indicate the person to contact to file a grievance or a box to place grievance forms. On 07/15/24 at 2:28 p.m., Resident #3's family member was asked if they knew how to file a grievance. They stated they did not know. On 07/15/24 at 2:49 p.m., the DON was asked was there a sign posted on how a grievance could be filed. They reviewed the signage posted near the front entrance and stated there was not one on how to file a grievance. They stated the information is in the admission packet. They were asked how would the resident know who to ask if time has passed. They stated they were usure. On 07/15/24 at 3:22 p.m., Resident #4's family member was asked if they knew how to file a grievance. They stated, they were unsure but thought it would be with the social services director. On 07/16/24 at 11:13 a.m., CNA #1 was asked if a resident wanted to file a grievance how did that process work. They stated they would tell the resident to go to the nurse. They were asked if they knew how the process worked. They stated no, they would just send them to the nurse. On 07/17/24 at 6:30 a.m., RN #2 was asked if a resident wanted to file a grievance how did that process work. They stated they were unsure and would take it to the DON or ADON. They were asked who was the grievance official. They were not sure. On 07/17/24 at 6:53 a.m., CNA #2 was asked if a resident wanted to file a grievance how did that process work. They stated they would tell their direct supervisor. They were asked who was the grievance official. They were not sure. On 07/17/24 at 3:04 p.m., the grievance procedure was reviewed with the Administrator. They were asked if there was a letter to identify who the grievance officer was. They stated the social services director is in every care plan meeting. They were asked if there was a box available for residents or representatives to file a grievance anonymously. They stated, No.

Based on record review and interview the faciity failed to report an allegation of misappropriation of property to the OSDH for one (#5) of three sampled residents reviewed for misappropriation of property. The Administrator identified 65 residents who resided in the facility. Findings: A Grievance Procedure, revised 03/2018, read in part .If there is an allegation of .or misappropriation of Guest property, an incident report outlining corrective and preventative measures will be sent to the Oklahoma State Department of Health and the Department of Human Services .The investigation will consist at least the following .Interviews with any witnesses to the incident or concern .a search of the resident room .An interview with team members having contact with the resident during the relevant periods or shifts of the alleged incident .interviews with the resident's roommate, family members, and visitors .A root cause analysis of all circumstanced surrounding the incident . A Abuse, Neglect, mistreatment and misappropriation of resident property, policy, revised 06/2023 read in part . It is the policy of this health center that reports of abuse .(misappropriation of property) are promptly and thoroughly investigated .the policy also read, The health center will ensure that all alleged violations involving .misappropriation of resident property, are reported immediately .but not later that 2 hours after the allegation is made . An email, dated 02/26/24, read in part I spoke with [resident] .west this morning [they] said that [they] is missing clothing from the time [they] was in isolation 3 gowns and a couple other items . The email was sent to the social services director on 03/04/24. A Concern/Suggestion form, dated 03/04/24, read in part [Resident #5] stopped me this morning to talk about missing clothing .[They] was missing 2 pair of black slacks, 1 denim capris 1 long sleeve stripped [sic] turtel [sic] neck, 1 aqua green sweat shirt 2 night gowns. pantsize lz pette [sic]. I asked [laundry] about these items [they] said they were never brought to laundry . A Grievance/Concern Form, dated 03/04/24, (author was Administrator and Social services)read in part Resident stopped me this morning to [NAME] about missing clothing. [They] said [they] was missing two pairs of black slacks, a pair of denim capris, one long sleeve striped turtleneck, a aqua green sweatshirt (name on shirt) [and] two nightgowns . signed by the Administrator. There was no documentation a report had been filed with the OSDH for misappropriation of property. There was no documentation, a search of the room was completed, or staff and other residents were interviewed regarding missing property. On 07/16/24 at 2:40 p.m., the Administrator was asked if they had concluded what happened to the resident's personal items that were missing. They stated they thought the items were put into a biohazard bag, the resident room was searched and laundry was searched the items were not found. They were asked if they had documented the investigation into the allegation and filed a state report. They stated they did not.

Based on record review and interview the facility failed to assess, and monitor for one (#5) of seven sampled residents reviewed for change in condition. The administrator identified 65 residents resided in the facility. Findings: Resident #5 had diagnoses which included renal insufficiency, and diabetes mellitus. A nurse's Change in Condition note, dated 04/21/24 at 5:19 a.m., read in part Res was noted with milky thick urine with foul oder [sic]. Encouraged res to drink more water . There was no documentation the resident had been monitored for worsening of symptoms. On 07/17/24 at 8:31 a.m., the DON was asked if the Resident should have been monitored for worsening of symptoms. They stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure an effective pest management program was in place to prevent rodents. On 10/17/23 at 12:30 p.m., the Administrator identified 64 Residents resided in the facility. Findings: A Pest Control policy, undated, read in part, . the facility maintains on-going pest control program to ensure the building is kept free of insects and rodents . A Maintenance Log, dated 4/25/23 through 10/13/23, documented the following: a. on 04/25/23, a resident saw a mouse, b. on 09/28/23, mouse debris was found in a Residents' drawers and staff said there was a bad smell, and c. on 10/10/23, rat droppings were seen in a staffs' desk. On 10/17/23 at 3:30 p.m., a family representative stated that there was rodent droppings in room [ROOM NUMBER] in the drawers of the dresser. On 10/18/23 at 9:05 a.m., an observation was made with CNA #1 in room [ROOM NUMBER]. Rodent droppings were observed with CNA #1 in the bottom drawer and two other drawers of a dresser. The bottom drawer was heavily soiled with droppings. The middle drawer and the third drawer from the bottom had mouse droppings intermingled with the residents underwear. CNA #1 was asked what they saw when observing the dresser in room [ROOM NUMBER]. They said they saw rodent droppings in the drawers. On 10/18/23, RN #1 was asked to observe the dresser drawer in room [ROOM NUMBER]. They stated there were mice droppings in four drawers. On 10/18/23 at 9:19 a.m., the Administrator stated they were unaware there was a issue with rodents. On 10/18/23 at 9:31 a.m., the Maintenance Supervisor was shown the dresser in room [ROOM NUMBER] on East hall. They checked the drawers and said they saw mouse droppings. They stated they were unaware there was problems on the east hall. On 10/20/23 at 10:41 a.m., the Maintenance Supervisor stated they have a rodent problem yearly at the facility. They said they have reduced the amount of rodents in the facility but had not prevented them. The Maintenance Supervisor was asked if the rodent management strategies were effective. They stated, No.

Based on record review and interview, the facility failed to ensure ABN and NOMNC letters were provided to two of three sampled residents reviewed for Beneficiary Protection Notification. The Entrance Conference Worksheet, Beneficiary Notice documented 16 residents had received skilled nursing services and discharged with benefit days remaining at the time of discharge. On 10/17/23 at 12:30 p.m., the Administrator stated the facility census was 64. Findings: 1. Resident #147 was admitted to Skilled Nursing Part A services on 07/13/23, and the last day of service was 08/11/23. The facility completed the Beneficiary Protection Notification Review form which documented the facility initiated the discharge from Part A services with benefit days remaining. The form documented the resident or representative did not receive ABN or NOMNC letters as required. 2. Resident #136 was admitted to Skilled Nursing Part A services on 08/01/23 and last day of service was 09/25/23. The facility completed the Beneficiary Protection Notification Review form which documented the facility initiated the discharge from Part A services with benefit days remaining. The form documented the resident or representative did not receive ABN or NOMNC letters as required. On 10/20/23 at 10:58 a.m., MDS coordinator #2 stated multiple staff had looked for the ABN and NOMNC letters for Residents #147 and #136, and the forms had not been completed or provided to the residents or representatives.

Based on observation, record review, and interview, the facility failed to ensure the facility was well maintained to facilitate a homelike environment. On 10/17/23 at 12:30 p.m., the Administrator identified 64 Residents resided in the facility. Findings: A Homelike Environment policy, revised 02/21, read in parts, .Residents are provided with a safe, clean, comfortable, and home like environment .emphasizes the residents' comfort, independence and personal needs and preferences . On 10/20/23 at 8:12 a.m., the following observations were made; a. the carpet on the south hall skilled unit had tape used to repair the frayed carpet, b. the tile in the main dining room had white paint stains, c. room [ROOM NUMBER] floor tiles were raised and splintering and the bathroom in room [ROOM NUMBER] was molded at the shower threshold and the baseboard was separated from the wall due to water damage, d. room [ROOM NUMBER] on the east hall had a large hole in the carpet approximately 8 inches x 16 inches with black tape in the center of the room and the bathroom was missing the front Formica trim and had exposed glue and bare wood, e. the carpet on the east hall outside room [ROOM NUMBER] was frayed, f. the carpet was frayed in the doorway of room [ROOM NUMBER] on west hall, g. the carpet was frayed in the hall outside room [ROOM NUMBER] on east hall, h. the carpet outside room [ROOM NUMBER] in the hall was frayed with tape as a repair,and i. the hall carpets were stained and soiled throughout the whole facility in common areas. On 10/20/23 at 8:26 a.m., Resident #12 stated that the tile felt rough on their feet and was raised causing them splinters in their feet. They stated there was mold in the shower, water damage to tile in the bathroom and the base board in bathroom was peeling from the wall. They stated, It's now how I live. On 10/20/23 at 8:37 a.m., Resident #17 was asked about how they felt about the condition of the facility. They stated the hole in carpet has been there for three months. They stated the front of the bathroom vanity has been tore up for three months. They stated it looks tacky and they did not like it. They stated, It is nasty and the carpets are stained and tore up and it made our home look bad. On 10/20/23 at 10:14 a.m., the Administrator was shown the items in disrepair and was asked what the policy was for maintaining a home like environment. They stated the facility should have been clean and well maintained. They stated the facility was not well maintained. On 10/20/23 at 10:41 a.m., the Maintenance Supervisor was shown the above observation and asked what they thought of them. The Maintenance. Supervisor stated they should of been repaired years ago and four maintenance staff can not handle the amount of repairs.

Based on observation, interview, and record review, the facility failed to ensure wound care was completed as ordered for one (#32) of two sampled residents reviewed for wound care. The Administrator identified the resident census was 24. The Matrix documented residents with wounds. Findings: A Wound Care policy, revised October 2010, read in parts .The purpose of this procdure is to provide guidelines for the care of wound to promote healing .Verify that there is a physician's order for this procedure . Resident #32 had diagnoses which included, non pressure chronic ulcer of the left foot, type two diabetes mellitus with foot ulcer, and atrial fibrillation. Resident #32's TAR, dated 09/21/23, read in part, .Every day Remove old dressing on left metatarsal head with NS, Clean wound with Vashe soak . A Physician Orders Details, dated 09/25/23, read in parts, .Dressing change frequency .3 x per week - [wound care company] will complete on M . A nurse progress note, dated 09/25/23, documented there was no changes to wound care orders. Resident #32's September TAR, dated 09/25/23 through 09/29/23 did not contain documentation wound care had been completed two of three times by the facility staff. The TAR did not contain an order for the facility staff to complete the dressing changes on Wednesday and Friday. Resident #32's TAR, dated 10/01/23 through 10/20/23, did not contain documentation wound care had been completed for five of five dressing changes by facility staff. The TAR did not contain an order for facility staff to complete the dressing changes on Wednesday and Friday. On 10/20/23 at 9:03 a.m., wound care was observed with the NP from an outside wound care company. The wound was cleansed with wound cleanser, vashe solution, debrided, and a dressing applied. On 10/20/23 at 10:03 a.m., the ADON stated the unit nurse had not entered the orders to change the frequency of the dressing changes. On 10/20/23 at 10:24 a.m., the DON was asked where was the documentation wound care had been completed in September and October by the facility staff. They acknowledged the dressing changes had not been completed by the facility staff.

Based on record review and interview, the facility failed to monitor for side effects related to the use of Wellbutrin, Trazadone, tramadol and Librium for one ( #58) of five sampled residents reviewed for unnecessary medications. The Administrator identified the census was 24. Findings: Resident #58 had diagnoses which included alcohol abuse, anxiety, and tobacco abuse. A Physician Order, dated 01/23/23, documented Resident #58 was to be administered Wellbutrin 75 mg one tablet twice a day. A MAR, dated 10/01/23 through 10/19/23, documented Resident #58 had been administered 37 doses of Wellbutrin. A Physician Order, dated 02/17/23, documented Resident #58 was to be administered Tramadol 50 mg one tablet every six hours for pain. A MAR, dated 10/01/23 through 10/19/23, documented Resident #58 had been administered 74 doses of Tramadol. A Physician Order, dated 07/28/23, documented Resident #58 was to be administered Trazadone 50 mg two tablets at hour of sleep. A MAR, dated 10/01/23 through 10/18/23, documented Resident #58 had been administered 18 doses of Trazadone. A Physician Order, dated 10/02/23, documented Resident #58 was to be administered Librium 5mg one tablet twice a day. A MAR, dated 10/02/23 through 10/19/23, documented Resident #58 had been administered 25 doses of Librium, and had refused nine doses. Resident #58's MAR, dated October 2023, did not contain documentation Resident #58 had been monitored for side effects related to the use of Trazadone, Wellbutrin, Tramadol and Librium. On 10/24/23 at 08:57 a.m., the ADON was asked if Resident #58 had been monitored for side effects related to the use of Trazadone, Wellbutrin, Tramadol and Librium. The ADON stated there was no monitoring for the medications. The ADON was asked if there was a physician order to monitor for the use of Librium. They stated, No.

Based on record review and interview, the facility failed to update/revise a care plan for the use of Wellbutrin and Librium for one (#58) of five sampled residents reviewed for unnecessary medications. The Administrator identified the census was 64. Findings: Resident #58 had diagnoses which included alcohol abuse, anxiety, and tobacco abuse. A Physician Order, dated 01/23/23, documented Resident #58 was to be administered Wellbutrin 75 mg one tablet twice a day. There was no diagnosis for Wellbutrin. A Physician Order, dated 10/02/23, documented Resident #58 was to be administered Librium 5mg one tablet twice a day. Resident #58's care plan, documented the Resident had a diagnosis of alcohol abuse and nursing staff was to notify the doctor as needed with any side effects. On 10/24/23 at 8:57 a.m., the ADON was asked if the care plan had been updated to address the use of Wellbutrin and Librium. The ADON stated the care plan did not address the medications.

Based on observation, record review, and interview the facility failed to ensure staff maintained infection control during the provision of perineal and catheter care for one (#21) of 19 sampled residents reviewed for infection control. The Administrator identifed the census was 64. Findings: Resident #21 had diagnoses of urinary retention, type two diabetes mellitus and urinary tract infection. An undated, Perineal Care policy and Procedure policy, read in parts, .to ensure residents are provided cleanliness and comfort, to prevent infections and skin irritations, and to observe the residents skin . A Physician Order, dated 04/19/22, documented to perform catheter care every shift. On 10/20/23 at 8:33 a.m., CNA #1 and CNA #2 was observed to provide pericare and catheter care for Resident #21. CNA #1 cleaned feces from the resident's buttocks and lower back. Then placed a clean brief and bed pad, using the same gloves. CNA #2 was observed to provide catheter care, then used the same gloves to secure the residents brief, and place the catheter in a dignity bag. CNA #1 and CNA #2 were observed to touch clean items with soiled gloves during care. On 10/20/23 at 10:54 am CNA #2 was asked when should they change gloves. They stated you should wash your hands when you change gloves. They were asked if they had changed gloves after pericare and putting the residents brief on. They stated, they had not changed their gloves before putting the residents brief on. On 10/20/23 at 11:02 a.m., CNA #1 was asked if they had changed their gloves after cleaning the resident and placing the incontinent pad and clean brief. They stated, No. On 10/24/23 9:09 a.m., the ADON was asked when should staff change their gloves. They stated, Anytime from dirty to clean, especially after cleaning the resident and moving on to a new brief or new bed pad.

Based on record review and interviews the facility failed to ensure that antibiotics for a urinary tract infection were administered as ordered resulting in the resident being admitted to the hospital for IV antibiotics, IV fluids, and close observation; for one (#2) of three sampled residents reviewed for medications being administered according to physicians' orders. Resident Census and Conditions of Residents report identified 66 residents resided in the facility. Findings: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's Telephone Orders, written 06/01/22, read in part, .Follow up UA with C+S post ABT- ESBL . Daily Skilled Progress Note, written 06/01/22 9:28 a.m. by LPN #3, read in part, .[CONDITION(S)] Assessment .Foul Odor Urine Yes .Mental Assessment .Disoriented/Confused Yes .Urine cloudy yellow with sediment. Straight cath UA collected and sent to lab as follow up ESBL/[CONDITION(S)] . Daily Skilled Progress Note, written 06/02/22 8:56 a.m. by LPN #3, read in part, .[CONDITION(S)] Assessment .Cloudy/Mucous Urine Yes .Foul Odor Urine Yes . Mental Assessment .Disoriented/Confused Yes .Urine C&S pending . Daily Skilled Progress Note, written 06/02/22 8:57 p.m. by LPN #4, read in part, .[CONDITION(S)] Assessment .Cloudy/Mucous Urine Yes .Foul Odor Urine Yes .Pending C&S/UA . Clinical note entry written by LPN #2, dated 06/03/22 at 11:25 a.m., read in part, Urine C&S sent to Dr. Benton, N/O received .med ordered from pharmacy, MAR updated . Microbiology Final Report, verified date 06/03/22, .Culture Urine .>100,000 cfu/ml Escherichia coli ESBL .N/O [MEDICATION(S)] BID x7 . Physician's Telephone Orders, written 06/03/22, read in part, .Foley for comfort care . The pharmacy manifest, dated 06/03/22 at 4:09 p.m., read in part, .Patient .[Resident #2] .Drug Name .SMZ/TMP DS TABS 800-160 .Qty Filled .28 .Days Supply .14 .Date Filled .6/3/2022 .Received By: [CMA #1] Date: 6/3/2022 . Clinical note entry written by LPN #5, dated 06/04/22 2:19 a.m., read in part, Resident up in wc, self propelling up and down hall .cath draining well with straw colored urine. Sediment and blood noted in tubing/foley bag . Clinical note entry written by LPN #1, dated 06/05/22 at 8:22 a.m., read in part, At 0800 [8:00 a.m.], resident's O2 sat was 75% on RA during initial assessment .administered O2 @ 2L per NC . Clinical note entry written by LPN #1, dated 06/05/22 at 1:51 p.m., read in part, .resident received first dose of [MEDICATION(S)] this AM .has been very drowsy this shift so she has remained in her bed . Clinical note entry written by LPN #1, dated 06/05/22 at 1:59 a.m., read in part, Resident daughter arrived at facility this AM .stated that she saw on the camera .her mother 'had not been offered water' nor had any in reach 'all night' .She asked about any changes in medications or if we had given her something new because it was unusual for her to be sleeping that much .The nurse and the CMA .discovered that she had not started taking the antibiotic yet and was supposed to start taking it on 06/03/22 . Medication Administration History, documented [MEDICATION(S)] 800mg-160mg tablet (1 tab) was not administered as ordered for the following times: 8 p.m. on 06/03/22, 8 a.m. on 06/04/22, and 8 p.m. on 06/04/22. Clinical note entry written by LPN #1, dated 06/05/22 3:35 p.m., read in part, .Resident has been drowsy and in bed all day . Clinical note entry written by LPN #1, dated 06/05/22 5:23 p.m., read in part, .Hospice nurse arrived to assess resident. Family .wanted to send her to the ER .EMS was called and transferred resident to [hospital] via ambulance @ 1640[4:40 p.m.] . [Hospital] notes from 06/05/22- ED to Hosp-Admission, read in part, .She has been at the nursing home for approximately 2 weeks .doing In-N-Out catheters due to her urinary retention. On Friday she had a UA .an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Over the weekend she became less and less interactive was eating and drinking less and since this morning she has not awakened .In the emergency room .oxygen saturation 86% on room air .appeared dehydrated .Assessment: 1. Altered mental status 2. [CONDITION(S)] (urinary tract infection) 3. [CONDITION(S)] admit the patient for IV antibiotics, IV fluids, close observation . On 07/08/22 at 3:04 p.m., CMA #1 was asked when antibiotics were started for Resident #2. CMA #1 stated, I remember that we had an issue trying to find it after it was delivered. Her daughter came in asking about it. I know I gave the first dose because I was the one who found it after I looked through all those boxes in the medication room. I can't remember if it was Saturday or Sunday, but the daughter came in that afternoon and I started [Resident #2] on it the next day. When asked how she knew she had given Resident #2 the first dose of the medication, she replied, Because the package was not open when I found it. On 08/01/22 at 12:46 p.m., LPN #3 was asked what had changed in Resident #2's condition to cause her to be sent to the hospital. She replied, The best I can recall she was oriented to herself and family but she was becoming more confused and her urine had developed a foul odor. She had a UA sent on 06/01/22 as a follow-up for ESBL. She was getting straight cathed routinely but she would often refuse. On 08/01/22 at 1:38 p.m., LPN #2 was asked what had changed in Resident #2's condition to cause her to be sent to the hospital. She replied, She came to my unit from the skilled unit on 06/03/22. We got her lab results back the same day and [MEDICATION(S)] was ordered. From what I remember, the agency nurse signed for the medication, put it in the med room and then they couldn't find it. LPN #2 was asked if there had been a noticeable change in Resident #2's condition from the time she was admitted to her unit until she was transferred to the hospital. She stated, I only saw her on that day. I was off after that. On 08/01/22 at 2:20 p.m., the ADON was asked if Resident #2's antibiotics were started in a timely manner. She responded, I would say no they were not started in a timely manner. She was asked if, according to nursing documentation, Resident #2 had experienced an obvious decline in her condition that resulted in her being transferred to the hospital. She stated, I would say yes probably or they would not have had to send her out.

Based on record review, interview, the facility failed to ensure a physician was notified of frequent medication refusals for one (#50) of five sampled residents reviewed for physician notification. The DON identified 64 residents resided in the facility. Findings: A Change in a Resident's Condition or Status policy, dated February 2021, read in part, .The nurse will notify the resident's attending physician or physician on call when there has been .refusal of treatment or medications two (2) or more consecutive times . Resident #50 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician ordered medications included [MEDICATION(S)] (anticoagulant), [MEDICATION(S)] (antidepressant), [MEDICATION(S)] (synthetic [CONDITION(S)]), [MEDICATION(S)] (vitamin), [MEDICATION(S)] (antidepressant), [MEDICATION(S)] (blocks a substance in the body that causes the blood vessels to tighten), [MEDICATION(S)] (lowers blood sugar), [MEDICATION(S)] (diuretic), acetaminophen (pain relief), [MEDICATION(S)] (antipsychotic), nitrofuantoin (antibiotic), potassium chloride (electrolytes), [MEDICATION(S)] (antipsychotic), and [MEDICATION(S)] (antibiotic). A review of February, March and April 2022 MARs, documented the resident refused the above medications several days each month. Nursing Notes for February, March, and April were reviewed. There was no documentation the physician had been notified of the frequent refusals. On 04/21/22 at 9:35 a.m., CMA #1 was asked what she was instructed to do when a resident refused medications. She stated she would try several times to get the resident to take the medications and tell the nurse. At 9:38 a.m., LPN #2 was asked what she was instructed to do when a resident refused medications. She stated they would try to administer the medications for three attempts and then notify the physician. She was asked where the physician notification would be documented. She stated it would be in the nurses' notes. LPN #2 was asked to locate documentation of physician notification for resident #50's refusals for February, March, and April 2022. She looked in the clinical records and stated she could not find any notification. LPN #2 was shown the February, March, and April 2022 refusals and was asked if the physician should have been notified. She stated, Yes.

Based on record review, observation, and interview the facility failed to review and revise the person-centered care plan for one (#9) of 13 residents whose care plans were reviewed. The DON identified 64 residents resided in the facility. Findings: Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, dated 10/18/21, had not been updated to reflect the oxygen use. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/19/22 at 3:03 p.m., resident #9 was observed in her room in recliner. An oxygen concentrator was observed in her room with O2 tubing connected and running at 2 LPM. Resident #9 did not have the nasal cannula on. On 04/21/22 at 11:06 a.m., the DON was asked if resident #9's O2 should have been care planned. She responded, Yes. The DON was asked to review resident #9's care plan and acknowledged that the O2 use was not documented.

Based on record review, observation, and interview, the facility failed to assess a resident's need for oxygen according to professional standards of practice for one (#9) of one sampled residents receiving as needed oxygen therapy. The DON identified five residents with as needed oxygen orders. Findings: Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for frequency of obtaining O2 sats, parameters for administering as needed O2, nor rate for O2 administration. Res #9's Care Plan, dated 10/18/21, had no documentation related to oxygen use. Res #9's Vital Signs record for 04/01/22 to 04/20/22 documented O2 sats on RA were not monitored every shift in order to assess the need for oxygen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for frequency of obtaining O2 sats, parameters for administering as needed O2, nor rate for O2 administration. On 04/19/22 at 3:03 p.m., resident #9 was observed in her room in her recliner. An oxygen concentrator was present with O2 tubing connected and running at 2 LPM. Resident #9 did not have the nasal cannula on. On 04/20/22 at 4:30 p.m., LPN #4 was asked if resident #9's oxygen was to be on all day. She replied, No, she comes to meals without it. LPN #4 was asked how often do you check her O2 sats. She stated, Before meals and about every fifteen minutes. On 04/21/22 at 10:30 a.m., LPN #3 was asked how resident #9's O2 was ordered. She replied, It says as needed. When she asks for it. When asked if resident #9's O2 sats were checked before putting O2 on, she replied, Her sats are usually 89 and up. If they are below 90 we put it on. If they are above 90 and she requests it, we put it on. LPN #3 was asked what rate the oxygen was to be administered. She stated, one to two liters per minute. When asked how frequently O2 sats were being checked, LPN #3 stated, each shift. When asked if they were documented in the clinical record, she responded, Yes, in vital signs.

On [DATE], an IJ situation was determined to exist related to the facility's failure to ensure a process for falls were in place to assess, monitor and prevent recurring falls. This resulted in resident #1 having recurring falls, requiring two different hospital stays, sustaining multiple rib fractures, and pneumothorax (collapsed lung). Resident #1 was readmitted to the facility from the second hospital stay on hospice services with a diagnosis of traumatic pneumothorax, and expired the next day. Resident #3 had a fall, required a hospital stay, and sustained a hematoma to their forehead, and a cervical (neck) fracture. As of [DATE], resident #3's plan of care had not been updated with any new interventions to prevent recurring falls. On [DATE] at 5:04 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 5:18 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:13 p.m., an acceptable plan of removal was provided. The plan of removal documented: Golden Oaks Healthcare Center Plan of Removal for IJ .Total number of residents potentially at risk are 61 .Action to Remove Immediacy .Effective [DATE] all team members will be educated to the fall prevention interventions for Resident #3 including processes for the safe application and removal of the safety belt. A binder will be maintained at the West nurses' station. This binder will contain the safety belt checklist confirming each delivery of care and subsequent check that the safety belt was securely in place. Additionally, the care plan for Resident #3 was updated to reflect this intervention. All direct care staff will be in serviced on proper protocol for the safety belt and where to document by [DATE] at 5:00 p.m. To remove the immediacy for all of the residents a Post Fall policy has been created. After a fall on any resident, the charge nurse will complete the Post Fall Huddle Form with input from the most recent direct care staff to determine possible causes of the fall to develop new intervention(s) to prevent fall recurrence. The Director of Nursing or designee will review 24 hours report each morning to identify those who have experienced new fall incidents and to confirm with nursing team that the Post Fall Huddle Form was completed and the appropriate interventions were implemented and added to the care plan. All direct care staff will be in serviced on the new Post Fall Policy by [DATE], at 5:00 p.m . Action to Prevent Recurrence .Thereafter, no team members will be allowed to deliver direct care to Resident #3 until the y have completed the safety belt education. Going forward, after a fall on any resident, the charge nurse will complete the Post Fall Huddle Form with input from the most recent direct care staff to determine possible causes of the fall to develop new intervention(s) to prevent fall recurrence. The Director of Nursing or designee will review 24 hours report each morning to identify those who have experienced the appropriate interventions were implemented and added to the care plan. Additionally, the Director of Nursing, or designee, will confirm that each care plan was updated. In addition, the IDT team will meet weekly to review all falls and to determine if interventions in place are appropriate . Monitoring Implementation of Plan of Removal .All education, implementation, and monitoring of this plan of removal will be completed by the Director of Nursing and Assistant Director of Nursing services and/or their designee in addition to being reviewed during each QAPI meeting . On [DATE], interviews were conducted with nursing staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. On [DATE] at 11:01 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 9:00 a.m. The deficiency remained at a level of actual harm at a pattern. Based on observation, record review and interview, the facility failed to ensure a process for falls were in place to assess, monitor and prevent recurring falls for two (#1 and #3) of three sampled residents reviewed for falls. This resulted in resident #1 having recurring falls, requiring two different hospital stays, sustaining multiple rib fractures, and pneumothorax. Resident #1 was readmitted to the facility from the second hospital stay on hospice services with a diagnosis of traumatic pneumothorax, and expired the next day. Resident #3 had a fall, required a hospital stay, and sustained a hematoma to their forehead, and a cervical fracture. The DON identified 61 resident resided in the facility. Findings: The facility's Fall Policy, revised ,d+[DATE], read in part, .While many falls are isolated incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions, As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified .The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls 1. Resident #1 had diagnoses which included repeated falls, malignant neoplasm of mandible, pneumothorax, and dementia. Resident #1's care plan documented the following falls without injuries: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions documented included: staff to remind resident throughout the day to take their walker with them when they were going to bathroom, closet, and meals; staff will walk with resident when they were going to and from meals, or when they were in the hall; sign placed on walker to remind the resident to take their walker; a pad alarm was placed on their bed and chair; remind them to reach back for bed or recliner before sitting, remind them to wear shoes to the bathroom; staff to assist with dressing and undressing; and to be checked on every two hours. Resident #1's clinical record did not document the interventions that were in place were monitor, or assessed for effectiveness. Resident #1's fall risk assessment, dated [DATE] , documented the resident was alert, had three or more falls in the past three months, and required an assistive device. The total score was a nine. A score of 10 or greater indicated resident was at high risk for potential for falls. Resident #1's significant change assessment, dated [DATE], documented the resident had adequate hearing, unclear speech, understands and was usually understood. It documented the resident had severely impaired cognition. It documented the resident required limited assistance with one staff member with transfers, ambulation, and toilet use. It documented the resident was unsteady and was only able to be steady with staff when balancing and walking. It documented the resident used a walker. It documented the resident had two non-injury falls since previous assessment. A facility's incident report, dated [DATE], read in part, .RESIDENT SITTING ON HER BUTTOCKS NEXT TO BED WITH PANTS BELOW BUTTOCKS, STATED [the resident] LOST [their] BALANCE [and] SAT ON THE FLOOR. RESIDENT WEARING POORLY FITTING SLIPPERS [and] WAS NOT UTILIZING HER WALKER .NO INJURY NOTED .WAS REMINDED TO USE CALL LIGHT, WAIT FOR STAFF TO ASSIST [them] [and] USE [their] WALKER, RESIDENT [and] STAFF EDUCATED ON APPROPRIATE FOOTWEAR, CALL LIGHT KEPT WITHIN EASY REACH, ADEQUATE LIGHTING [and] CLUTTER FREE PATHWAYS AS WELL AS USE OF PRESSURE PAD ALARM [and] HOURLY VISUAL CHECKS FOR SAFETY . The new intervention for the hourly visual checks was not updated on the care plan. Resident #1's clinical record did not contain hourly documentation was completed. A state reported incident report, dated [DATE], read in part, .[at] 7:17 [p.m.] [the resident] was found sitting on the bathroom floor .no apparent injury at the time of fall .relevant resident history .[the resident] has a high history of falls, [the resident] refuses help and any kind of therapy .[the resident] has a pad alarm on but will take it off and hide it. [The resident] is a 2 hour check and change, but when [the resident] needs help [the resident] will not ask for it, Call light is always within reach .Dx of Dementia, Repeated Falls .final reports .in afternoon of ,d+[DATE] started to c/o pain in abdomanial [sic] area and hard to breath while lying in bed .[the resident] was sent to [local hospital] . Resident #1's care plan was not updated with new intervention after the fall dated [DATE]. Resident #1's Notes Report, dated [DATE], read in part, .RESIDENT FOUND IN BED BY CNA .COMPLAINS OF PAIN IN RIGHT SIDE AND HIP AREA .RESIDENT SLEEPY. SLOW TO ANSWER QUESTIONS .TRANSFERRED TO [hospital] . Hospital clinical records, dated [DATE], read in part, .Chief Complaint .fall, L shoulder and R upper back pain .Patient .who fell night before last .had a chest x-ray that showed fractures of the seventh and eighth rib and was noted on physical exam and .to have subcu [CONDITION(S)] [air trapped in tissues beneath the skin]. A pneumothorax is not readily seen on the chest x-ray but on the cervical films you can say a remnant of an apical pneumothorax . A final state reported incident report, dated [DATE], read in part, .[the resident] WILL DISCHARGE TO SKILLED TODAY .[the resident] WILL NOW BE A 30 MINUTE CHECK AND CHANGE. PT TO EVALUATE SAFETY OF WALKER USE, IN THE PROCESS OF LOOKING FOR A TYPE OF ALARM THAT [the resident] CAN NOT DISARM. WILL CONTINUE WITH CALL LIGHT WITHIN IN REACH, BED IN LOWEST POSITION, FALL MAT ON FLOOR, REORIENTATE [sic] TO CALL FOR ASSISTANCE . Resident #1's fall risk assessment, dated [DATE], documented the resident had intermittent confusion, had three or more falls in the past three months, and had poor vision status. The total score was a 20. A score of 10 or greater indicated resident was at high risk for potential for falls. Resident #1's Incident Report, dated [DATE] at 9:40 p.m., documented Resident #1 fell and was lying on the floor. They complained of their head hurting and was sent to the hospital for evaluation. It documented staff were notified by the alarm and the CNA. It documented the activity at the time of fall was unknown. A combined initial and final state reported incident report, dated [DATE], read in part, .[the resident] WAS OBSERVED ON THE FLOOR LAYING ON HER LEFT SIDE .WAS SENT TO .ER FOR EVALUATION .relevant resident history .[the resident] IS A HIGH FALL RISK, DESPITE 30 MINUTE VISUAL CHECK, PAD AND PULL AWAY ALARM IN PLACE, CALL LIGHT WITHIN REACH, PLACED CLOSEST ROOM AVAILABLE TO NURSES STATION, FALL STILL OCCURRED .[the resident] WAS discharged FROM THE HOSPITAL [DATE] AROUND LUNCH TIME AND WAS SENT BACK .THAT SAME EVENING .[the resident] WAS admitted TO .HOSPITAL WITH DIAGNOSIS OF PNEUMONIA AND LARGER PNEUMOTHORAX . There was no documentation in clinical record a fall mat had been put into place prior to the resident's second fall. Resident #1's care plan, dated [DATE], documented the interventions for fall was a pressure alarm mat that sounds at the nurse's station and the resident was to be checked on every 30 minutes. The care plan had not been updated for 13 days. The hospital's discharge summary, dated [DATE], read in part, .[the resident] that was discharged from the hospital on the 28th after an admission for small pneumothorax following a fall .did have rib fractures .was discharged to skilled nursing. Immediately after admission to skilled nursing, [[DATE]] it appears the patient got out of bed unassisted and fell again .was transferred back to the emergency department where [the resident] was found to be hypoxic [not enough oxygen] and have increased size in [their] pneumothorax . Chest tube was placed and .was started on antibiotics and oxygen . Chest tube was removed on ,d+[DATE] after serial x-rays showed no residual pneumothorax. The patient continued to have [CONDITION(S)] .[their] WBC increased as did [their] oxygen demands .[the resident] developed low grade fever .On [DATE], [the resident] developed worsening respiratory issues. Rapid response was called. [The resident] required [CONDITION(S)] [positive pressure ventilator] to maintain adequate oxygen saturations. Family conference was held and they elected to make [the resident] DNR .Pt will be discharged to Golden Oaks NH with hospice . The resident clinical notes documented the resident returned to the facility on [DATE], and expired on [DATE]. On [DATE] at 10:20 a.m., CNA #1 and CMA #1 was asked how staff prevented falls. CNA #1 stated they use gait belts and hydraulic lifts. CMA #1 stated they checked on them, and some resident had alarms and seat belts with alarms. They were asked how new fall interventions were determined. CNA #1 stated by the nurse, administrator and DON. CMA #1 stated it had to be in the care plan. CMA #1 was asked how they were updated on new fall interventions. CMA #1 stated it was supposed to be documented on the communication log for CNAs. CMA #1 stated, Not everyone is a good communicator. CMA #1 was asked who was responsible and where documentation was located for residents who required hourly checks. CMA #1 stated the person who checked on them were responsible for documenting and there usually were forms in the residents' rooms for documentation. CMA #1 was asked about resident #1's fall on [DATE]. CMA #1 stated the resident had came back earlier that day from the hospital, the resident was on every 30 minute checks, and had two alarms in place . CMA #1 stated they heard a bang and ran to the resident's room. CMA #1 stated the resident wasn't close to the bed when staff responded to the room. CMA #1 was asked if there was a floor mat in place. CMA #1 stated, No. On [DATE] at 10:32 a.m., LPN #2 stated night shift staff were to put the hourly check forms up every night. LPN #2 stated, It's been a challenge. LPN #2 stated the forms were either filed in the resident's chart, or in someone's office. On [DATE], at 11:41 a.m., the DON was asked what a nine indicated on the fall risk assessment. She stated she wasn't sure but was surprised the resident wasn't a 10. She stated the resident was a high fall risk. At 1:35 p.m., LPN #1, the nurse who readmitted Resident #1 on [DATE], was asked what fall interventions were in place. LPN #1 stated the resident had a pad alarm, clip alarm, positioning bar, and call light within reach. LPN #1 stated the resident was on a regular mattress and denied the resident having a floor mat in the room. LPN #1 stated when the resident readmitted from the second hospital stay, the resident was on hospice services, unresponsive, flaccid, and wasn't moving around. At 2:35 p.m., the DON was asked what the policy was for new fall interventions. The DON stated the ADON came up with new intervention, updated the care plan and would notify the floor nurses, who then would notify the CNAs. The DON was asked for documentation the hourly checks were completed. The DON stated the only documentation was in nurse's notes. The DON stated, I don't know what the staff did with the sheets. The DON was asked what fall interventions were in place when the resident readmitted from the first hospital stay on [DATE]. The DON stated the resident was on 30 minute checks, pad and clip away alarm was in place. The DON stated they had ordered a laser pad that would send an alert to the nurse. The DON confirmed this pad did not get implemented. The DON was asked if there was a floor mat in the resident's room, as it was documented in the state reported incident report. The DON stated, There should have been one. The DON was made aware there was no documentation, or staff knowledge, of the floor mat in place. The DON stated the resident readmitted from the hospital on [DATE] with hospice services. The DON stated Resident #1's hospice diagnosis was traumatic pneumothorax. 2. Resident #3 had diagnoses which included mild cognition impairment, unspecified displaced fracture of second cervical vertebra, contusion of the scalp, and unspecified injury of the head. Resident #3's care plan documented the following non-injury falls: [DATE], [DATE], and [DATE]. Interventions documented included: applied a pull away alarm and one hour visual checks for 48 hours. Resident #3's care plan, dated [DATE], documented a seat belt was applied to the resident's wheelchair. The resident's annual assessment, dated [DATE] , documented the resident's cognition was intact, and they required extensive assistance from one staff member for bed mobility, transfers, and toilet use. It documented the resident had two non-injury falls and two falls with minor injury since prior assessment. The resident's fall risk assessment, dated [DATE], documented a total score of 15. A score of 10 or greater indicated the resident was at high risk for potential for falls. An initial state reported incident report, dated [DATE], documented the resident was laying on floor on their left side. It documented the resident stated they were reaching forward to pick something off of floor and fell . It documented the safety belt was not in place. It documented the resident had a large hematoma was on the resident's forehead. It documented the resident complained of neck and left shoulder pain. It documented the resident was sent to the hospital. The final state reported incident report, dated [DATE], documented the resident was air lifted to another hospital with a diagnosis of cervical neck fracture. The resident's care plan did not document any new fall intervention. The resident's Clinical Notes, dated [DATE], read in part, .RETURNED FROM .HOSPITAL .ASPEN COLLAR INTACT. HAS HEMATOMA WITH SCABS TO CENTER AND PURPLE BRUISING TO FOREHEAD. BOTH EYES ARE BRUISED PURPLE .BRUISING TO BILATERAL FOREARMS AND SKIN TEAR TO LEFT WRIST . The resident's Clinical Notes, dated [DATE], documented hourly checks for safety initiated, the resident was to have the Aspen collar on at all times, the resident was not to be left unattended in the bathrooms, and alarms must be in place at all times with seatbelt in place when up in their wheelchair. On [DATE] at 1:17 p.m., Resident #3 was observed wearing a neck brace and sitting in their recliner. They were observed to have hematoma to forehead and purple bruising down the right side of their face. They were asked to describe what happen when they fell on [DATE]. The resident stated, I fell on my head. The resident stated they were reaching down to get something and fell . The resident was asked what the staff did when the resident returned from the hospital. The resident stated they put alarms in place. On [DATE] at 10:20 a.m., CMA #1 was asked what interventions were in place for the resident. They stated the resident had a pad alarm, a clip away alarm, and a seat belt. At 10:32 a.m., LPN #2 was asked about resident's fall on [DATE]. LPN #2 stated they were told the resident fell forward out of wheelchair. LPN stated the resident's fall interventions were hourly checks, and seat belt with alarm. At 3:05 p.m., the DON was asked what interventions were in place prior to the resident's fall. The DON stated there were multiple alarms, and eventually had a seat belt put in place that the resident could undo. The DON was asked about the seat belt that was ordered but not in place at the time of fall. The DON stated the resident was able to undo it themselves. The DON was asked what the fall intervention were after the resident came back from the hospital. The DON stated they weren't sure. On [DATE] at 4:55 p.m., the DON was asked if the staff and physician monitor and documented the residents' responses to fall interventions. She stated the physician was notified and they would come up with interventions. The DON was asked if the physician was consulted when coming up with fall interventions. The DON stated, No. The DON was asked how fall interventions were monitored by staff and physician to ensure effectiveness. The DON stated, We don't have a policy for that.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure agency staff were knowledgeable of the policy and procedure for the use of the mechanical whirlpool lift. This resulted in resident #1 falling from the mechanical whirlpool lift, sustaining a head injury, fractured ribs and right femur fracture. He was sent to the emergency room and expired from a brain bleed. On [DATE] at 6:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 7:05 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:10 p.m., an acceptable plan of removal was provided. The plan of removal documented: Action to Remove Immediacy .On [DATE], the whirlpool was taken out of commission pending proper training of staff. A sign was posted on the door that reads 'Whirlpool Not in Use'. At that time, the key to the location was placed in the possession of the charge nurse to ensure that no untrained staff members were allowed entry. Effective [DATE], the key was placed in the possession of the Director of Nursing Services until all extended agency contract staff, other agency employees assigned to the [DATE] schedules, as well as all core [facility] staff are educated/re-educated to whirlpool policy and procedures-including but not limited to two staff members must be present at all times and safety belts must be utilized for a safe mechanical whirlpool transfer. A list of fully trained core staff and agency staff will be created and maintained. This plan of removal will be completed by [DATE] at 16:00 [4:00 p.m.]. Action to Prevent Recurrence .Thereafter, all new agency team members and new core team members will not be allowed to accept an assignment until they have completed the whirlpool competency education and their name is added to the list of fully trained nursing staff. After all competencies are completed, the key will be returned to the west charge nurse with a list of team members/agency team members that have completed the whirlpool competency education. This list will be kept in a Whirlpool Competency book at West nurses' desk and will be updated daily as competencies are completed. Monitoring Implementation of Plan of Removal .All education, implementation and monitoring of this plan of removal will be completed by the Director of Nursing Services and Assistant Director of Nursing services and/or their designee . On [DATE] at 8:35 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 4:00 p.m. The deficiency remained at a level of actual harm at a pattern. On [DATE], interviews were conducted with core nursing staff and agency staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on record review and staff interviews, the facility failed to ensure two staff members were present for a mechanical lift transfer for one (#1) and adequate supervision was provided to prevent falls for one (#3) of three sampled residents reviewed for falls. This resulted in resident #1 falling from the mechanical shower lift, sustaining a head injury, fractured ribs and right femur fracture. He was sent to the emergency room and expired from a brain bleed. Resident #3 had a fall and sustained a right hip fracture and was sent to the emergency room and required surgical intervention. The DON identified 59 resident resided in the facility. Findings: An Abuse and Neglect policy, revised ,d+[DATE], read in part, .Neglect .the failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain . A Falls and Fall Risk policy, revised ,d+[DATE], read in part, .the nurse shall assess and document .Musculoskeletal function, observing for change in normal range of motion .Pain .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . RUBY'S LIST .EQUIPMENT .Chair alarms .Bed alarms .QUALIFIERS Dementia . AMechanical Lift policy, revised ,d+[DATE], read in part, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Mechanical lifts may be used for tasks that require .bathing .Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. An agency Welcome Packet, read in part, .Whirlpool .TWO AIDS AT ALL TIMES .RESIDENT MUST WEAR SAFETY BELT AT ALL TIMES WHILE IN CHAIR/TUB .PUSH RESIDENT IN SIDEWAYS WHEN USING THE CHAIR DO NOT LIFT THEM OVER THE TUB .Have all supplies by you so you do not need to walk away from resident/tub to obtain supplies . 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated [DATE], read in part, .HX [HISTORY] OF FALLS I AM AT RISK FOR FALLS .DUE TO MY HX OF FALLS A PRESSURE ALARM IS UTILIZED TO ALERT STAFF IF I GET UP UNASSISTED . A comprehensive resident assessment, dated [DATE], documented resident #1 had severe cognitive impairment and had two falls since admission. A fall risk assessment, dated [DATE], documented the resident was at high risk of falls. An incident-falls report, dated [DATE] at 2:00 a.m., read in part, .Location of Fall .Bathroom .Did Resident call for Help .No .THIS NURSE WHILE ON THE CORRIDOR HAS SEEN CALL LIGHT GOING OFF THE ENTRANCE OF THE WHIRLPOOL AREA AND WENT TO CHECK WHAT WAS HAPPENING. FOUND THE ABOVE RESIDENT ON THE FLOOR WITH IS HIS HEAD BLEEDING WHILE THE AIDE WAS TRYING TO ASSIST HIM .Witness .THE NURSING AIDE STAFF THAT GAVE HIM SHOWER . Notes .@ [at] [7:40 p.m.] GOT NOTIFIED OF RESIDENT FALL, RESIDENT WAS REPORTED TO HAVE SWING HIMSELF FORWARD OUT OF THE SHOWER CHAIR AND LANDED ON THE HARD FLOOR HITTING HIS HEAD OF THE RT [RIGHT] SIDE OF HIS FACE, ELBOW AND RIGHT HIP. UPON ASSESSMENT NOTED RESIDENT HAD A SWOLLEN FACE ON THE RT HEAD WITH COUPLE OF CUT BLEEDING PROFUSELY, RT ARM ELBOW BRUISE WITH BLOOD, FRACTURE SUSPECTED TO THE RIGHT HIP .RESIDENT WAS TRANSFERRED [sic] .ER . An email communication from LPN #3, dated [DATE] at 2:39 p.m., read in part, .[DATE] .around 7:40pm .knocked and opened the door .found this male resident [resident #1] on the floor with the nursing aide [name deleted] standing by him who told me she had just completed his whirlpool shower, set him on the transfer shower chair. She said the resident had swing himself forward and fell on the cold floor hitting his head .transferred him to .ER . On [DATE] at 11:17 a.m., CNA #1 was asked to describe how resident #1 had fallen. She stated she had him up in the whirlpool lift chair. She stated there was no device to secure the resident to the chair. She stated the whirlpool chair was approximately waist high when she turned to get a towel. She stated the towel was about three steps away from the resident. When she turned back around she observed the resident had fallen off of the whirlpool chair and was laying on the floor. CNA #1 was asked what type of training she had received from the facility prior to providing care. She stated she worked for agency and had received no education. At 2:47 p.m. the DON was asked how many staff should be present during a mechanical lift transfer. She stated two. She stated during the above transfer, there was only one staff member present. Inservice binders for November and [DATE] documented education on mechanical lifts, whirlpool check-offs and an agency welcome packet. There was no documentation 27 of the 48 agency staff utilized from [DATE] to [DATE] had been educated on the mechanical lifts, the whirlpool check-offs or the agency welcome packet. An [DATE] at 2:27 p.m., the ADM was asked who was responsible to inservice agency staff regarding the mechanical whirlpool lift. She stated one of their LPNs conducted competency checks prior to their shift. She was asked for a list of all agency staff who had worked since [DATE] and any in-services that had been conducted with agency staff. She stated, I think it might have been just the core staff. At 2:49 p.m., the DON stated they did not have whirlpool competencies for agency staff due to they were not using agency staff to give whirlpools. At 3:19 p.m., the DON stated between the end of November and mid-December, the decision was made to not have agency staff in the whirlpool room. She was made aware the agency Welcome Packet for agency staff had whirlpool instructions. She stated she had just seen it and it needed to be removed. At 3:35 p.m., agency CNA #5 was asked if she uses the whirlpool room. She stated she had been trained to use it but had not used it. She was asked if she could use it if a resident wanted a whirlpool. She stated, Yes, as long as no one is in it. At 3:55 p.m., agency CNA #6 was asked if she uses the whirlpool room. She stated she had a couple months ago. She was asked if she was able to use the whirlpool currently. She stated, Yes. At 4:00 p.m., agency CNA #7 was asked if she uses the whirlpool room. She stated she had not. She was asked if she could use the whirlpool. She stated, Yes, if someone requested one. At 4:02 p.m., agency CNA #8 was asked if she had every used the whirlpool room. She stated she had not. She was asked if she could use the whirlpool room if a resident requested one. She stated, Yes. At 7:05 p.m., the Administrator and DON were made aware of the above agency staff stating they could use the whirlpool if they had a resident that requested a whirlpool bath and that 27 of the 48 staff utilized since [DATE] had not been educated on the mechanical lifts, the whirlpool check-offs or the agency welcome packet. 2. Resident #3 was admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An admission Fall Risk Assessment, dated [DATE], documented the resident was high risk for fall with a score of 12. A care plan, dated [DATE], read in part, .Problem .I AM A HIGH FALL RISK R/T FALL RESULTING IN HIP FRACTURE AND HX OF PRIOR FALLS .Approach .2 PERSON ASSIST FOR ALL TRANSFERS .I DO NOT REMEMBER TO USE MY CALL BUTTON TO ASK FOR HELP R/T MY DEMENTIA. I HAVE A PULL AWAY ALARM ON AT ALL TIMES . An Incident-Falls report, dated [DATE], read in part, .Location of Fall .Resident Room .RESIDENT WAS FOUND ON THE FLOOR BY STAFF. ASKED RESIDENT WHAT SHE WAS DOING TO FALL. SHE STATED SHE WAS TRYING TO GET OUT OF HER RECLINER AND GET INTO HER WHEELCHAIR. RESIDENT STATED THAT SHE FORGOT TO LOCK THE BRAKES ON HER WHEELCHAIR AND IT SLIDE [sic] FROM UNDER HER AND SHE fell . RESIDENT WAS ASKED WHY SHE DIDN'T USE HER CALL LIGHT RESIDENT STATED SHE FORGOT. RESIDENT STATED CANT PUT PRESSURE ON HER RIGHT LET IT HURTS. RESIDENT WAS ASSISTED TO HER BED TO LAY DOWN. RESIDENT POSSIBLE [sic] HIT HER HEAD SO NEURO CHECKS WERE COMPLETED .SENT TO ER FOR EVAL AND TREATMENT . Hospital records, dated [DATE], documented the resident had a right hip fracture. Resident #3 returned to the facility on [DATE]. No new fall interventions had been implemented. An Incident-Falls report, dated [DATE], read in part, .Location of Fall .Resident Room .[at] 2130 [9:30 p.m.] THIS NURSE WAS NOTIFIED OF THE RESIDENT FOUND TO HAVE FALLEN ON THE FLOOR MAT. RESIDENT WAS ASSESSED AND NEURO CHECK STARTED, SCRATCH NOTED TO THE BACK OF HER LEFT LEG, DENIES PAIN. DR NOTIFIED AND SAID TO CONTINUE TO MONITOR . On [DATE] at 2:03 p.m., the DON was asked what interventions were implemented after the [DATE] fall. She stated the MDS nurse would implement new interventions and update the care plan. She stated the interventions should be implemented immediately and that the care plan had not been updated. On [DATE] at 2:19 p.m., LPN #1 was asked why resident #3 had been sent out on [DATE]. He stated she was a high fall risk and had alarms on her bed, wheelchair and recliner. He stated she had tried to use her wheelchair to get up and forgot to lock the brakes or use the call light. He stated he assessed her for injuries and she had none. He stated she did not complain of pain until she walked a few steps, then she complained of right leg pain. She was assisted to bed, then sent to the ER. She was found to have a closed right hip fracture. LPN #1 was asked what interventions were put in place when resident #3 returned from the hospital. He stated staff were just trying to watch her more. He stated she had a pull alarm in her wheelchair and a pressure alarm in her recliner and bed. He stated resident #3 could turn off the pressure alarm. At 2:47 P.M., the DON was asked what interventions were put in place after the resident fell on [DATE]. She stated there were no new interventions.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure two staff members were present and a safety belt was utilized during a mechanical whirlpool lift transfer per the facilities policy for a safe mechanical lift transfer. This resulted in resident #1 falling from the mechanical whirlpool lift, sustaining a head injury, fractured ribs and right femur fracture. He was sent to the emergency room and expired from a brain bleed. On [DATE] at 6:53 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 7:05 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:10 p.m., an acceptable plan of removal was provided. The plan of removal documented: Action to Remove Immediacy .On [DATE], the whirlpool was taken out of commission pending proper training of staff. A sign was posted on the door that reads 'Whirlpool Not in Use'. At that time, the key to the location was placed in the possession of the charge nurse to ensure that no untrained staff members were allowed entry. Effective [DATE], the key was placed in the possession of the Director of Nursing Services until all extended agency contract staff, other agency employees assigned to the [DATE] schedules, as well as all core [facility] staff are educated/re-educated to whirlpool policy and procedures-including but not limited to two staff members must be present at all times and safety belts must be utilized for a safe mechanical whirlpool transfer. A list of fully trained core staff and agency staff will be created and maintained. This plan of removal will be completed by [DATE] at 16:00 [4:00 p.m.]. Action to Prevent Recurrence .Thereafter, all new agency team members and new core team members will not be allowed to accept an assignment until they have completed the whirlpool competency education and their name is added to the list of fully trained nursing staff. After all competencies are completed, the key will be returned to the west charge nurse with a list of team members/agency team members that have completed the whirlpool competency education. This list will be kept in a Whirlpool Competency book at West nurses' desk and will be updated daily as competencies are completed. Monitoring Implementation of Plan of Removal .All education, implementation and monitoring of this plan of removal will be completed by the Director of Nursing Services and Assistant Director of Nursing services and/or their designee . On [DATE] at 8:35 a.m., the IJ was removed when all components of the plan of removal had been completed. This was effective as of [DATE] at 4:00 p.m. The deficiency remained at a level of actual harm at a pattern. On [DATE], interviews were conducted with core nursing staff and agency staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on record review and staff interviews, the facility failed to ensure two staff members were present for a mechanical lift transfer for one (#1) and adequate supervision was provided to prevent falls for one (#3) of three sampled residents reviewed for falls. This resulted in resident #1 falling from the mechanical shower lift, sustaining a head injury, fractured ribs and right femur fracture. He was sent to the emergency room and expired from a brain bleed. Resident #3 had a fall and sustained a right hip fracture and was sent to the emergency room and required surgical intervention. The DON identified 59 resident resided in the facility. Findings: A Falls and Fall Risk policy, revised ,d+[DATE], read in part, .the nurse shall assess and document .Musculoskeletal function, observing for change in normal range of motion .Pain .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . RUBY'S LIST .EQUIPMENT .Chair alarms .Bed alarms .QUALIFIERS .Dementia . AMechanical Lift policy, revised ,d+[DATE], read in part, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Mechanical lifts may be used for tasks that require .bathing .Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. 1. Resident #1 had diagnoses which included [CONDITION(S)] and hypertension. A physician's order, dated [DATE], documented the resident was on a blood thinner. A care plan, dated [DATE], read in part, .HX [HISTORY] OF FALLS I AM AT RISK FOR FALLS .DUE TO MY HX OF FALLS A PRESSURE ALARM IS UTILIZED TO ALERT STAFF IF I GET UP UNASSISTED . A comprehensive resident assessment, dated [DATE], documented resident #1 had severe cognitive impairment and had two falls since admission. A fall risk assessment, dated [DATE], documented the resident was at high risk of falls. An incident-falls report, dated [DATE] at 2:00 a.m., read in part, .Location of Fall .Bathroom .Did Resident call for Help .No .THIS NURSE WHILE ON THE CORRIDOR HAS SEEN CALL LIGHT GOING OFF THE ENTRANCE OF THE WHIRLPOOL AREA AND WENT TO CHECK WHAT WAS HAPPENING. FOUND THE ABOVE RESIDENT ON THE FLOOR WITH IS HIS HEAD BLEEDING WHILE THE AIDE WAS TRYING TO ASSIST HIM .Witness .THE NURSING AIDE STAFF THAT GAVE HIM SHOWER . Notes .@ [at] [7:40 p.m.] GOT NOTIFIED OF RESIDENT FALL, RESIDENT WAS REPORTED TO HAVE SWING HIMSELF FORWARD OUT OF THE SHOWER CHAIR AND LANDED ON THE HARD FLOOR HITTING HIS HEAD OF THE RT [RIGHT] SIDE OF HIS FACE, ELBOW AND RIGHT HIP. UPON ASSESSMENT NOTED RESIDENT HAD A SWOLLEN FACE ON THE RT HEAD WITH COUPLE OF CUT BLEEDING PROFUSELY, RT ARM ELBOW BRUISE WITH BLOOD, FRACTURE SUSPECTED TO THE RIGHT HIP .RESIDENT WAS TRANSFERRED [sic] .ER . An email communication from LPN #3, dated [DATE] at 2:39 p.m., read in part, .[DATE] .around 7:40pm .knocked and opened the door .found this male resident [resident #1] on the floor with the nursing aide [name deleted] standing by him who told me she had just completed his whirlpool shower, set him on the transfer shower chair. She said the resident had swing himself forward and fell on the cold floor hitting his head .transferred him to .ER . On [DATE] at 2:03 p.m., the DON was asked what interventions were implemented after the [DATE] fall. She stated the MDS nurse would implement new interventions and update the care plan. She stated the interventions should be implemented immediately and that the care plan had not been updated. On [DATE] at 11:17 a.m., CNA #1 was asked to describe how resident #1 had fallen. She stated she had him up in the whirlpool lift chair. She stated there was no device to secure the resident to the chair. She stated the whirlpool chair was approximately waist high when she turned to get a towel. She stated the towel was about three steps away from the resident. When she turned back around she observed the resident had fallen off of the whirlpool chair and was laying on the floor. CNA #1 was asked what type of training she had received from the facility prior to providing care. She stated she worked for agency and had received no education. At 2:47 p.m. the DON was asked how many staff should be present during a mechanical lift transfer. She stated two. She stated during the above transfer, there was only staff member present. An [DATE] at 2:27 p.m., the ADM was asked who was responsible to inservice agency staff regarding the mechanical whirlpool lift. She stated one of their LPNs conducted competency checks prior to their shift. She was asked for a list of all agency staff who had worked since [DATE] and any in-services that had been conducted with agency staff. She stated, I think it might have been just the core staff. At 2:49 p.m., the DON stated they did not have whirlpool competencies for agency staff due to they were not using agency staff to give whirlpools. At 3:19 p.m., the DON stated between the end of November and mid-December, the decision was made to not have agency staff in the whirlpool room. She was made aware the agency Welcome Packet for agency staff had whirlpool instructions. She stated she had just seen it and it needed to be removed. At 3:35 p.m., agency CNA #5 was asked if she uses the whirlpool room. She stated she had been trained to use it but had not used it. She was asked if she could use it if a resident wanted a whirlpool. She stated, Yes, as long as no one is in it. At 3:55 p.m., agency CNA #6 was asked if she uses the whirlpool room. She stated she had a couple months ago. She was asked if she was able to use the whirlpool currently. She stated, Yes. At 4:00 p.m., agency CNA #7 was asked if she uses the whirlpool room. She stated she had not. She was asked if she could use the whirlpool. She stated, Yes, if someone requested one. At 4:02 p.m., agency CNA #8 was asked if she had every used the whirlpool room. She stated she had not. She was asked if she could use the whirlpool room if a resident requested one. She stated, Yes. At 7:05 p.m., the Administrator and DON were made aware of the above agency staff stating they could use the whirlpool if they had a resident that requested a whirlpool bath and that 27 of the 48 staff utilized since [DATE] had not been educated on the mechanical lifts, the whirlpool check-offs or the agency welcome packet. 2. Resident #3 was admitted on [DATE], and had diagnoses which included dementia and diabetes mellitus. An admission Fall Risk Assessment, dated [DATE], documented the resident was high risk for fall with a score of 12. A care plan, dated [DATE], read in part, .Problem .I AM A HIGH FALL RISK R/T FALL RESULTING IN HIP FRACTURE AND HX OF PRIOR FALLS .Approach .2 PERSON ASSIST FOR ALL TRANSFERS .I DO NOT REMEMBER TO USE MY CALL BUTTON TO ASK FOR HELP R/T MY DEMENTIA. I HAVE A PULL AWAY ALARM ON AT ALL TIMES . An Incident-Falls report, dated [DATE], read in part, .Location of Fall .Resident Room .RESIDENT WAS FOUND ON THE FLOOR BY STAFF. ASKED RESIDENT WHAT SHE WAS DOING TO FALL. SHE STATED SHE WAS TRYING TO GET OUT OF HER RECLINER AND GET INTO HER WHEELCHAIR. RESIDENT STATED THAT SHE FORGOT TO LOCK THE BRAKES ON HER WHEELCHAIR AND IT SLIDE [sic] FROM UNDER HER AND SHE fell . RESIDENT WAS ASKED WHY SHE DIDN'T USE HER CALL LIGHT RESIDENT STATED SHE FORGOT. RESIDENT STATED CANT PUT PRESSURE ON HER RIGHT LET IT HURTS. RESIDENT WAS ASSISTED TO HER BED TO LAY DOWN. RESIDENT POSSIBLE [sic] HIT HER HEAD SO NEURO CHECKS WERE COMPLETED .SENT TO ER FOR EVAL AND TREATMENT . Hospital records, dated [DATE], documented the resident had a right hip fracture. Resident #3 returned to the facility on [DATE]. No new fall interventions had been implemented. An Incident-Falls report, dated [DATE], read in part, .Location of Fall .Resident Room .[at] 2130 [9:30 p.m.] THIS NURSE WAS NOTIFIED OF THE RESIDENT FOUND TO HAVE FALLEN ON THE FLOOR MAT. RESIDENT WAS ASSESSED AND NEURO CHECK STARTED, SCRATCH NOTED TO THE BACK OF HER LEFT LEG, DENIES PAIN. DR NOTIFIED AND SAID TO CONTINUE TO MONITOR . On [DATE] at 2:19 p.m., LPN #1 was asked why resident #3 had been sent out on [DATE]. He stated she was a high fall risk and had alarms on her bed, wheelchair and recliner. He stated she had tried to use her wheelchair to get up and forgot to lock the brakes or use the call light. He stated he assessed her for injuries and she had none. He stated she did not complain of pain until she walked a few steps, then she complained of right leg pain. She was assisted to bed, then sent to the ER. She was found to have a closed right hip fracture. LPN #1 was asked what interventions were put in place when resident #3 returned from the hospital. He stated staff were just trying to watch her more. He stated she had a pull alarm in her wheelchair and a pressure alarm in her recliner and bed. He stated resident #3 could turn off the pressure alarm. At 2:47 P.M., the DON was asked what interventions were put in place after the resident fell on [DATE]. She stated there were no new interventions.

On [DATE], an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) due to the facility's failure to ensure a resident who had fallen and sustained a head injury was thoroughly and consistently monitored and the physician was informed of all pertinent information. At 2:01 p.m., the DON (director of nurses) was notified of the existence of the IJ situation. Resident #1 had a previous heart valve replacement and received [MEDICATION NAME] (a blood thinner) once daily since [DATE]. On [DATE] at 3:25 p.m., the resident was found in her room on the floor beside her bed, lying on her right side. The resident was assessed and found to have a skin tear on her right temple. At 3:40 p.m., the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. At 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. Her blood pressure readings continued to be high throughout the day; however, the physician was not notified of these abnormal blood pressure readings. At 7:25 p.m., the resident's blood pressure had risen to ,[DATE]. The physician was never notified. At 8:45 p.m., one hour and 20 minutes after her blood pressure was measured at ,[DATE], she started vomiting and lost consciousness. At 9:01 p.m., 16 minutes later, after the resident was found nonresponsive, the facility called EMSA (emergency medical services) to transport the resident to a local hospital. On arrival to the facility, EMSA found the resident unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing, but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. At 9:54 p.m., the resident was admitted to the local hospital where she was found to have a subdural hematoma (a brain bleed), approximately 1.5 cm (centimeters) in size, which was causing her brain to shift past the midline and herniate. Additionally, the resident was diagnosed with [REDACTED]. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. At 5:28 a.m., she was admitted to the hospital with [REDACTED]. Surgery was performed to remove the hematoma from her brain, and the resident was transferred to ICU (Intensive Care Unit); however, imaging after surgery revealed her brain contained multiple infarcts (areas which had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. The resident did not improve or regain consciousness. She was unable to breath without the assistance of a ventilator. The family decided to place the resident on comfort care and removed the ventilator. The resident expired on [DATE] at 8:55 a.m. O[DATE] at 5:11 p.m., an acceptable plan of removal was received. The plan of removal documented: Plan of Removal for (Named facility) [DATE] 1600 (4:00 p.m.) 1) Inservice (see attached page for in service details) will be done for all nursing staff (RN (registered nurse), LPN's (licensed practical nurse), CMA (certified medication aide) and CNA (certified nurse aide)). Nursing staff currently on duty will be educated by Director of Nursing during the current ,[DATE] pm (3:00 p.m. to 11:00 p.m.). All other nursing staff, including agency staff will be in serviced prior to starting or next shift. 2) Review of charts will be conducted to ensure assessments including neuro (neurological) checks and vital signs are being properly completed and reported to physician as needed for residents who are on neuro checks and residents on anticoagulants who have fallen. A list of residents who are on anticoagulants will be made and reviewed. a) 3. Residents in the facility that have fallen with neuro checks will be reviewed include (1) (Named resident #2) [DATE] with major injury (2) (Named resident #7) [DATE] with injury (3) (Named resident #8) [DATE] no injury (4) (Named resident #3) (9 falls since Feb (February) 1, 2019) out of all falls 1 with neuro checks (5) (Named resident #6) [DATE] with major injury (6) (Named resident #9) [DATE] with no injury 3) All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent through out the (Named facility) and at no time will a new form be implemented by any staff member other that the Director of Nursing. 4) Will be adding at least one licensed personnel on evening shift until a thorough review of facility assessment and resident acuity is reviewed. (signed DON). An attachment to the plan of removal titled, Plan of Removal In Service, documented: 1. All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent throughout the (Named facility) and at no time will a new form be implemented by any staff member other than the Director of Nursing. 2. Neurological Protocol timing, documentation, signs and symptoms 3. Blood pressure parameters reporting to physician in timely, thorough manner including vitals, neuros, L[NAME] (level of consciousness), s/sx (signs and symptoms) related to head injury. 4. Sign and symptoms of neurological issues who have fallen including vomiting, change in L[NAME], increased confusion, difficult to arouse, [MEDICAL CONDITION], bleeding or watery drainage from nose or ears, pupils slow to react or unequal, blurred vision, loss of sensation to any extremity, slurred speech and vomiting. 5. Instruct staff to report change of condition to physician. The IJ was removed effective [DATE] at 11:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained a harm, at a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure: ~ a resident (#1), who was on an anticoagulant (medication to thin the blood), and had fallen and sustained a head injury was thoroughly and consistently monitored and the physician was informed of all pertinent information such as high blood pressure readings. The resident became unresponsive and was then transferred to the hospital. She was diagnosed with [REDACTED]. She expired on [DATE]. ~ a resident's (#2) fall risk assessment was accurate and ~ a resident's (#4) post fall assessments were complete for three (#1, 2 and #4) of six sampled residents reviewed for falls. The DON identified 39 residents who were at high risk for falls. Findings: A facility policy titled, Head Injury Actual or Potential, documented: Policy: To observe, record and report any condition change to the attending Physician to (sic, so) proper treatment will be implemented. Equipment .Blood pressure cuff . Procedure .Following any head trauma, monitoring the following . Observe for swelling and discoloration; if present, chart size, site, amount and color .Observe and inquire if resident has headache or pain .Observe for personality changes .Observe for generalized weakness .Take vital signs .Observe for unequal pupils .Have someone stay with the resident while charge nurse call the attending physician . A facility policy titled, (Named facility) Protocol, documented: .If resident falls with head injury immediate complete assessment will be performed by licensed personnel. Neurological checks will begin immediately with all suspected head injuries. The physician will be notified of incident and full report of all abnormal neurological findings. Physician will be notified by phone only .Charting should continue every shift for at least 72 (hours) post fall .Corrective and or intervention must be documented on all incident reports and care plan must be updated. A facility policy titled, Neurological Protocol, documented: .Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology .Observe the resident for obvious injuries to the scalp, including .bruises .pupils of unequal size or reactions; headache; vomiting .lethargy. Monitoring must continue for a minimum of 72 hours . Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements . A facility policy titled, Change in a Resident's Condition or Status, documented: .Policy Statement .Our facility shall promptly notify the resident, his or her attending physician .of changes in the resident's medical .condition and/or status . Policy Interpretation and Implementation .the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .A significant change in the resident's physical .condition . 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. physician's orders [REDACTED].[MEDICATION NAME] sodium (an anticoagulant - a blood thinner) Tab(s) (tablets) give 1 tab by mouth daily at 1400 (2:00 p.m.) . A fall risk assessment, dated [DATE], documented she had a fall risk score of 10 which was a high risk for falls. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. She required extensive two person assistance from staff with bed mobility, transfers and toilet use. She had upper and lower extremity impairment on one side of her body. For seven of the last seven days reviewed she had received an anticoagulant routinely. She did not have a life expectancy of less than six months. A lab report, dated [DATE], documented she had blood testing done, a PT ([MEDICATION NAME]) test and an INR (international normalized ratio) test, to monitor her coagulation and her risk of bleeding from taking [MEDICATION NAME], a blood thinner. Her PT was 33.3 seconds with a reference range of 10.0 - 12.0 seconds. Her INR was 3.26 with a reference range of 1.00- 1.20. The reference ranges were therapeutic for the resident's diagnoses, but did put her at a greater risk for bleeding. A care plan, dated [DATE], documented, .I am a high risk for falls . I'm at risk of brusing (sic, bruising) and bleeding r/t (related to) the use of [MEDICATION NAME] ([MEDICATION NAME]/blood thinner) .observe for bruising and excessive bleeding . I am at risk for having pain .observe me for s/s of pain since I am unable to tell you when I hurt . A late entry nurse's note, dated [DATE] at 11:26 p.m., documented at 3:25 p.m., the resident was found in her room on the floor beside her bed lying on her right side. The resident was assessed and found to have an abrasion and a skin tear on her right temple and her temple was beginning to swell. She had redness on her right shoulder, redness on her right knee with light purple bruising and a small bruise on her right elbow. She was assisted to standing and transferred to her bed. She was soiled and perineal care was provided. She was then transferred to her wheelchair and neurological checks and vital sign monitoring was started. A neurological assessment, dated [DATE] at 3:40 p.m., documented the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. Her pupil size was assessed to be 2 mm. A hypertensive or high blood pressure reading is defined by the American Heart Association as a systolic (top number) of 120 or above and/or a diastolic (bottom number) of 80 or above. The late entry documented at 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. A neurological assessment, dated [DATE] at 3:55 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 4:10 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A late entry nurse's note at 11:32 p.m., documented one hour after the fall (4:25 p.m.) the resident was given Tylenol and a slight raised area to the right side of temple starting to appear. A neurological assessment, dated [DATE] at 4:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 5:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 6:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A vital sign record, dated [DATE] at 7:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The doctor was never notified of the critical blood pressure reading A Medication Administration Record, [REDACTED]. A late entry nurse's note at 11:51 p.m., documented at 8:45 p.m., CNAs #3 and #4 called the nurse to the resident's room. The resident had started vomiting and lost consciousness. The nurse documented the resident's pupils measured 5 mm (millimeters), which was a change from the 2 mm the pupils had measured the entire evening. The late entry nurse's note further documented, at 9:01 p.m., the facility called EMSA to transport the resident to a local hospital. A physician's telephone order, dated [DATE] at 9:04 p.m., documented, .transfer to (named local hospital) ER (emergency room ) .to further eval (evaluate) and tx (treat) . An EMSA record, dated [DATE] at 9:15 p.m., documented on arrival to the facility, the resident was found unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing , but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. An ED (emergency department) admission note, at 9:54 p.m., documented she was admitted to the local hospital. An ED provider note, at 10:05 p.m., documented on arrival her blood pressure was ,[DATE]. She was intubated and unresponsive. She had decreased breath sounds. She had a contusion (bruise) on her head and redness around her right eye. The note documented throughout the night the resident received IV (intravenous) [MEDICATION NAME] (an antihypertensive medication) to control her blood pressure and IV mannitol (to decrease brain swelling), IV fresh frozen plasma and IV vitamin K to control her bleeding. The note documented the resident was intubated with a 7.0 mm tube because of [MEDICAL CONDITION]. The note documented the final result of a CT (computerized tomography) of the head without contrast, at 11:01 p.m., as, .acute subdural hematoma along the right cerebral convexity with significant mass-effect and shift of midline structures towards the left measuring approximately 1.5 cm. Associated parafalcine herniation noted .large scalp soft tissue hematoma noted over the forehead on the right as well as the right periorbital region . The note documented an assessment of a post-traumatic subdural hematoma and coagulopathy. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. A hospital note, dated [DATE] at 5:28 a.m., documented she was admitted to the metropolitan hospital with [DIAGNOSES REDACTED]. An operative report, dated [DATE] at 7:13 a.m., documented the resident had right-sided craniotomy surgery to remove the subdural hematoma. A CT scan report, dated [DATE] at 9:01 a.m., documented the resident had an .acute, subdural, subarachnoid, and intraparenhcymal hemorrhage .1.9 cm of right-to-left shift with findings concerning for a trapped left ventricle . A CT scan report, dated [DATE] at 11:35 a.m., documented her brain was found to contain multiple infarcts (areas that had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. A neurosurgery progress note, dated [DATE] at 12:36 p.m., documented the resident presented with a right side subdural hematoma with a midline shift. The note documented her pupils were nonreactive and dilated to 5 mm. The note documented she was nonresponsive, except to noxious stimuli, and then she only responded by posturing. A case management report, dated [DATE] at 2:58 p.m., documented, as the resident had not improved and her [MEDICAL CONDITION] prognosis was poor, the family decided to make the resident DNR (do not resuscitate). The family placed the resident on comfort care and the ventilator was removed. A hospital death log documented the resident died on [DATE] at 8:55 a.m. A hospital discharge summary, dated [DATE] at 10:55 a.m., documented the resident had a discharge [DIAGNOSES REDACTED]. The summary documented her admission [DIAGNOSES REDACTED]. On [DATE] at 3:40 p.m., LPN #8, the charge nurse the night the resident fell , was asked to describe the process of assessing neurological and vital signs, including blood pressure, after a head injury. She stated a new process and worksheet had recently been implemented to record the neurological assessment and vital signs. She stated all of the information was recorded on one page. She stated a CMA took the vital signs, and the nurse, did the neurological assessments. She stated sometimes she did not learn of the vital signs the CMA took immediately because both she and the CMA would be taking care of other duties and might not see each for a while to exchange information. She was asked if she knew the resident's initial blood pressure reading prior to calling the physician about the fall. She said, No. She stated she thought she learned about the blood pressure after calling the physician. She was asked if she communicated with the physician about anything related to the resident and the fall after the initial call to him. She stated she did not communicate with the physician anymore about this resident until she told him the resident was going to the hospital. She was asked if she was concerned the resident was having high blood pressure readings. She stated she remembered the resident had a history of [REDACTED]. She stated at one point during the night the resident's blood pressure appeared to be improving. She confirmed the blood pressure was ,[DATE] at 5:25 p.m. She stated when the 7:25 p.m. blood pressure reading was so much higher, at ,[DATE], she thought she should let the physician know. She stated she intended to call the physician with this information, but an alarm went off in another resident's room and she was pulled away. She stated she did not get the call made to the physician. She stated at 8:45 p.m., one hour and twenty minutes later, CNAs #3 and #4 called her to the resident's room. She stated the resident had been vomiting, was unresponsive and her pupil size had increased. She stated she stayed with the resident to make sure the resident was breathing. She stated they began cleaning up the resident as they did not want the resident to go to the hospital in such a mess. She then stated EMSA was paged at 9:01 p.m., sixteen minutes later. She stated there was not enough staff that night. She stated many of the residents on that hall were women who would not let a male take care of them so she and the female CMA had to handle most of the workload. She stated there were also two males working the hall that evening, but one of them was a new agency nurse and he was not able to help much. She stated there had been an increasing use of agency staff over the past several months and, it makes it hard to care for residents because the agency staff did not know the residents. At 7:10 p.m., CMA #2, who was working on the hall the day the resident fell , was asked to describe the process of assessing neurological and vital signs, including blood pressure, after a head injury. She stated there was a new neurological assessment sheet, and she really did not understand it. She stated she would take the vital signs on a piece of paper, and, if she had time, would tell the nurse. She stated most nurses would usually ask her for the vital sign readings first. She stated that night she and LPN #8 were both working on taking the vital signs. She stated she did not take the blood pressure reading at 7:25 p.m. because she was passing medication, so someone else did. On [DATE] at 10:26 a.m., a family member was asked if the resident appeared to be in distress the evening of the fall. The family member stated they had dinner with the resident that evening and she ate, but she had a goose egg on the right side of her head by her eye. The family member stated at times the resident would lean forward and hold her head. She had been known to do that in the past when her head hurt. At 10:58 a.m., the physician was asked if he had been informed of the resident's initial blood pressure reading when he was informed of the fall. He stated he was not informed of the blood pressure reading. He stated knowing the blood pressure readings would have been a relevant contribution and may have led to an earlier evaluation of the resident. At 1:42 p.m., the DON said, I knew this would be a problem when I saw the doctor had not been told about the blood pressure. At 1:46 p.m., CNA #3, who took care of the resident that evening, was asked when the resident began vomiting. He stated the resident had been sitting at the nurse's station and began vomiting. He stated he immediately took the resident into her room to begin cleaning her up. He stated he realized she needed to have a shower and so he started the water in the shower. He stated when he went to stand the resident up, she was limp and not herself. He stated he told CNA #4 to get the nurse. He stated about ten minutes past between the time he took the resident to her room and the time the nurse was alerted. At 2:00 p.m., CNA #4 stated when they tried to stand the resident to put her in the shower they realized the resident was limp. She stated the resident had a big shiner on her head all night long, and it was seeping. 2. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. Her gait was not steady but she was able to stabilize herself without staff assistance. A nurse's progress note, dated [DATE], documented, .resident was observed lying in the grass on her left side beside wheelchair with a guest standing by her .She had blood in her mouth from a lip abrasion, small abrasion to the tip of her nose, scrapes on her right hip .complaining of left wrist pain and the left wrist had started to swell . A nurse's progress note, dated [DATE], documented, . 0805 (8:05 a.m.) used call light in bathroom .forgot too weak to transfer to wheelchair from toilet .fell to ground on buttocks . A fall risk assessment, dated [DATE], documented the resident was alert and oriented x 3 (to person, place, and time). The section for systolic blood pressure was left blank. The total fall risk score was 7. A score of 10 or above represents a high risk for falls. There was no definition of what a score of 7 represented. Only a definition for a score of 10 or above. On [DATE] at 9:02 a.m., the DON was asked who completed fall assessments. She stated LPN #5 updated the quarterly fall assessments and any nurse could update them between the quarterly assessments. She stated the resident's blood pressure was not included on the fall assessment and it should have been because it could have changed the fall score. She was asked if she would have considered the resident oriented x 3 on [DATE]. She stated no. She then stated she would have marked her as intermittent confusion because she had been confused at times. She stated if the resident had been assessed accurately with intermittent confusion this would have changed the fall risk assessment. At 10:48 a.m., LPN #5 was asked if she completed quarterly fall risk assessments. She stated she did. She was asked if she completed the fall risk assessment on [DATE] for the resident. She stated she had completed the fall risk assessment. She was asked if the resident was awake, alert and oriented x 3. She stated she usually was at times. She then said, I am sure at times she has been confused. She recognizes her daughter but I might not have asked her about the time and place. She was asked if the fall risk assessment was completed regarding the evaluation of the resident's systolic blood pressure. She stated she admitted she had not completed the section. She was asked if the sections had been completed accurately, would that have changed her fall score and made her a high risk for falls. She stated it would. 3. Resident #4 had [DIAGNOSES REDACTED]. A nurse's progress note, dated [DATE] at 7:41 a.m., .0630 (6:30 a.m.) aide states that while transferring resident from w/c (wheelchair) to recliner resident legs became weak and she had to sit her on the floor . She was placed on post fall observation for 72 hours every shift. Nurse's progress notes, dated [DATE] through [DATE], documented seven out of nine post fall assessments were completed. There were no post fall assessments documented for [DATE] on the 11:00 p.m. to 7:00 a.m. shift and no post fall assessment documented for the [DATE] 7:00 a.m. to 3:00 p.m. shift. A quarterly assessment, dated [DATE], documented the resident was cognitively intact in skills for daily decision making. She required extensive assistance of two staff members with transfers. On [DATE] at 9:02 a.m., the DON was asked if the resident fell on [DATE] at 7:41 a.m. when would the 72 hour post fall monitoring be completed. She stated it would have been on [DATE] around seven am. She was asked to review the nurse's progress notes for post fall assessments. She stated there was not an entry between [DATE] and [DATE] on the 11:00 p.m. to 7:00 a.m. shift and there should have been one. She also stated there should have been a day shift entry on [DATE] because it would have ended the 72 hour post fall monitoring.

On [DATE], an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) due to the facility's failure to ensure there was sufficient staff to ensure residents were safe from falls and staff could respond promptly to residents who had fallen. At 2:01 p.m., the DON (director of nurses) was notified of the existence of the IJ situation. Resident #1 had a previous heart valve replacement and received [MEDICATION NAME] (a blood thinner) once daily since [DATE]. On [DATE] at 3:25 p.m., the resident was found in her room on the floor beside her bed, lying on her right side. The resident was assessed and found to have a skin tear on her right temple. At 3:40 p.m., the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. At 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. Her blood pressure readings continued to be high throughout the day; however, the physician was not notified of these abnormal blood pressure readings. At 7:25 p.m., the resident's blood pressure had risen to ,[DATE]. The nurse was notified of this critical reading and intended to inform the doctor right away, but an alarm went off in another resident's room and the nurse responded to that alarm. The nurse did not call the doctor with the critical blood pressure reading. The nurse further stated there was not enough staff working the night of the resident's fall. She stated many residents preferred only female staff members and so she and another female nurse aide had to handle most of the work load. She stated there was an increased usage of agency staff over the previous few months and they were not familiar with the residents and how to care for them. At 8:45 p.m., the resident began throwing up and became unresponsive. This occurred one hour and 20 minutes after her blood pressure was measured at ,[DATE]. At 9:01 p.m., 16 minutes later, after the resident was found nonresponsive, the facility called EMSA (emergency medical services) to transport the resident to a local hospital. On arrival to the facility, EMSA found the resident unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing, but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. At 9:54 p.m., the resident was admitted to the local hospital where she was found to have a subdural hematoma (a brain bleed), approximately 1.5 cm (centimeters) in size, which was causing her brain to shift past the midline and herniate. Additionally, the resident was diagnosed with [REDACTED]. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. At 5:28 a.m., she was admitted to the hospital with [REDACTED]. Surgery was performed to remove the hematoma from her brain, and the resident was transferred to ICU (Intensive Care Unit); however, imaging after surgery revealed her brain contained multiple infarcts (areas which had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. The resident did not improve or regain consciousness. She was unable to breath without the assistance of a ventilator. The family decided to place the resident on comfort care and removed the ventilator. The resident expired on [DATE] at 8:55 a.m. Throughout the course of the survey multiple staff members from different disciplines were interviewed and stated the facility did not provide sufficient staffing to ensure residents were safe from falls and could respond promptly in the event of a fall or a change in a resident's condition. [DATE] at 5:11 p.m., an acceptable plan of removal was received. The plan of removal documented: Plan of Removal for (Named facility) [DATE] 1600 (4:00 p.m.) 1) Inservice (see attached page for in service details) will be done for all nursing staff (RN (registered nurse), LPN's (licensed practical nurse), CMA (certified medication aide) and CNA (certified nurse aide)). Nursing staff currently on duty will be educated by Director of Nursing during the current ,[DATE] pm (3:00 p.m. to 11:00 p.m.). All other nursing staff, including agency staff will be in serviced prior to starting or next shift. 2) Review of charts will be conducted to ensure assessments including neuro (neurological) checks and vital signs are being properly completed and reported to physician as needed for residents who are on neuro checks and residents on anticoagulants who have fallen. A list of residents who are on anticoagulants will be made and reviewed. a) 3. Residents in the facility that have fallen with neuro checks will be reviewed include (1) (Named resident #2) [DATE] with major injury (2) (Named resident #7) [DATE] with injury (3) (Named resident #8) [DATE] no injury (4) (Named resident #3) (9 falls since Feb (February) 1, 2019) out of all falls 1 with neuro checks (5) (Named resident #6) [DATE] with major injury (6) (Named resident #9) [DATE] with no injury 3) All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent through out the (Named facility) and at no time will a new form be implemented by any staff member other that the Director of Nursing. 4) Will be adding at least one licensed personnel on evening shift until a thorough review of facility assessment and resident acuity is reviewed. (signed DON). An attachment to the plan of removal titled, Plan of Removal In Service, documented: 1. All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent throughout the (Named facility) and at no time will a new form be implemented by any staff member other than the Director of Nursing. 2. Neurological Protocol timing, documentation, signs and symptoms 3. Blood pressure parameters reporting to physician in timely, thorough manner including vitals, neuros, L[NAME] (level of consciousness), s/sx (signs and symptoms) related to head injury. 4. Sign and symptoms of neurological issues who have fallen including vomiting, change in L[NAME], increased confusion, difficult to arouse, [MEDICAL CONDITION], bleeding or watery drainage from nose or ears, pupils slow to react or unequal, blurred vision, loss of sensation to any extremity, slurred speech and vomiting. 5. Instruct staff to report change of condition to physician. The IJ was removed effective [DATE] at 11:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained a harm, at a pattern. Based on record reviews and interviews, it was determined the facility failed to provide sufficient staff to ensure residents were safe from falls and staff could respond promptly to residents who had fallen for one (#1) of six sampled residents reviewed for falls. Resident #1 had fallen on [DATE] and acquired a head injury. The resident was not consistently assessed and interventions were not promptly made. The resident eventually lost consciousness and was sent to the hospital where she was diagnosed with [REDACTED]. She expired on [DATE]. The DON identified 39 residents who were at high risk for falls. Findings: Resident #1 was admitted with [DIAGNOSES REDACTED]. physician's orders [REDACTED].[MEDICATION NAME] sodium (an anticoagulant - blood thinner) Tab(s) (tablets) give 1 tab by mouth daily at 1400 (2:00 p.m.) . A fall risk assessment, dated [DATE], documented she had a fall risk score of 10 which was a high risk for falls. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. She required extensive two person assistance from staff with bed mobility, transfers and toilet use. She had upper and lower extremity impairment on one side of her body. For seven of the last seven days reviewed she had received an anticoagulant routinely. She did not have a life expectancy of less than six months. A lab report, dated [DATE], documented she had blood testing done, a PT ([MEDICATION NAME]) test and an INR (international normalized ratio) test, to monitor her coagulation and her risk of bleeding from taking [MEDICATION NAME], a blood thinner. Her PT was 33.3 seconds with a reference range of 10.0 - 12.0 seconds. Her INR was 3.26 with a reference range of 1.00- 1.20. The reference ranges were therapeutic for the resident's diagnoses, but did put her at a greater risk for bleeding. A care plan, dated [DATE], documented, .I am a high risk for falls . I'm at risk of brusing (sic, bruising) and bleeding r/t (related to) the use of [MEDICATION NAME] ([MEDICATION NAME]/blood thinner) .observe for bruising and excessive bleeding . I am at risk for having pain .observe me for s/s of pain since I am unable to tell you when I hurt . A late entry nurse's note, dated [DATE] at 11:26 p.m., documented at 3:25 p.m., the resident was found in her room on the floor beside her bed lying on her right side. The resident was assessed and found to have an abrasion and a skin tear on her right temple and her temple was beginning to swell. She had redness on her right shoulder, redness on her right knee with light purple bruising and a small bruise on her right elbow. She was assisted to standing and transferred to her bed. She was soiled and perineal care was provided. She was then transferred to her wheelchair and neurological checks and vital sign monitoring was started. A neurological assessment, dated [DATE] at 3:40 p.m., documented the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. Her pupil size was assessed to be 2 mm. A hypertensive or high blood pressure reading is defined by the American Heart Association as a systolic (top number) of 120 or above and/or a diastolic (bottom number) of 80 or above. The late entry documented at 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. A neurological assessment, dated [DATE] at 3:55 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 4:10 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A late entry nurse's note at 11:32 p.m., documented one hour after the fall (4:25 p.m.) the resident was given Tylenol and a slight raised area to the right side of temple starting to appear. A neurological assessment, dated [DATE] at 4:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 5:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 6:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A vital sign record, dated [DATE] at 7:25 p.m., documented the resident's vital signs were taken. Her blood pressure was measured at ,[DATE], a hypertensive reading. The nurse was notified of this critical reading and intended to inform the doctor right away, but an alarm went off in another resident's room and the nurse responded to that alarm. The nurse did not call the doctor with the critical blood pressure reading. A Medication Administration Record, [REDACTED]. A late entry nurse's note at 11:51 p.m., documented at 8:45 p.m , CNAs #3 and #4 called the nurse to the resident's room. The resident had started vomiting and lost consciousness. The nurse documented the resident's pupils measured 5 mm (millimeters), which was a change from the 2 mm the pupils had measured the entire evening. The late entry nurse's note further documented, at 9:01 p.m., the facility called EMSA to transport the resident to a local hospital. A physician's telephone order, dated [DATE] at 9:04 p.m., documented, .transfer to (named local hospital) ER (emergency room ) .to further eval (evaluate) and tx (treat) . An EMSA record, dated [DATE] at 9:15 p.m., documented on arrival to the facility, the resident was found unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing , but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. An ED (emergency department) admission note, at 9:54 p.m., documented she was admitted to the local hospital. An ED provider note, at 10:05 p.m., documented on arrival her blood pressure was ,[DATE]. She was intubated and unresponsive. She had decreased breath sounds. She had a contusion (bruise) on her head and redness around her right eye. The note documented throughout the night the resident received IV (intravenous) [MEDICATION NAME] (an antihypertensive medication) to control her blood pressure and IV mannitol (to decrease brain swelling), IV fresh frozen plasma and IV vitamin K to control her bleeding. The note documented the resident was intubated with a 7.0 mm tube because of [MEDICAL CONDITION]. The note documented the final result of a CT (computerized tomography) of the head without contrast, at 11:01 p.m., as, .acute subdural hematoma along the right cerebral convexity with significant mass-effect and shift of midline structures towards the left measuring approximately 1.5 cm. Associated parafalcine herniation noted .large scalp soft tissue hematoma noted over the forehead on the right as well as the right periorbital region . The note documented an assessment of a post-traumatic subdural hematoma and coagulopathy. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. A hospital note, dated [DATE] at 5:28 a.m., documented she was admitted to the metropolitan hospital with [DIAGNOSES REDACTED]. An operative report, dated [DATE] at 7:13 a.m., documented the resident had right-sided craniotomy surgery to remove the subdural hematoma. A CT scan report, dated [DATE] at 9:01 a.m., documented the resident had an .acute, subdural, subarachnoid, and intraparenhcymal hemorrhage .1.9 cm of right-to-left shift with findings concerning for a trapped left ventricle . A CT scan report, dated [DATE] at 11:35 a.m., documented her brain was found to contain multiple infarcts (areas that had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. A neurosurgery progress note, dated [DATE] at 12:36 p.m., documented the resident presented with a right side subdural hematoma with a midline shift. The note documented her pupils were nonreactive and dilated to 5 mm. The note documented she was nonresponsive, except to noxious stimuli, and then she only responded by posturing. A case management report, dated [DATE] at 2:58 p.m., documented, as the resident had not improved and her [MEDICAL CONDITION] prognosis was poor, the family decided to make the resident DNR (do not resuscitate). The family placed the resident on comfort care and the ventilator was removed. A hospital death log documented the resident died on [DATE] at 8:55 a.m. A hospital discharge summary, dated [DATE] at 10:55 a.m., documented the resident had a discharge [DIAGNOSES REDACTED]. The summary documented her admission [DIAGNOSES REDACTED]. On [DATE] at 3:40 p.m., LPN #8, the charge nurse the night the resident fell , stated a CMA took the vital signs, and the nurse, did the neurological assessments. She stated sometimes she did not learn of the vital signs the CMA took immediately because both she and the CMA would be taking care of other duties and might not see each for a while to exchange information. She stated when the 7:25 p.m. blood pressure reading was so much higher, at ,[DATE], she thought she should let the physician know. She stated she intended to call the physician with this information, but an alarm went off in another resident's room and she was pulled away. She stated she did not get the call made to the physician. An hour and 20 minutes later, at 8:45 p.m., CNAs #3 and #4 called LPN #8 to the resident's room. She stated the resident had been vomiting, was unresponsive and her pupil size had increased. She stated she stayed with the resident to make sure the resident was breathing. She stated they began cleaning up the resident as they did not want the resident to go to the hospital in such a mess. She then stated EMSA was paged at 9:01 p.m., sixteen minutes later. LPN #8 further stated there was not enough staff that night. She stated many of the residents on that hall were women who would not let a male take care of them so she and the female CMA had to handle most of the workload. She stated there were also two males working the hall that evening, but one of them was a new agency nurse and he was not able to help much. She stated there had been an increasing use of agency staff over the past several months, and it makes it hard to care for residents because the agency staff did not know the residents. At 7:10 p.m., CMA #2 stated there was a new neurological assessment sheet, and she really did not understand it. She stated she would take the vital signs on a piece of paper, and, if she had time, would tell the nurse. She stated most nurses would usually ask her for the vital sign readings first. She stated that night she and LPN #8 were both working on taking the vital signs. She stated she did not take the blood pressure reading at 7:25 p.m. because she was passing medication, so someone else did. She added she did not feel there was sufficient staff working the evening the resident fell and stated it was not unusual to have insufficient staff on the evening shift. On [DATE] at 9:30 a.m., CNA #1 stated she worked 7:00 a.m. to 3:00 p.m. and occasionally she worked the 3:00 p.m. to 11:00 p.m. shift. She stated she had worked at the facility for the last year. She was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents' were safe from falls. She said, Yes and no. She further stated some days staffing was insufficient. She stated this occurred one day out of every three she worked. At 10:00 a.m., LPN #1 stated she worked the 3:00 p.m. to 11:00 p.m. shift. She was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents were safe from falls. She said, Not really. She further stated sometimes there were only one to two staff members working a hall with 27 to 32 residents. She stated there were several residents on the hall she worked who requested women staff only and the facility staffed several male staff members. At 10:11 a.m., CMA #1 stated she worked the 3:00 p.m. to 11:00 p.m. shift. She was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents were safe from falls. She said, Weekend staffing gets ignored and we have to fend for ourselves. She then stated often she was required to work the medication cart and pass residents' medications as well as work the halls and provide residents all necessary assistance with their activities of daily living. At 10:21 a.m., LPN #2 stated she worked the 3:00 p.m. to 11:00 p.m. shift. She stated sometimes they were short-handed. She stated several residents preferred only women staff members to assist them and the facility had several male staff members. At 10:25 a.m., LPN #3 stated she was a charge nurse who had worked at the facility for five years and she currently worked the 3:00 p.m. to 11:00 p.m. shift on the skilled unit. She was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents' were safe from falls. She said, No. She stated the DON tried the best she could. She stated the administrative staff states they have sufficient staff according to the ratios. She further stated the facility does not provide sufficient staff according to the acuity level of the residents in the facility. She was then asked to describe the types of residents she had on the skilled unit. She stated there were a lot of residents with severe dementia who could not remember things for longer than five minutes. She stated at times staff had to be pulled to monitor residents one on one and follow them around the unit. She said, It can be pretty crazy. She further stated there were a lot of residents who requested only women staff and it was difficult to accommodate this request. At 11:00 a.m., CMA #2 stated she worked the 3:00 p.m. to 11:00 p.m. shift. She was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents' were safe from falls. She stated sometimes, but they could use more staff members. At 12:38 p.m., agency CNA #2 stated she thought it would be wise to have at least one more staff member on night shifts. She stated occasionally there is just one CNA, one CMA, and one nurse working a hall which had between 25 to 30 residents. At 3:38 p.m., agency CNA #1 was asked if the facility staffed sufficiently to ensure residents' needs were met and ensure residents were safe from falls. She stated absolutely not. She further stated there had been a staff shortage ever since she had worked at the facility. She stated she had been working at the facility very often since (MONTH) (YEAR). She stated she worked the 11:00 p.m. to 7:00 a.m. shift. She stated when she first worked a shift for the facility there were only two nurses and herself working. She then stated three falls occurred that night. She stated one resident was on the floor for 30 minutes before she found her. She stated she thought she remembered the resident had a head injury. She then stated staffing had not improved at the facility since she started working there. On [DATE] at 11:27 a.m., agency CNA #4 was asked if there was enough staff at the facility to take care of resident needs. She stated at times there was enough staff and at other times there was not. She stated it had been that way for several years. She stated at times there were only two CNA's on the hall and that was not enough. She stated part of the problem was other staff, like nurses, would not help. She stated there was only one nurse on her shifts who would help the CNA's. She was asked if the facility provided training on falls and/or head injuries. She stated the facility did not provide any extra training for falls or head injuries as they expected the contract staff to already be trained and hit the floor running.

On [DATE], an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) due to the facility's failure to ensure staff were competently trained to notify the physician promptly and thoroughly of all pertinent facts for a resident on blood thinners who sustained a head injury from a fall and experienced hypertension. At 2:01 p.m., the DON (director of nurses) was notified of the existence of the IJ situation. Resident #1 had a previous heart valve replacement and received [MEDICATION NAME] (a blood thinner) once daily since [DATE] On [DATE] at 3:25 p.m., the resident was found in her room on the floor beside her bed, lying on her right side. The resident was assessed and found to have a skin tear on her right temple. At 3:40 p.m., the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. At 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. Her blood pressure readings continued to be high throughout the day; however, the physician was not notified of these abnormal blood pressure readings. At 7:25 p.m., the resident's blood pressure had risen to ,[DATE]. The nurse was notified of this critical reading, but did not call the doctor. At 8:45 p.m., the resident began throwing up and became unresponsive. This occurred one hour and 20 minutes after her blood pressure was measured at ,[DATE]. At 9:01 p.m., 16 minutes later, after the resident was found nonresponsive, the facility called EMSA (emergency medical services) to transport the resident to a local hospital. On arrival to the facility, EMSA found the resident unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing, but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. At 9:54 p.m., the resident was admitted to the local hospital where she was found to have a subdural hematoma (a brain bleed), approximately 1.5 cm (centimeters) in size, which was causing her brain to shift past the midline and herniate. Additionally, the resident was diagnosed with [REDACTED]. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. At 5:28 a.m., she was admitted to the hospital with [REDACTED]. Surgery was performed to remove the hematoma from her brain, and the resident was transferred to ICU (Intensive Care Unit); however, imaging after surgery revealed her brain contained multiple infarcts (areas which had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. The resident did not improve or regain consciousness. She was unable to breath without the assistance of a ventilator. The family decided to place the resident on comfort care and removed the ventilator. The resident expired on [DATE] at 8:55 a.m. O[DATE] at 5:11 p.m., an acceptable plan of removal was received. The plan of removal documented: Plan of Removal for (Named facility) [DATE] 1600 (4:00 p.m.) 1) Inservice (see attached page for in service details) will be done for all nursing staff (RN (registered nurse), LPN's (licensed practical nurse), CMA (certified medication aide) and CNA (certified nurse aide)). Nursing staff currently on duty will be educated by Director of Nursing during the current ,[DATE] pm (3:00 p.m. to 11:00 p.m.). All other nursing staff, including agency staff will be in serviced prior to starting or next shift. 2) Review of charts will be conducted to ensure assessments including neuro (neurological) checks and vital signs are being properly completed and reported to physician as needed for residents who are on neuro checks and residents on anticoagulants who have fallen. A list of residents who are on anticoagulants will be made and reviewed. a) 3. Residents in the facility that have fallen with neuro checks will be reviewed include (1) (Named resident #2) [DATE] with major injury (2) (Named resident #7) [DATE] with injury (3) (Named resident #8) [DATE] no injury (4) (Named resident #3) (9 falls since Feb (February) 1, 2019) out of all falls 1 with neuro checks (5) (Named resident #6) [DATE] with major injury (6) (Named resident #9) [DATE] with no injury 3) All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent through out the (Named facility) and at no time will a new form be implemented by any staff member other that the Director of Nursing. 4) Will be adding at least one licensed personnel on evening shift until a thorough review of facility assessment and resident acuity is reviewed. (signed DON). An attachment to the plan of removal titled, Plan of Removal In Service, documented: 1. All vital signs pertaining to neurological checks will be obtained by the charge nurse on duty in accordance with neurological flow sheet. Obtaining vital signs is part of the nursing assessment process and will NOT be delegated to other staff. Neurological flow sheet will be consistent throughout the (Named facility) and at no time will a new form be implemented by any staff member other than the Director of Nursing. 2. Neurological Protocol timing, documentation, signs and symptoms 3. Blood pressure parameters reporting to physician in timely, thorough manner including vitals, neuros, L[NAME] (level of consciousness), s/sx (signs and symptoms) related to head injury. 4. Sign and symptoms of neurological issues who have fallen including vomiting, change in L[NAME], increased confusion, difficult to arouse, [MEDICAL CONDITION], bleeding or watery drainage from nose or ears, pupils slow to react or unequal, blurred vision, loss of sensation to any extremity, slurred speech and vomiting. 5. Instruct staff to report change of condition to physician. The IJ was removed effective [DATE] at 11:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained a harm, at a pattern. Based on record reviews and interviews, it was determined the facility failed to ensure staff were competently trained to notify the physician promptly and inform him/her of all the pertinent facts for a resident receiving blood thinners and experiencing hypertension after sustaining a head injury from a fall for one (#1) of six sampled residents reviewed for falls. Resident #1 had fallen on [DATE] and acquired a head injury. Interventions were not promptly made. The resident eventually lost consciousness and was sent to the hospital where she was diagnosed with [REDACTED]. She expired on [DATE]. The DON identified 39 residents who were at high risk for falls. Findings: A facility policy titled, Head Injury Actual or Potential, documented: Policy: To observe, record and report any condition change to the attending Physician to (sic, so) proper treatment will be implemented. Equipment .Blood pressure cuff . Procedure .Following any head trauma, monitoring the following . .Take vital signs .Have someone stay with the resident while charge nurse call the attending physician . A facility policy titled, (Named facility) Protocol documented: .If resident falls with head injury immediate complete assessment will be performed by licensed personnel . The physician will be notified of incident and full report of all abnormal neurological findings. Physician will be notified by phone only . A facility policy titled, Neurological Protocol documented: .Assess the resident .Observe the resident for obvious injuries to the scalp, including .bruises .pupils of unequal size or reactions; headache; vomiting .lethargy. Monitoring must continue for a minimum of 72 hours . Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements . Resident #1 was admitted with [DIAGNOSES REDACTED]. physician's orders [REDACTED].[MEDICATION NAME] sodium (an anticoagulant - a blood thinner) Tab(s) (tablets) give 1 tab by mouth daily at 1400 (2:00 p.m.) . A fall risk assessment, dated [DATE], documented she had a fall risk score of 10 which was a high risk for falls. A quarterly assessment, dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making. She required extensive two person assistance from staff with bed mobility, transfers and toilet use. She had upper and lower extremity impairment on one side of her body. For seven of the last seven days reviewed she had received an anticoagulant routinely. She did not have a life expectancy of less than six months. A lab report, dated [DATE], documented she had blood testing done, a PT ([MEDICATION NAME]) test and an INR (international normalized ratio) test, to monitor her coagulation and her risk of bleeding from taking [MEDICATION NAME], a blood thinner. Her PT was 33.3 seconds with a reference range of 10.0 - 12.0 seconds. Her INR was 3.26 with a reference range of 1.00- 1.20. The reference ranges were therapeutic for the resident's [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, .I am a high risk for falls . I'm at risk of brusing (sic, bruising) and bleeding r/t (related to) the use of [MEDICATION NAME] ([MEDICATION NAME]/blood thinner) .observe for bruising and excessive bleeding . I am at risk for having pain .observe me for s/s of pain since I am unable to tell you when I hurt . A late entry nurse's note, dated [DATE] at 11:26 p.m., documented at 3:25 p.m., the resident was found in her room on the floor beside her bed lying on her right side. The resident was assessed and found to have an abrasion and a skin tear on her right temple and her temple was beginning to swell. She had redness on her right shoulder, redness on her right knee with light purple bruising and a small bruise on her right elbow. She was assisted to standing and transferred to her bed. She was soiled and perineal care was provided. She was then transferred to her wheelchair and neurological checks and vital sign monitoring was started. A neurological assessment, dated [DATE] at 3:40 p.m., documented the resident's vital signs were taken by a certified medication aide. Her blood pressure reading was ,[DATE], a hypertensive or high reading. Her pupil size was assessed to be 2 mm. A hypertensive or high blood pressure reading is defined by the American Heart Association as a systolic (top number) of 120 or above and/or a diastolic (bottom number) of 80 or above. The late entry documented at 3:41 p.m., the physician was notified of the resident's fall by a charge nurse; however, he was not provided with the critical blood pressure reading. A neurological assessment, dated [DATE] at 3:55 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 4:10 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A late entry nurse's note at 11:32 p.m., documented one hour after the fall (4:25 p.m.) the resident was given Tylenol and a slight raised area to the right side of temple starting to appear. A neurological assessment, dated [DATE] at 4:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 5:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A neurological assessment, dated [DATE] at 6:25 p.m., documented her blood pressure was measured at ,[DATE], a hypertensive reading. The physician was not notified of this reading. A vital sign record, dated [DATE] at 7:25 p.m., documented the resident's vital signs were taken. Her blood pressure was measured at ,[DATE], a hypertensive reading. The nurse was notified of this critical reading and intended to inform the doctor right away, but an alarm went off in another resident's room and the nurse responded to that alarm. The nurse did not call the doctor with the critical blood pressure reading. A Medication Administration Record, [REDACTED]. A late entry nurse's note at 11:51 p.m., documented at 8:45 p.m , CNAs #3 and #4 called the nurse to the resident's room. The resident had started vomiting and lost consciousness. The nurse documented the resident's pupils measured 5 mm (millimeters), which was a change from the 2 mm the pupils had measured the entire evening. The late entry nurse's note further documented, at 9:01 p.m. (16 minutes after losing consciousness), the facility called EMSA to transport the resident to a local hospital. A physician's telephone order, dated [DATE] at 9:04 p.m., documented, .transfer to (named local hospital) ER (emergency room ) .to further eval (evaluate) and tx (treat) . An EMSA record, dated [DATE] at 9:15 p.m., documented on arrival to the facility, the resident was found unresponsive, hypertensive, in [MEDICAL CONDITION] (an abnormal heart rhythm) and continuing to experience projectile vomiting. An attempt was made to intubate the resident to protect her airway and breathing , but her vomiting was excessive and the first attempt at intubation failed. Due to excessive vomiting, a [NAME] Airway (a tube to keep her airway open) was placed, oxygen was started and the resident was transferred to the local hospital. An ED (emergency department) admission note, at 9:54 p.m., documented she was admitted to the local hospital. An ED provider note, at 10:05 p.m., documented on arrival her blood pressure was ,[DATE]. She was intubated and unresponsive. She had decreased breath sounds. She had a contusion (bruise) on her head and redness around her right eye. The note documented throughout the night the resident received IV (intravenous) [MEDICATION NAME] (an antihypertensive medication) to control her blood pressure and IV mannitol (to decrease brain swelling), IV fresh frozen plasma and IV vitamin K to control her bleeding. The note documented the resident was intubated with a 7.0 mm tube because of [MEDICAL CONDITION]. The note documented the final result of a CT (computerized tomography) of the head without contrast, at 11:01 p.m., as, .acute subdural hematoma along the right cerebral convexity with significant mass-effect and shift of midline structures towards the left measuring approximately 1.5 cm. Associated parafalcine herniation noted .large scalp soft tissue hematoma noted over the forehead on the right as well as the right periorbital region . The note documented an assessment of a post-traumatic subdural hematoma and coagulopathy. The decision was made to transfer the resident to a larger hospital in a metropolitan area where a specialist could evaluate her and perform needed surgery to remove the subdural hematoma. Due to the weather, transportation was delayed. On [DATE] at 2:43 a.m., she was transported to the larger hospital. A hospital note, dated [DATE] at 5:28 a.m., documented she was admitted to the metropolitan hospital with [DIAGNOSES REDACTED]. An operative report, dated [DATE] at 7:13 a.m., documented the resident had right-sided craniotomy surgery to remove the subdural hematoma. A CT scan report, dated [DATE] at 9:01 a.m., documented the resident had an .acute, subdural, subarachnoid, and intraparenhcymal hemorrhage .1.9 cm of right-to-left shift with findings concerning for a trapped left ventricle . A CT scan report, dated [DATE] at 11:35 a.m., documented her brain was found to contain multiple infarcts (areas that had not been [MEDICATION NAME]) and hemorrhages. Her brain was found to contain a 1.2 cm midline shift to the left. A neurosurgery progress note, dated [DATE] at 12:36 p.m., documented the resident presented with a right side subdural hematoma with a midline shift. The note documented her pupils were nonreactive and dilated to 5 mm. The note documented she was nonresponsive, except to noxious stimuli, and then she only responded by posturing. A case management report, dated [DATE] at 2:58 p.m., documented, as the resident had not improved and her [MEDICAL CONDITION] prognosis was poor, the family decided to make the resident DNR (do not resuscitate). The family placed the resident on comfort care and the ventilator was removed. A hospital death log documented the resident died on [DATE] at 8:55 a.m. A hospital discharge summary, dated [DATE] at 10:55 a.m., documented the resident had a discharge [DIAGNOSES REDACTED]. The summary documented her admission [DIAGNOSES REDACTED]. On [DATE] at 3:40 p.m., LPN #8, the charge nurse the night the resident fell , was asked if she was concerned the resident was having high blood pressure readings following a fall with a head injury. She stated she remembered the resident had a history of [REDACTED]. She stated when the 7:25 p.m. blood pressure reading was so much higher, ,[DATE], she thought she should let the physician know. She stated instead of calling the physician immediately about the resident's blood pressure, she answered an alarm in another resident's room. She stated she did not get the call made to the physician and the next physician communication was to inform the physician the resident was being transferred to the hospital for an evaluation. An hour and 20 minutes later, at 8:45 p.m., CNAs #3 and #4 called LPN #8 to the resident's room. She stated the resident had been vomiting, was unresponsive and her pupil size had increased. She stated she stayed with the resident to make sure the resident was breathing. She stated they began cleaning up the resident as they did not want the resident to go to the hospital in such a mess. She then stated EMSA was paged at 9:01 p.m., sixteen minutes later. At 7:10 p.m., CMA #2, who was working on the hall the day the resident fell , was asked to describe the process of assessing neurological and vital signs, including blood pressure, after a head injury. She stated there was a new neurological assessment sheet, and she really did not understand it. She stated she would take the vital signs on a piece of paper, and, if she had time, would tell the nurse. She stated most nurses would usually ask her for the vital sign readings first. On [DATE] at 10:58 a.m., the physician was asked if he had been informed of the resident's initial blood pressure reading when he was informed of the fall. He stated he was not informed of the blood pressure reading. He stated knowing the blood pressure readings would have been a relevant contribution and may have led to an earlier evaluation of the resident. At 1:42 p.m., the DON said, I knew this would be a problem when I saw the doctor had not been told about the blood pressure. At 1:46 p.m., CNA #3, who took care of the resident that evening, was asked when the resident began vomiting. He stated the resident had been sitting at the nurse's station and began vomiting. He stated he immediately took the resident into her room to begin cleaning her up. He stated he realized she needed to have a shower and so he started the water in the shower. He stated when he went to stand the resident up, she was limp and not herself. He stated he told CNA #4 to get the nurse. He stated about ten minutes past between the time he took the resident to her room and the time the nurse was alerted. At 2:00 p.m., CNA #4 stated when they tried to stand the resident to put her in the shower they realized the resident was limp. She stated the resident had a big shiner on her head all night long, and it was seeping. On [DATE] at 10:00 a.m., LPN #1 was asked if she had been provided with orientation from the facility related to the facility fall protocol including monitoring after a fall and neurological checks and vital sign monitoring including parameters for blood pressures. She said, No, I was not. She then stated a nurse showed her some things when she first started work at the facility. She then stated nothing is really set in stone. She stated things keep changing and no one was really sure what to do. At 11:00 a.m., CMA #2 was asked if she had been provided with orientation from the facility related to the facility fall protocol including monitoring after a fall and neurological checks and vital sign monitoring including parameters for blood pressures. She stated she had received no training on the topics when she was newly hired. She then stated she could not remember any training on the topics since her hire. At 12:12 p.m., an agency staff coordinator was asked if the staff members they sent to the facility to work completed training prior to starting a shift on facility policies and protocols. She said, We expect the facility to provide the training. She stated the agency completed competency training with staff upon hire and annually, but the facility was required to train the staff on all facility protocols and policies. At 12:38 p.m., agency CNA #2 was asked if she was provided any orientation prior to working at the facility including training on the facility fall protocol and head injuries. She stated she was not provided any training on facility policies and protocols. At 3:38 p.m., agency CNA #1 was asked if she was provided any orientation prior to working at the facility including training on the facility fall protocol and head injuries. She said, As agency we are expected to know the business and we are just let loose. That is typical for every facility though. On [DATE] at 11:27 a.m., agency CNA #4 was asked if the facility provided training on falls and/or head injuries. She stated the facility did not provide any extra training for falls or head injuries as they expected the contract staff to be already trained and hit the floor running.

Based on observation, record review, and interview, it was determined the facility failed to notify and/or provide pertinent information to the physician; a) for one (#41) of three sampled residents who had falls. Resident #41 had a fall out of her wheelchair and onto her right shoulder. The physician was not notified of the severe pain or limited range of motion. The resident was transferred to the emergency room (ER) almost 30 hours after the fall. On 07/20/17 the director of nurses (DON) provided a fall log sheet which documented twenty-two residents had falls in the month of June, 2017. b) for one (#52) of two sampled residents whose records were reviewed for pressure ulcers. Resident #42 acquired a stage II pressure ulcer and the physician had not been notified. The facility Resident Census and Conditions of Residents form, dated 07/17/17, documented 4 residents with pressure ulcers resided in the facility. Findings: 1. Resident #41 had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 04/22/17, documented the resident was able to understand others, made herself understood, and had moderately impaired hearing. The resident was moderately impaired in cognition. The assessment also documented the resident was independent with all of her activities of daily living (ADLs) except bathing, which required assistance with transfer only. An incident report, dated 06/15/17 at 3:35 a.m., documented the resident had fallen out of her wheelchair while sleeping. A nurse's note, dated 06/15/17 at 4:54 a.m., documented the resident was in her room and she fell out of her wheelchair, while sleeping. The note also documented the resident had refused to get out of her wheelchair and sleep in bed or in her recliner. The resident landed on her right shoulder. She initially complained of pain in her right shoulder. The note documented three staff members assisted the resident to a standing position. The resident stood with back and shoulders slumped. The note documented it took persistent cueing from staff to get the resident to stand erect. The note also documented the resident's bilateral extremities had normal range of motion (ROM), no bruising, abrasions, and no skin tears. The resident's vital signs were documented as; temperature (T) 98.1, heart rate (HR) 74, respirations (R) 18, blood pressure (BP) 100/64, and oxygen saturation (O2) was 94%. The note further documented the physician had been notified via (by) fax. The facility facsimile cover sheet addressed to the physician, dated 06/15/17 without a time, documented, .(Named resident) fell asleep in her wheelchair, and fell from it onto the floor, she landed on her R shoulder. No bruising, abrasions, etc (and so forth)- noted- only c/o (complaints of) pain. The fax form had three areas available for the facility to indicate the importance of the information being faxed to the physician. The responses available for documentation were; urgent, for review, and please reply. The facility had checked the box indicating, for review. The physician had not been provided with information, which would have been obtained from a thorough assessment of the resident's shoulder. He had not been informed of the resident's pain level, posturing, slumping over, and reluctance to stand erect. The physician faxed a handwritten response of, OK. A skilled narrative nurse's note for the day shift, dated 06/15/17 at 8:10 a.m., documented the resident had not complained of pain: however, the note documented at 7:15 a.m., the resident had complained of pain to her right shoulder which she had rated a 7 out of 10. The resident had been administered [MEDICATION NAME] 5 mg (milligram). The note documented the resident's vital signs were HR 121, R 20, and BP 137/75. The Baker-Wong pain scale rated pain from zero to ten, with a rating of zero being no pain and a rating of ten as the worst pain possible. A pain level of seven indicated severe pain. There was no documentation the physician had been notified of the resident's complaints of severe pain to the right shoulder. A physical therapy (PT) note, dated 06/15/17 without a time, documented that nursing had reported the resident had a fall out of her wheelchair, hurt her shoulder, and was very sore all over. A skilled day shift narrative nurse's note, at 8:17 a.m., documented the resident had deep purple bruising to the top of the right shoulder. A physical therapy note, dated 06/16/17 no time provided, documented the resident had minimal ROM due to pain. The resident needed occasional rests due to all over body pain. The note additionally documented the resident reported pain from her neck to her waist due to a prior fall from her wheelchair. The PT note documented nursing reported an x-ray would be obtained for the resident's right shoulder area. The clinical record contained no documentation the physician had been contacted to request an x-ray. A nurse's note, dated 06/16/17 at 9:06 p.m., documented the director of nurses (DON) had spoken to the resident's daughter about bruising to the back of the resident's head, which had just been noticed by the evening charge nurse. The note documented the daughter told the DON she was aware the resident had a recent fall. The daughter further stated she had taken her mother to an appointment earlier in the day and was concerned about her mother's limited ROM and complaints of pain in her right shoulder. The note also documented the daughter requested her mother be transferred to a local emergency room (ER) for evaluation and treatment. The note added the DON notified the charge nurse to transfer the resident to the ER for evaluation, per the daughter's request. There was no documentation the physician had been notified of the transfer, limited ROM, or complaints of severe pain. A skilled night shift nurse's note, dated 06/17/17 at 5:13 a.m., documented the resident had returned from the ER at 2:50 a.m., with a [DIAGNOSES REDACTED]. The resident had been administered a pain pill, per the resident's request. On 07/20/17 at 2:30 p.m., licensed practical nurse (LPN) #4 was asked if she had notified the physician of the resident's inability to use her right arm and/or request an x-ray. She stated she didn't. On 07/19/17 at 5:25 p.m., the resident's daughter was interviewed. She stated she had arrived at the facility about 1:00 p.m., to take her mother to the hearing aid specialists on the 16th, the day after the fall. She stated when she tried to get her mother in the car she couldn't move her arm and I could barely get her in the car. She was complaining of pain to her right shoulder. The daughter stated when she returned to the facility about 30 to 45 minutes later she told the charge nurse, LPN #4, about her mother's pain and inability to lift her right arm. She stated the LPN stated she would contact the physician and get her arm checked. The clinical record contained no documentation the physician had been notified of the resident's severe pain, inability to use her right arm, or to request an x-ray. The daughter stated the DON had called her about 9 p.m., on the night of the 16th to tell her about the bruise on the back of her mother's head. She stated she had informed the DON that earlier in the day her mother had been in a great deal of pain and had been unable to lift her right arm. The daughter stated she had informed the DON she had reported this to a nurse, about 2:00 p.m., and the nurse had stated she would notify the physician. The daughter said, The DON said, in a shocked voice. You told a nurse that? I'm going to send her to the emergency room right now. On 07/20/17 at 10:00 a.m., the director of nurses (DON) was interviewed about physician notifications. The DON was asked if the physician had been notified of the resident's assessments, the resident's inability to lift her right arm and complaints of severe pain. She stated she would look for documentation. She was asked if the physician had been notified of the resident's transfer and/or condition. She stated she thought the physician had been notified. She was asked to provide documentation. The DON stated she wasn't sure if the charge nurse or if she had notified the physician. No additional documentation had been provided prior to survey exit. 2. Resident #52 had [DIAGNOSES REDACTED]. A nursing admission evaluation, dated 04/26/17, documented the resident had no pressure ulcers. An admission assessment, dated 05/09/17, documented the resident's cognition was moderately impaired, required extensive two person assistance with bed mobility, transfers, dressing, and toilet use. The assessment further documented the resident was always incontinent of bladder and occasionally incontinent of bowel. The resident was at risk for pressure ulcers and had no pressure ulcers on admission. The resident received applications of ointments/medications to areas other than his feet and no other skin/pressure ulcers interventions were documented on the assessment. A care plan, dated 05/09/17, documented, Problem I am always incontinent of bladder and occasionally incontinent of bowel . Goal I will be clean, dry and odor free with no skin breakdown . check skin for any s/s of skin break down and notify the nurse for treatment orders as needed . report any changes to the physician and family . The current physician's orders [REDACTED].Routine treatment .Dermadrox-apply to stage 2 pressure ulcer on lt (left) inner buttocks Q shift and prn . The original order date was 05/23/17. A nurse's note dated 06/08/17 at 10:16 p.m. documented, .Stage II to R (right) inner buttock has now closed. A nurse's note, dated 07/14/17 at 10:24 p.m. by licensed practical nurse (LPN) #1, documented, 1530 (3:30 p.m.) CNA (certified nurse aide) notified this nurse resident had an opening (area was not documented) to be 0.2 cm (centimeter) in diameter, barrier cream applied and resident started on a turning and schedule .resident agrees to frequent turning and repositioning to stop any further skin breakdown . There was no documentation the physician had been notified of the resident's newly identified pressure ulcer on 07/14/17. An interview was conducted on 07/17/17 at 4:00 p.m., with LPN #1. She was asked if the resident currently had one or more pressure ulcers. She stated the resident had a 0.2 cm area on his right buttock and it was being treated with a barrier cream every shift. She was asked what the doctor had to say about the wound and treatment. She stated, I did not notify the doctor. I just applied the cream that was already ordered. On 07/18/17 at 9:50 a.m., the director of nursing (DON) was asked to describe the resident's pressure ulcer and verify what stage it was. She stated she was not aware the resident had a pressure ulcer because the paperwork from the weekend had not been pulled out. She stated she would locate the paperwork and check on the stage of the pressure ulcer. At 10:43 a.m., the DON stated she went and assessed the resident's pressure ulcer and it was a small stage two pressure ulcer to his left buttock. She stated it was .5 cm X .5 cm and that she was going to call the primary care physician to see what he wanted to do for the wound. The DON further stated the nurse should have known to notify the family, doctor and herself of any newly identified pressure ulcer. A physician's telephone order, dated 07/17/17, documented, Dermagram to open area buttocks q shift and PRN redness. The order was signed by the DON. An interview was conducted on 07/19/17 at 4:55 p.m., the DON stated the physician should have been called on 7/14/17, when the pressure ulcer was first identified.

Based on observation, record review, and interview, it was determined the facility failed to assess, monitor, and intervene; a. for one (#41) of one sampled resident who sustained a fracture as the result of a fall. The clinical records were reviewed for two additional sampled residents with falls. The director of nurses provided a facility fall log sheet which documented 24 residents had falls in the month of June, 2017. b. for the management of blood sugars for one (#70) of two sampled residents who received sliding scale insulin. The director of nurses identified eight residents who received sliding scale insulin. Findings: 1. Resident #41 had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 04/22/17, documented the resident was able to understand others, made herself understood, and had moderately impaired hearing. The resident was moderately impaired in cognition. The assessment also documented the resident was independent with all of her activities of daily living (ADLs) except bathing, which required assistance with transfer only. The resident's care plan, dated 05/17/17, documented: .Problem I am at risk for falls r/t (related to) taking an antianxiety medication and due to my failing vision in my left eye and having no right eye. Approach Be sure my room is clutter free and well lighted. Do not rearrange my personal belongings. Encourage me to use call light when I am needing assist (assistance) Have call light within reach and answer promptly. Frequent checks and assist with position changes since I sleep in my recliner Comments .6-15-17 I had a fall in my room. I have R (right) shoulder and R knee pain since fall + (plus) a bruise (deep purple) to top of right shoulder. .6-16-17 I was attempting to get out bed & (and) I had an increase in pain & bumped head. Neuro (neurological checks) started & sent to hospital for eval (evaluation). Dr (doctor) & family notified returned to facility fx (fracture) of clavicle. Sling in place & instructions not to pull or push & to keep sling in place except to shower The resident fell from her wheelchair at 3:35 a.m., on 06/15/17 and was transferred to the hospital at 9:30 p.m., on 06/16/17. The resident sustained [REDACTED]. There was no documentation the facility had provided and/or notified the physician of the resident's ROM limitations and complaints of severe pain. An incident report, dated 06/15/17 at 3:35 a.m., documented the resident had fallen out of her wheelchair while sleeping. The intervention was to assist the resident to her recliner, where she normally sleeps, prior to falling asleep. The incident report also documented the physician had been notified via (by) fax at 4:23 a.m. A nurse's note, dated 06/15/17 at 4:54 a.m., documented the resident was in her room when she fell out of her wheelchair, while sleeping. The note also documented the resident had refused to get out of her wheelchair and sleep in bed or in her recliner. The resident had fallen on her right shoulder. She initially complained of pain in her right shoulder. The note documented three staff members assisted the resident to a standing position. The resident stood with back and shoulders slumped. The note documented it took persistent cueing from staff to get the resident to stand erect. The note also documented the resident's bilateral extremities had normal range of motion (ROM), no bruising, abrasions, and no skin tears. The resident's vital signs were documented as; temperature (T) 98.1, heart rate (HR) 74, respiration's (R) 18, blood pressure (BP) 100/64, and oxygen saturation (O2) was 94%. The note further documented the physician had been notified via fax. The facility facsimile cover sheet addressed to the physician, dated 06/15/17 and without a time, documented, .(Named resident) fell asleep in her wheelchair, and fell from it onto the floor, she landed on her R (right) shoulder. No bruising, abrasions, etc (and so forth)- noted- only c/o (complaints of) pain. The physician faxed a handwritten response of, OK. The fax form had three areas available for the facility to indicate the importance of the information being faxed to the physician. The responses available for documentation were; urgent, for review, and please reply. The facility had checked the box indicated, for review. The physician had not been provided with information, which would have been obtained from a thorough assessment of the resident's shoulder. He had not been informed of the residents's posturing, slumping over, reluctance to stand erect, and the location of the resident's pain. The fax contained no documentation the facility had requested an x-ray. A skilled narrative nurse's note for the day shift, dated 06/15/17 at 8:10 a.m., documented the resident had not complained of pain: however, the note documented at 7:15 a.m., the resident had complained of pain to her right shoulder which she had rated a 7 out of 10. The resident had been administered [MEDICATION NAME] 5 mg (milligram). The note documented the resident's vital signs were HR 121, and BP 137/75. The Baker-Wong pain scale rated pain from zero to ten, with a rating of zero being no pain and a rating of ten as the worst pain possible. A rating of seven indicated severe pain. The clinical record contained no documentation the staff had conducted an assessment of the resident's right shoulder after her complaints of severe pain. There was no documentation the physician had been notified of the resident's complaints of severe pain to the right shoulder. There was no documentation an x-ray had been requested. A skilled narrative nurse's note for the evening shift, dated 06/15/17 at 11:30 p.m., documented the resident had been administered [MEDICATION NAME] 5 mg at 4:14 p.m., for complaints of pain to her right shoulder and knee. The note also documented the resident had a poor appetite. The skilled nurses' note form had an area for documentation of decreased grasp for upper extremities and decreased range of motion for all four extremities. The areas contained no documentation the assessments had been conducted by the day, evening, or night shifts. The response boxes had been left blank. A physical therapy (PT) note, dated 06/15/17 and without a time, documented that nursing had reported the resident had a fall out of her wheelchair, hurt her shoulder, and was very sore all over. A skilled narrative nurse's note for the night shift, dated 06/16/17 at 12:30 a.m., documented the resident continued to have a bruise to left (sic right) shoulder from recent fall. A skilled day shift narrative nurse's note, dated 06/16/17 at 8:17 a.m., documented the resident had deep purple bruising to the top of her right shoulder. The skilled note form had an area for documentation of decreased grasp for upper extremities and decreased range of motion for all four extremities. The areas contained no documentation the assessments had been conducted by the day shift. The response boxes had been left blank. A physical therapy note, dated 06/16/17 and without a time, documented the resident had minimal ROM due to pain. The resident needed occasional rests due to all over body pain. The note also documented the resident reported pain from her neck to her waist due to a prior fall from her wheelchair. The PT note documented nursing reported an x-ray would be obtained for the resident's right shoulder area. The clinical record contained no documentation the physician had been contacted to request an x-ray. There was no documentation the facility nursing staff had assessed the resident's shoulder, pain levels, and had requested an x-ray. A skilled evening shift nurse's note, without a time, documented the resident complained of pain to her right shoulder, which she rated as a 7 out of 10. The note also documented the resident had an increase in pain while attempting to get out of bed and sustained a bruise to the back of her head. Neuro checks were initiated and the resident was transported to the hospital via ambulance for evaluation and treatment. The care plan, dated 06/16/17, documented the resident fell back and bumped her head while attempting to get out of bed. A nurse's note, dated 06/16/17 at 9:06 p.m., documented the director of nurses (DON) had spoken to the resident's daughter about bruising to the back of the resident's head, which had just been noticed by the evening charge nurse. The note documented the daughter told the DON she was aware the resident had a recent fall. The daughter further stated she had taken her mother to an appointment earlier in the day and was concerned about her mother's limited ROM and complaints of pain in her right shoulder. The note also documented the daughter requested her mother be transferred to a local emergency room (ER) for evaluation and treatment. The note added the DON notified the charge nurse to transfer the resident to the ER for evaluation, per the daughter's request. A skilled night shift nurse's note, dated 06/17/17 at 5:13 a.m., documented the resident had returned from the ER at 2:50 a.m., with a [DIAGNOSES REDACTED]. The resident had been administered a pain pill, per the resident's request. The clinical record contained no documentation of ongoing assessments after her fall in regard to her increased pain and limited ROM. There was no documentation the physician had been notified of the limited ROM or complaints of severe pain after the resident fell on [DATE]. On 07/19/17 at 2:23 p.m., the resident was interviewed about her fall on 06/15/17. She was asked if she she had been able to use her right arm to get dressed or feed herself without assistance from staff after her fall. She stated she could not, staff had to help her because it hurt too bad to lift her arm. The resident added at first she couldn't use her right arm to eat because it hurt too much. She was asked if she had told staff it was too painful to lift her right arm. She stated she had because, she had to ask them for help. She stated they had to know she couldn't lift her arm. The resident was asked if she had been able to dress herself, feed herself, and transfer herself without assistance before she broke her clavicle. She stated she had. She was asked if the resident would request pain medication when she was in pain. She stated she had. She was asked if staff had asked the resident to rate her pain whenever she requested a pain pill. She stated they had and most of time the pain was a 7 or 8 out of 10. On 07/19/17 at 2:43 p.m., licensed practical nurse (LPN) #4 was asked if the resident had requested/needed more assistance after her fall with a fracture. She stated she had. The LPN was asked if the resident had requested more pain medication than usual after her fracture. She stated she had. The LPN added the resident did complain of more pain after the fracture. She stated the resident would try to eat with her left hand. At 3:45 p.m., certified nurse aide #3 (CNA) was interviewed. She was asked if the resident was able to make her needs known. The aide stated the resident could make her needs known. The CNA was asked if the resident required more assistance after she fell . The CNA stated the resident had needed more assistance. We helped her to the toilet because since the fall she couldn't take herself. She used to be able to ambulate with a walker to the toilet. She needed more help getting dressed, transferring, toileting, and eating. The CNA was asked if the resident's increased need for assistance had been reported to the charge nurses. She stated they knew, everyone was aware of it. At 4:00 p.m., certified medication aide #1 (CMA) stated she would inform the charge nurse when the resident requested pain medication. The nurse would ask the resident to rate her pain, then tell me what to give the resident. The resident had usually rated her pain a 7 or more (after the fracture). We don't routinely ask residents if they need something for pain. At 4:15 p.m. CNA #4 stated the resident usually rated her pain a 7 or higher. I would tell the nurse or CMA if the resident wanted something for pain. We did have to help her more with her activities of daily living when she broke her collar bone. She was asked if the charge nurse was informed of this. She said, Yes, everyone knew she couldn't use her right arm. On 07/19/17 at 5:25 p.m., the resident's daughter was interviewed. She stated she had arrived at the facility about 1:00 p.m., to take her mother to the hearing aid specialists on the 16th, the day after the fall. She stated when she tried to get her mother in the car she couldn't move her arm. She stated she could barely get her in the car. She stated her mother was complaining of pain to her right shoulder. The daughter stated she asked her mother if she wanted to continue to the appointment. The resident stated she did because she couldn't hear without her hearing aides. The daughter stated when she returned to the facility about 30 to 45 minutes later she told the charge nurse LPN #4 about her mother's pain and inability to lift her right arm. She stated the LPN stated she would contact the physician and get her arm checked. The record contained no documentation the charge nurse had assessed the resident's shoulder after the daughter had informed her of the resident's severe pain and inability to lift her arm. The clinical record contained no documentation the physician had been notified of the resident's continued pain, inability to use her right arm, or to request an x-ray. The daughter stated her mother is timid, didn't like to complain, and didn't want to bother the staff. She stated you would have to ask her if she was okay. If she complained of something it would be important. The clinical record contained no documentation the nursing staff had asked the resident about her ROM or pain. The daughter stated the DON had called her about 9 p.m., on the night of the 16th to tell her about the bruise on the back of her mother's head. She stated she had informed the DON that earlier in the day her mother was in a great deal of pain and she had been unable to lift her right arm. The daughter stated she had informed the DON she had reported this to a nurse, about 2:00 p.m., and the nurse had stated she would notify the physician. The daughter said, The DON said, in a shocked voice. You told a nurse that? I'm going to send her to the emergency room right now. On 07/20/17 at 10:00 a.m., the director of nurses (DON) was interviewed about the fall. She was asked to provide any and all assessments. She stated she had provided the fall, pain assessments, and the nurses' notes. She would look for more. She stated she had phoned for transportation at 9:00 p.m., right after she hung up with the daughter. She added the resident left just before 9:30 p.m. by ambulance. The DON stated the skilled notes had a routine assessment conducted every shift. She was asked if the skilled notes documented a thorough and individualized assessment had been completed, by a nurse, for the resident's right shoulder injury and complaints of severe pain. She stated not exactly. The DON was asked why she had phoned the daughter at 9:00 pm. She stated the charge nurse had noticed a bruise on the back of the resident's head. She stated she had phoned the daughter to inform her and ask if she knew about it. The daughter told me that earlier in the day her mother had been in pain and couldn't use her right arm. The daughter informed me she had reported this to the charge nurse when she returned her mother, earlier in the day, about 1:30 p.m. or 2:00 p.m. She stated she had informed the daughter she was transporting the resident immediately, to the ER. The DON was interviewed about physician notifications. She was asked to provide documentation of physician notifications related to the resident's assessments, inability to lift her right arm, and severe pain. She stated she would look. The DON was asked if the physician had been notified of the resident's inability to lift her right arm and complaints of severe pain when the resident returned to the facility with her daughter on the 16th. She stated she would look for documentation. She was asked if the physician had been notified of the resident's transfer and/or condition. She stated she thought the physician had been notified. She was asked to provide documentation. The DON stated she wasn't sure if the charge nurse or if she had notified the physician. She was asked when neuro checks had been initiated. She stated she thought after the fall. She was asked to provide documentation. She was asked about the skilled notes which documented neuro checks were initiated after the visit to the ER. She stated she would look to see when they started. At 10:10 a.m., LPN #4 was asked if she was working on the 16th. She stated she was. She was asked if she visited with the resident's daughter when she returned from the hearing aid clinic. She stated she did. She was asked what was said during the conversation. She stated the daughter stated the resident was in pain and couldn't use her arm. The LPN added the daughter asked when the doctor was going to see her mother. LPN stated I told her maybe a day or two. The LPN was asked if she had conducted an assessment after the daughter informed her of the resident's inability to use her right arm and complaints of severe pain. She stated she did. The LPN was asked to provide documentation of the assessment. She stated she would have to look for it. The LPN stated she had helped her to the recliner. She was asked if the resident could use her arm and/ or complained of pain. She stated I think she was in pain. She was asked if she remembered anything else about the resident's condition when she returned with the daughter. She stated she couldn't. She was asked if the physician had been contacted and/or an x-ray requested. She stated she had not contacted the physician or requested an x-ray. No additional documentation was provided prior to exit. 2. Sliding - Scale Insulin: An Ineffective Practice .The primary goal of diabetes management is to achieve a level of glycemic control that closely mimics that of non-diabetic patients in an effort to prevent the long-and short-term complications associated with the disease. Inadequate blood glucose control over an extended period of time can result in significant long - term complications affecting multiple organ systems with reduced quality of life and increased mortality and morbidity . Best practice guidelines now recommend the use of structured insulin regimens with three components: basal insulin, nutritional insulin, and correctional insulin. Regimens combining these components have been shown to reduce fluctuations in blood glucose levels, increase the number of days patients maintain acceptable blood glucose levels, and reduce the length of non - ICU (Intensive Care Unit) stays for the hospitalized patients . (Today's Geriatric Medicine - Sliding - Scale Insulin An Ineffective Practice By Mark D. Coggins, PharmD CGP, FASCP - Aging Well Vol. 5 No. 6 P. 8). Resident #70 had a [DIAGNOSES REDACTED]. A care plan, dated 02/2017, documented, .Problem .I am on consistent carbohydrate diet . Goal .I will be encouraged to stay within my diabetic restrictions. Keep FSBS (finger stick blood sugar) and other labs within desired limits set by physician . Approach .administer [MEDICATION NAME]as ordered per physician 8 units in the AM (morning) and 24 units at HS (hours of sleep). Administer [MEDICATION NAME] via FSBS AC (before meal) & HS followed by sliding scale (See diabetic MAR ( medication administration record)) .draw all labs as ordered and directed by physician: notify physician of results An update to the care plan, dated 02/24/17, documented, [MEDICATION NAME] 500 mg (milligrams) ; PO (by mouth) Q (every) AM. Finger stick blood sugars four times a day; [MEDICATION NAME] (a short acting insulin) to be used for sliding scale as follows: 70-150 no units, 151-200 6 units, 201-250 10 units, 251-300 14 units, 301-350 18 units, and 351-400 20 units. Call doctor if greater then 400. Consistent Carbohydrate diet. The HgbA1C (glyconated hemoglobin) an indicator of a blood sugar level for a three month average, dated 02/01/17 had a result of 8.2 with a reference range of 4.0 to 6.0. The HgbA1C, dated 05/03/17 had a result of 6.9 with a reference range of 4.0 to 6.0. A review of the clinical record of the diabetic log for May 2017, documented, the resident had received sliding scale insulin 93 out of 124 opportunities. The readings ranged from 110 to 294. A review of the clinical record of the diabetic log for June 2017, documented, the resident had received sliding scale insulin 75 out of 120 opportunities. The readings ranged from 112 to 382. The HgbA1C, dated 06/25/17 had a result of 6.8 with a reference range of less then 5.7% of total Hgb. A review of the clinical record of the diabetic log for July 2017 through the 18th of the month, documented, the resident had received sliding scale insulin 63 out of 72 opportunities. The readings ranged from 106 to 308. There was no documentation the pharmacy had addressed the regular use of short acting [MEDICATION NAME] insulin. There was no documentation the facility had assessed the high use of short acting insulin and consulted with the physician. An interview was conducted on 07/19/17 at 3:10 p.m., with licensed practical nurse (LPN) #3, the charge nurse on the west hall. She was asked how the facility managed the resident's blood sugar. She stated finger stick blood sugars were checked before meals and at bed time and the facility administered [MEDICATION NAME] 8 units in the morning and 24 units at bedtime. She then stated the resident received [MEDICATION NAME] sliding scale. She was asked at what frequency the resident received her sliding scale insulin. She stated she received it all the time. She then added in the morning is less often than at other times of the day. She was asked if the facility had consulted with the physician about the high frequency use of the resident's sliding scale insulin. She stated no one had spoken to the physician about the sliding scale use, but she had an A1C that was 6.9 on 05/01/17 and no changes were made. She was asked if the resident received any other medications for her diabetes. She stated the resident was on [MEDICATION NAME] (an oral diabetic medication), but it was not on the orders when she came back from the hospital in June. She then stated some doctors try not to use sliding scale insulin. An interview was conducted on 07/19/17 at 3:28 p.m., with the director of nursing (DON). She was asked how well the resident's blood sugar was being managed. She stated she would have to look, then added the resident had [MEDICATION NAME] and [MEDICATION NAME] sliding scale. She was asked what the best practice was for managing FSBS's. She stated, Check FSBS and administer medications as ordered. She was asked if the facility assessed the resident's frequent use of short acting insulin for management of blood sugars. She stated, We have and I know the doctor has looked at it. A request was made for documentation where the facility had assessed the resident's use of short acting insulin and the physician's response. She stated she would look for it. She was asked if the pharmacy had addressed this, had anyone consulted with the physician, and had the facility identified an issue with the FSBS and sliding scale insulin use. No further documentation was provided. On 07/20/17 at 9:45 a.m., the administrator was asked for the facility policy and procedure for blood sugar management. At 11:02 a.m., the administrator stated she did not have a policy for blood sugar management. At 11:10 a.m., the DON stated the facility had not assessed or addressed the management of the resident's blood sugars and/or consulted with the physician.