Every finding on record at Berry Hill Nursing Home

Based on observation, staff interview and facility documentation review, the facility staff failed to store food in accordance with professional standards for food service safety in the main kitchen and the nourishment refrigerators on two of two nursing units. The findings included: 1. In the main kitchen, the facility staff failed to store food in a manner to prevent contamination and to label items to indicate when they were opened and when they were to be used by. On 8/20/24 at 10:40 a.m., observations were conducted in the main kitchen with the dietary manager accompanying the surveyor. In the dry storage area, there was a bag of graham cracker crumbs that the bag was folded over and secured with a binder clip, used to secure a stack of papers. There was no date to indicate when they were opened or when they were to be used by. The dietary manager stated that she expects all items to be secured and closed properly, labeled when opened and when to be used by for safety reasons and to keep items fresh. In the stand-alone freezer there was a bag of breaded patties that the dietary manager identified as crab cakes. The bag was twisted at the top but not secured and had no date to indicate when it was opened. There was a bag of chicken tenders that had no date and a bag of french fries that were open, not closed or secured and had no date of when it was opened. In the stand alone cooler there was a container covered with aluminum foil that was labeled as chicken noodle soup. The foil was torn and had an open area approximately one and a half inches long which left the food open to air and contaminates. There was an item that was covered with aluminum foil that was not labeled with the contents, date prepared or date to be used by. The cook identified the item as boiled eggs. In the walk-in cooler there was a metal tray rack that had cherry cheesecakes that were covered in parchment paper. There was no date to indicate when they were prepared or to be used by. The dietary manager stated they had just made them, and they were for the next day's supper. In the walk-in freezer a bag of meatballs that was twisted at the top and not secured, was observed to not have a date they were opened. There was a bag of chicken that was tied closed but had no date. The dietary manager said they had taken it out of the box yesterday and confirmed there was no date on the package. Review of the facility policy titled; Food Storage was conducted. The policy read in part, All incoming foods will have a delivery date and an open date or use by date. When the foods are stored in a container other than the original container, the container will be labeled with the name of the product and incoming wash and fill date . 2. In the main kitchen the facility staff failed to ensure milk was maintained at an appropriate temperature. On 8/20/24 at approximately 11 a.m., just before the dietary staff were to begin the meal service/tray line at 11:15 a.m., the dietary manager took temperatures of the foods on the tray line. This also included a beverage station where juices and milk here being held until time to serve. The dietary manager took the temperature of a carton of milk which was 45.7 degrees farenheight. During the above observation, the dietary manager was interviewed. When asked what temperature milk is to be held at, she said it should have been less than 40 degrees. The dietary manager asked the food service aide to put the milk back in the cooler until they were ready to serve. Review of the facility provided policies with regards to food storage were reviewed and did not address the temperature dairy products are to be held at. According to the Temperature Chart for Refrigerators and Freezers the Temperature Ranges were noted as Refrigerators 35-41 degrees. 3. On two of two nursing units, the refrigerators used for resident foods had items stored beyond the date to be used and items were not labeled and dated appropriately. On 8/21/24 at 9:29 a.m., observations were conducted of the unit two nourishment fridge. It was noted that there were two cups of what appeared to be apple sauce that had no labeling as to the contents, date prepared or date to be used by. There was a small container of what appeared to be coleslaw that had no label of contents or date. On 8/21/24 at 9:37 a.m., observations were conducted of the unit one nourishment refrigerator. It was noted that the temperature log did not have any temperature recordings for August 17-19. There was a Ziplock bag containing an undetermined food item and multiple food storage containers that had no label as to whom they belonged to, contents, date prepared or to be used by. There was a pan covered in aluminum foil with no date or labeling. There was a cake that was not labeled or dated. There was a container of honey thickened cranberry juice that had a date of 8/13/24, written on it. The director of nursing confirmed that this was supposed to be for the storage of resident's food items but stated that it appeared the majority of the items belonged to staff. On 8/21/24 at approximately 9:45 a.m., the dietary manager provided a document titled, use by dates: refrigerator that noted prepared thickened juice, tea, water was to be used within 5 days of opening. Review of the facility provided policy titled, Use and Storage of Leftovers was reviewed. This policy read in part, . Each day, an assigned person will check leftovers and throw out any foods that have been kept up to the maximum length of time allowed. The maximum length of time a food may be kept is shown on the following chart . The policy titled; Outside Food Policy was reviewed. It detailed no information as to how foods would be stored if maintained in the nourishment refrigerators on the units. According to SERV Safe Fourth Edition manual page 7-3 read, When food is stored improperly and not used in a timely manner, quality and safety suffer. Poor storage practices can cause food to spoil quickly with potentially serious results. General Storage Guidelines: Label food. All potentially hazardous, ready-to-eat food prepared onsite that has been held for longer than twenty-four hours must be properly labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Page 7-4 stated, Discard food that has passed the manufacturer's expiration date. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.15, page 64 stated: Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-305.11 Food Storage .D. A date marking system that meets the criteria . (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . Section 3-501.17 Ready-to-eat, Time/temperature control for safety food, date marking read, (A) .refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises . The CFR [Code of Federal Regulations] read, 3-305.11 Food Storage .D. A date marking system that meets the criteria . (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . On 8/21/24 at 9:55 a.m., the facility administrator was made aware of concerns with food storage as noted above. He stated he had already been made aware. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to implement the abuse policy with regards to the pre-screening of employees for 15 employees in a survey sample of 25 employee records reviewed. The findings included: For fifteen employees, the facility staff failed to obtain a sworn statement, criminal background within 30 days of employment and conduct verification with the board of nursing for nursing staff prior to allowing staff to work. On 8/21/24, a sample of twenty-five employees who had been hired within the last two years was identified and their employee files were requested. On 8/21/24, a review of the employee files was conducted and revealed the following. Three employees, a licensed practical nurse (LPN #4) and two certified nursing assistants (CNA #2 and CNA #7) did not have signed sworn statements on file. LPN #4 had no sworn statement in the file and CNA #2 and #7 had a sworn statement that was not signed by the employees. One employee, who was a licensed practical nurse (LPN #4), was hired 6/23/23. The criminal background check from the Virginia State Police was not requested by the facility until 11/13/23. Eleven employees who were nursing department employees, did not have their professional nursing license or certification verified until after the survey had commenced on 8/20/24. Therefore, the facility did not know if the staff had active and unencumbered licenses to practice or if they had any adverse actions reported against their license. They included registered nurses (RN #3 and RN #4), a licensed practical nurse (LPN #5), and certified nursing assistants (CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #8, and CNA #9). Two of the nursing department employees did not have their professional license verified until after then had been permitted to work with residents. CNA #12 was hired 3/8/23, and her nurse aide certification was not checked until 2/19/24, and CNA #10 was hired 9/12/23, and her certification was not verified with the board of nursing until 11/13/23, to see if they had an active and unencumbered certification to practice as a certified nursing assistant. On 8/21/24 at 4:07 p.m., an interview was conducted with the payroll/human resources manager (HRM). The HRM stated that upon hire she is responsible for verifying the applicant/employee's professional license. When the surveyor asked about so many of the employees' license having been verified the day before or that day, the HRM said, we don't have an SDC [staff development coordinator] person and I don't know where they kept their information at. When asked if this information should have been part of the employees file, the HRM said yes. During the above interview the HRM further stated that the sworn statements are to be completed at the time the employee completes their application for employment and the criminal background check is to be obtained within 30 days of hire. The HRM confirmed that each of these items are done for the safety of the residents and a way to verify who they have working with residents. A review was conducted of the facility's policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy. This policy read in part, .The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property . The facility will not employ individuals that have been found guilty of abusing, neglecting, exploiting, or mistreating residents by a court of law or who have had a finding entered into the state's Nurse Aide Registry concerning abuse, neglect, or misappropriation of their property . Screening of Employees: Potential employees (including contracted, temporary agency, and volunteers) will be screened by the facility for abuse, neglect, exploitation, or misappropriation of property. This screening process will include requesting of information from previous and/or current employers and checking with the appropriate licensing boards and/or registries . On 8/21/24 at 4:30 p.m., during an end of day meeting with the facility administrator, the above findings were discussed. On 8/22/24 at 10:01 a.m., the facility administrator stopped the surveyor in the hallway and provided a document that was titled, pre hire action with regards to LPN #4. The administrator pointed out on the second page a comment that was dated 6/20/23 at 2:56 p.m., that read, This person has passed all our background checks. When asked if he had evidence that the check was conducted with the Virginia State Police, he did not answer. On 8/22/24 at 10:30 a.m., an interview was conducted with the facility administrator. When asked what the purpose of the sworn statement and criminal background checks are for, the administrator said, so I don't have an employee who could be barred from employment due to a barrier crime working. When asked about the purpose of verifying the employee's license or certification with the board of nursing was for, the administrator said to ensure that staff hold an active license without any adverse actions for the position they are being hired for. No additional information was provided.

Based on observations, staff interviews, resident interview and clinical record review the facility staff failed to provide a physician's ordered supplement for Resident #64 (R64), one resident out of 21 residents in the survey. The findings included: The facility staff failed to provide a nutritional supplement on R64's lunch meal tray. On 8/20/24 at 12:00 p.m. an observation was made of the lunchtime meal. R64's lunch tray was observed and there was no boost on the tray. On 8/20/24 at 12:05 an interview was conducted with R64. R64 stated, my daughter will bring me in some boost sometimes, but I don't get one on my trays here. On 8/21/24 at 11:40 a.m. an observation was made of R64's lunchtime meal. There was no nutritional supplement on R64's tray. R64 shook her head and stated, not one today either. On 8/21/24 at 11:45 an interview was conducted with CNA#5 (CNA5). CNA5 was in R64's room and verified that there was no nutritional supplement on the lunch tray. CNA5 stated, it should be on it every day and it is on the meal ticket. On 08/21/24 at 3:15 p.m. an interview with the dietary manager was conducted. The dietary manager verified she had the order for the supplement to be on the lunch tray and stated, don't know why the girl did not put the boost on the tray. This surveyor was going to interview the dietary aide that was working but the dietary manager said the aide was gone for the day. On 8/21/24 at approximately 3:30 p.m. a clinical record review was performed. R64 had a physician's order written on 8/14/24 for the nutritional supplement to be on the lunch tray and this was a recommendation from the registered dietician. On 8/21/24 a facility document was provided titled, Dietetic Services Policy, it read in part, .importance of providing a hygienic dietetic service that meets the food and nutritional needs of the residents in accordance with the attending physician's orders. On 8/21/24 a facility document was provided titled, Bulk nourishments/supplements, read in part, .high calorie, high protein supplemental oral feeding can be provided for residents experiencing weight loss. Order should indicate name of product, ounces or cc's ordered and number of times a day. Residents receiving supplement will have a physician's order. On 8/21/24 at approximately 4:10 p.m. an end of day meeting was held with the administrator and the nurse consultant to discuss the above concerns. No additional information was provided.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care during medication administration on one of two units (unit two). The findings include: During a medication pass observation, the medication Breo Ellipta was administered with no prompt or instruction for the resident to rinse after administration as recommended by the manufacturer and per a physician's order. A medication pass observation was conducted on 8/21/24 at 8:05 a.m. with licensed practical nurse (LPN) #3 administering medications to Resident #20 (R20). Among the medications administered was Breo Ellipta 100 mcg - 25 mcg. LPN #3 activated the Breo Ellipta inhaler device and instructed Resident #20 to inhale the medication. After R20 inhaled the medication, the resident did not rinse her mouth. LPN #3 provided no prompt or instruction to the resident to rinse after the administration of the medication. R20's clinical record documented a physician's order dated 7/19/21 for Breo Ellipta inhaler 100-25 mcg (micrograms), inhale one puff daily for treatment of COPD (chronic obstructive pulmonary disease). The physician's order included instructions, Rinse mouth after use . On 8/21/24 at 9:00 a.m., registered nurse (RN #2) caring for R20 was interviewed about the Breo Ellipta administration observed with no rinsing. RN #2 stated nurses were supposed to ask and assist the resident to rinse/spit after the administration of inhaled medications like Breo Ellipta. On 8/21/24 at 9:45 a.m., the director of nursing (DON) was interviewed about the Breo Ellipta administration. The DON stated that mouth rinsing was required after the administration of Breo Ellipta. The DON stated nurses were expected to prompt and ensure residents rinsed after taking Breo Ellipta. The Breo Ellipta manufacturer's instruction/prescribing information sheet documented under warnings and precautions, .Candida albicans infection of the mouth and pharynx may occur .Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk . The information sheet documented under instructions for administration, .After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis . This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for two residents (Resident #35- R35, and Resident #61-R61) in a survey sample of 21 residents. The findings included: 1. For R35, the facility staff failed to review and revise the care plan to reflect a fall and significant weight changes the resident had experienced. On [DATE]-[DATE], a clinical record review was conducted of R35's chart. According to the weight records, on [DATE], the resident weighed 124.3 pounds. On [DATE], a weight of 116.5 was recorded and on [DATE] a weight of 110 pounds was noted. Then on [DATE] R35 was noted to weigh 120.2 pounds and on [DATE], R35 weighed 113 pounds. R35 had several instances of significant weight loss. According to R35's nutritional care plan which was initiated on [DATE], the goal had a revision date of [DATE]. The focus area read, State of nourishment; less than body requirement characterized by weight loss, inadequate intake, decreased appetite related to: Being on mechanically altered diet, Decreased Appetite, illness, Leaves 25% or more of food uneaten at most meals. The most recent revision to any of the interventions was performed on [DATE]. According to multiple progress notes written by the registered dietician (RD), R35's significant weight changes were noted. On [DATE], the RD noted, . has significant weight loss of 12.8% x 180 days ., on [DATE], the note read, . shows a 5% G [gain] this month ., then [DATE] the note indicated, -5.0% change over 30 days . The RD continued to make routine notes indicating the significant weight changes R35 was experiencing, but the care plan was not reviewed or revised to reflect such changes and the interventions being implemented. According to a nursing note dated [DATE], R35 had a fall. The note read, Called to residents' room by staff. Entered room to find resident laying on floor mat beside bed with both legs on the bed. Resident denies pain or discomfort at thit time. No injuries or markings noted from fall. Roommate stated resident slid from bed on to floor. VS: 98.3, 20, 78, ,d+[DATE], O2 98% on RA. Resident assisted back to bed and positioned by staff. ROM within normal limits for resident. MD/RP made aware. Call bell and safety measures in place. According to R35's care plan, the focus area which was last revised on [DATE], read, .is at Risk for falls characterized by history of falls and multiple risk factors related to: impaired self-mobility, impaired cognition, CVA with Left hemiplegia. The goal for this focus area was revised on [DATE] and the most recent revision to the interventions to prevent falls was dated [DATE]. There was no indication within the care plan that R35's care plan was reviewed or revised following the fall on [DATE]. On [DATE] at 3:08 p.m., an interview was conducted with the registered nurse (RN #1), who was the care plan coordinator. RN #1 accessed R35's care plan and noted the last revision date of [DATE], and said, it doesn't look like I updated since [DATE]. When asked about the process for updating care plans RN #1 said, usually I do them as we go, as they come up, we discuss them in our morning meetings and if there is a new fall I will update it with the preventative intervention we come up with. It is supposed to be updated on the floor but that doesn't always work. You are correct, I don't see anything for the 28th and I believe at that time I was out with gallbladder surgery and that may be why it was missed. Review of the facility policy titled, Interdisciplinary Teams, was conducted. This policy read in part, . The care plan team meets on a regular basis to develop and review the residents' care plans . On [DATE] at 4:30 p.m., during an end of day meeting, the facility administrator was made aware of the above concerns. No additional information was provided. 49456 2. The facility staff failed to revise R61's care plan when her code status changed from do not resuscitate (DNR) to a full code. On [DATE] at approximately 2:00 p.m. a clinical record review was performed. R61's care plan had her as a DNR. R61 had a physician's order in her chart dated [DATE] for DNR code status. On [DATE] there was a physician's order in the chart for being a full code status. There was no evidence of a DDNR (durable do not resuscitate) signed by R61 in the clinical record. On [DATE] at 9:00 a.m. an interview was conducted with R61 about her code status. R61 stated, I want to be a full code, I want CPR. On [DATE] at 10:03 a.m. an interview was conducted with LPN#6 (LPN6). LPN6 was asked how she would know a resident's code status and she stated, I go by the paper on the MAR [ medication administration record] for the code status. It's at the front of every resident. On [DATE] at 10:05 an observation was made of the sheets in front of the residents MAR that had residents code status. R61's code status was a full code on the sheet. On [DATE] a clinical record review was performed. R61's code status on the care plan was DNR code status dated [DATE] with only one revision date in this section of the care plan of [DATE]. On [DATE] at approximately 4:10 p.m. an end of day meeting was held with the administrator and the nurse consultant to discuss the above concerns. On [DATE] at 8:55 a.m. an interview was conducted with a registered nurse, RN#1 (RN1). RN1 was the MDS (minimum data set) coordinator and stated, I don't know why this wasn't done, she was a DNR, and I didn't realize she changed code status. I will have to investigate this. On [DATE] a review of a facility policy was performed. A policy titled, Interdisciplinary Teams, read in part, .the care plan team meets on a regular basis to develop and review the residents care plans. No additional information was provided.

Based on observation, staff interview and clinical record review, the facility failed to develop a care plan for one of twenty one residents. Resident #39 (R39) did not have a care plan developed for oxygen therapy. The Findings Include: Diagnoses for R39 included; Congestive heart failure, and shortness of breath. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 7/30/2024. R39 was assessed with a cognitive score of 6 indicating moderately cognitively intact. On 8/20/24 at 11:37 a.m. R39 was observed using oxygen at 2 liters per minute (LPM). R 39 was unable to verbalized the reason for the oxygen. R39's clinical record was reviewed, an order for oxygen continuously at 2 LPM was documented but did not indicate a start date. R39's care plan was then reviewed and did not evidence a care plan for oxygen therapy. On 8/21/24 at 11:48 a.m. registered nurse (RN #1, MDS coordinator) was interviewed regarding a missing care plan for oxygen. RN #1 said she would review the clinical record and find out. On 8/21/24 at 1:30 p.m. RN #1 verbalized the order originated on 11/13/23 when R39 had a diagnoses of COVID and also has congestive heart failure along with shortness of breath. RN #1 verbalized a care plan should have been developed at that time but was overlooked. On 8/21/24 at 4:30 p.m. the above finding was presented to the administrator and nurse consultant. No other information was presented prior to exit conference on 8/22/24.

Based on staff interviews and clinical record reviews, the facility staff failed to complete the pre-admission screening and resident review (PASARR) for three out of 21 residents in the survey, Resident #17 (R17), Resident #21 (R21) and Resident #46 (R46). The findings included: 1. The facility staff failed to complete a PASARR on R46, who had a diagnosis of schizoaffective disorder and anxiety disorder. On 8/20/24 at 3:00 p.m. a clinical record review was conducted of R46's chart. There was no evidence of a PASARR being completed prior to R46's admission on 7/28/21. On 8/21/24 at 9:00 a.m. an interview was conducted with the social worker. She reviewed R46's chart and stated, he doesn't have one in his chart. On 8/21/24 at 11:09 a.m. the social worker presented a PASARR for R46 that was completed on 8/21/24. The social worker was interviewed and stated, I filled out one today because the resident did not have one from admission on 7/28/21. On 8/21/24 at approximately 4:10 p.m. an end of day meeting was held with the administrator and the nurse consultant to discuss the above concerns. No additional information was provided 21875 2. The facility failed to perform a PASARR (preadmission screening and resident review) for Resident #21. Resident #21 (R21) was admitted to the facility with diagnoses that included psychosis, mood disorder, anxiety, depression, stroke, vascular dementia, colitis, aphasia, dysphagia, chronic obstructive pulmonary disease, and heart failure. Review of R21's clinical record revealed no evidence that a PASARR screening was completed prior to or after admission to the facility. R21 was routinely evaluated and treated by psychiatry for mental health disorders and related behaviors. On 8/21/24 at 11:46 a.m., the social worker (other staff #1) was interviewed about a PASARR for R21. The social worker reviewed R21's clinical record and stated, He [R21] does not have one. The social worker stated R21 was admitted prior to her employment at the facility. The social worker stated prior to her employment, she was not sure who was completing or performing the PASARR screenings. This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey. 28106 3. Resident #17 (R17) did not have a PASARR level 1 completed upon admission. Diagnoses for R17 included; Schizoaffective disorder, depression, and dementia. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 7/26/2024. R17 was assessed with a cognitive score of 10 indicating moderately cognitively intact. R17 was triggered for 'No PASARR level II with a diagnosis' on the LTCSP. Review of Section A1510. titled Preadmission Screening and Resident Review (PASARR). of the current MDS was blank. On 8/20/24 R17's clinical records were reviewed. R17 had an active diagnosis of depression, schizoaffective disorder, and dementia and was receiving medication for the diagnoses. Resident #17's clinical record did not evidence documentation that a level 1 PASRR had been completed. On 8/20/24 at 3:17 p.m. the social worker (Other staff, OS #1) was interviewed regarding a PASARR for R17. OS #1 reviewed the clinical record and the PASARR log book and did not find a PASARR for R17. OS #1 said, normally when a resident is admitted she will do the PASARR and place it in the log book and her or the business manager would scan into the clinical record. OS #1 verbalized not being employed at the facility when R17 was admitted but would look into the concern and see if the PASARR may have been misplaced. On 8/21/24 at 11:09 a.m. OS #1 presented a completed PASARR with the completion date of 8/21/24. When asked about the completion date, OS #1 verbalized she had completed the form today because the form had not been completed when R17 was admitted . On 8/21/24 at 4:30 p.m. the above finding was presented to the administrator and nurse consultant. The facility presented a PASARR policy that read in part '[ .] A PASRR must be completed for all new residents prior to Admission. Residents should be admitted with an assigned PASSR Number that indicates the Level 1 Screening was completed. If the screening identifies a disability then the individual is referred for a Level 11 evaluation. No other information was presented prior to exit conference on 8/22/24.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for three of twenty-one residents in the survey sample (Residents #3, #5 and #21). The findings include: 1. Section L. of Resident #3's significant change MDS dated [DATE] did not accurately reflect the resident's oral/dental status. Resident #3 (R3) was admitted to the facility with diagnoses that included atrial fibrillation, gastroesophageal reflux disease, diabetes, osteoporosis, psychosis with delusions, depression and dementia. The MDS dated [DATE] assessed R3 with moderately impaired cognitive skills. On 8/20/24 at 2:30 p.m., R3 was observed. During conversation with R3, the resident's lower, front teeth were observed missing. The lower, front teeth were broken and/or decayed at the gum with the dark/black tooth fragments visible. R3's clinical record documented a denture consultation dated 5/14/24. This consultation documented R3 had dental caries, residual teeth roots and large dental [NAME] (bony growths). R3's significant change MDS dated [DATE] documented the resident with no oral/dental concerns. Items under section L. indicated the resident had no tooth fragments, no broken natural teeth and no teeth with likely decay. There was no indication on this MDS of an inability to exam R3's oral/dental status. On 8/21/24 at 1:51 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about the accuracy of R3's dental MDS. RN #1 stated it was not obvious to her that R3 had broken, missing or decayed teeth. RN #1 stated she did not think that R3 had any of the items in section L. On 8/21/24 at 3:24 p.m., RN #2 caring for R3 was interviewed about the resident's teeth. RN #2 stated the resident had an appointment with an oral surgeon for teeth removal in preparation for dentures. RN #2 stated the resident's front, lower teeth were missing and looked decayed. 2. Section L. of Resident #5's annual MDS dated [DATE] did not accurately reflect the resident's oral/dental status. Resident #5 (R5) was admitted to the facility with diagnoses that included multiple sclerosis, hypertension, diabetes, depression, osteopenia, neurogenic bladder and cognitive communication deficit. The MDS dated [DATE] assessed R5 as cognitively intact. On 8/20/24 at 2:22 p.m., R5 was interviewed about quality of life/care in the facility. R5 was observed during this interview with multiple missing teeth. The resident's visible teeth had broken, uneven edges and dark areas of likely decay. When asked about dental problems, R5 stated she was missing most of her teeth and the teeth she had were not in good condition. R5's plan of care (initiated 4/6/23) documented the resident had poor oral/dental health due to poor dentition related to aging and multiple comorbidities. R5's annual MDS dated [DATE] documented the resident with no oral/dental concerns. Items under section L. indicated the resident had no broken natural teeth and no teeth with likely decay. There was no indication on this MDS of an inability to exam R5's oral/dental status. On 8/21/24 at 1:50 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about the accuracy of R5's dental MDS. RN #1 stated R5 was missing most of her teeth with only a few, sparse teeth intact. RN #1 stated she was not sure if the resident's remaining teeth were likely decayed. 3. Section L. of Resident #21's annual MDS dated [DATE] did not accurately reflect the resident's oral/dental status. Resident #21 (R21) was admitted to the facility with diagnoses that included psychosis, mood disorder, anxiety, depression, stroke, vascular dementia, colitis, aphasia, dysphagia, chronic obstructive pulmonary disease, and heart failure. The MDS dated [DATE] assessed R21 with moderately impaired cognitive skills. On 8/21/24 at 1:21 p.m., R21 was observed. R21's top, front teeth were missing and the resident had several visible teeth with dark, likely decayed areas. R21's clinical record documented an oral surgeon consultation on 4/25/23. This assessment listed the resident had cavities, mobile teeth and needed multiple teeth extractions prior to proceeding with a dental plan. R21's plan of care (initiated 12/5/22, revised 9/14/23) documented the resident had oral/dental problems and needed extractions. R21's annual MDS dated [DATE] documented the resident with no oral/dental concerns. Items under section L. documented the resident had no broken natural teeth, no loose teeth and no teeth with likely decay. There was no indication on this MDS of an inability to exam R5's oral/dental status. On 8/21/24 at 1:55 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about the accuracy of R21's dental MDS assessment. RN #1 stated R21 was missing teeth but she did not see any broken teeth at the time of the assessment. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (October 2023) documents on page L-1 concerning oral/dental status, This item is intended to record any dental problems present in the 7-day look-back period. Page L-2 of this manual documents in steps for assessment, .Conduct exam of the resident's lips and oral cavity with dentures or partials removed .Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining .The assessor should use their gloved fingers to adequately feel for masses or loose teeth .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) These findings were reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, Centers for Medicare & Medicaid Services, Revised October 2023.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a discharge plan of care and recapitulation of the residents stay for one resident (resident #43- R43) in a survey sample of 3 discharged residents reviewed. The findings included: For R43, the facility staff failed to prepare a post-discharge plan of care with instructions and failed to prepare a discharge summary and recapitulation of stay that included the required information. On 8/21/24, a closed clinical record review was performed of R43's chart. This review revealed that R43 discharged from the facility on 8/10/24. According to a nursing progress note written on 8/10/24 at 1:09 p.m., it read, Writer went over medication list and upcoming appointments with RR [resident representative]. No distress noted upon discharge. Treatment to leg was done before resident discharged from the facility. According to a nursing progress note dated 8/2/24, regarding the leg it read, . one open area to left lateral lower leg, cleansed with wound cleanser, padded dry, xeroform, 4x4 and kling applied to area On 8/21/24 at 2:00 p.m., an interview was conducted with the social worker (SW). The SW confirmed that she arranged for R43 to receive home health services upon discharge and arranged a follow-up medical appointment with the resident's doctor upon discharge. The SW stated that she initiated the Discharge Instructions and Plan of Care and noted the follow-up doctor appointment and home health agency information. The SW said she then gave the form to nursing for completion of the other areas. On 8/21/24 at 2:12 p.m., the SW provided the surveyor with a copy of the form where the resident's family member and the nurse signed upon R43's discharge on 8/10/24. The following areas were noted to be incomplete and blank, . 2. Medications released, 3. Treatments, 4. Diet, and 6. Other education needs . On 8/21/24, in the afternoon, an interview was conducted with the medical records employee (other employee #5- OE #5). OE #5 indicated in the misc. tab of the closed record was a discharge summary. The surveyor accessed this document, which was dated 8/10/24. It was titled, Discharge Summary and read as follows: discharge date : undefined 8/10/2024. discharged to: Home. Rehabilitation Potential: Good. Primary Diagnosis on admission: Resident has a history of HTN [hypertension], sacral fracture, chronic diastolic CHF [congestive heart failure], chronic hypoxic resp [respiratory] failure, chronic a fib [atrial fibrillation], h/o TAVR [history of Transcatheter aortic valve replacement] secondary to aortic stenosis, recurrent GI [gastrointestinal] blood loss anemia, CKD [chronic kidney disease] stage 3b, hypothyroidism, blindness in both eyes. Primary Diagnosis at time of discharge: same. Reason for discharge: completion of care. Recapitulation of stay: Other resident completed all required therapies and treatments. Resident stable for discharge. Review of systems: Constitutional: generalized weakness. All other systems negative. Vital Signs: [no information recorded]. Physical Exam: [made no mention of any wounds or treatments to the leg(s)], Medications: chart and medications reviewed, prescriptions written, Discharge Medication/Treatment list reviewed. Instructions: advised to f/u [follow up] with PCP [primary care physician] in 1-2 days and keep all f/u appointments. Discusses with: Patient; Responsible Party; Staff On 8/21/24, the medical records employee and social worker confirmed that no additional information was available with regards to a discharge summary or recapitulation of R43's stay. Review of the facility policy titled; Discharge Planning was reviewed. It read in part, Discharge Summary: When a resident's discharge is anticipated, the interdisciplinary team members will communicate the necessary information to the resident, continuing care provider, and other authorized persons at the time of an anticipated discharge. Method: The resident will have a discharge summary that includes, but is not limited to: A recapitulation of the resident's stay that includes diagnosis, court of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results; A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies . that includes: identification and demographic information, customary routine, cognitive pattern, communication, vision, mood and behavior patterns, psychological well-being, physical functioning, and structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin conditions, activity pursuit, medications, special treatments and procedures, discharge planning as evidenced by most recent discharge care plan, documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS [an assessment type], and documentation of participation in the assessment process . On 8/21/24 at 4:30 p.m., during an end of day meeting, the facility administrator and corporate nurse consultant were made aware of the above concerns and asked if they find any additional information with regards to a recapitulation of stay, discharge summary or discharge plan of care to provide it to the survey team. No additional information was provided prior to conclusion of the survey.

Based on resident interview, staff interview and clinical record review, the facility staff failed to implement a physician's order for one of twenty-one residents in the survey sample (Resident #5). The findings include: A physician's order for as needed Orajel topical gel was not added to Resident #5's medication administration record (MAR) so that nurses were aware to offer/administer the medicine if needed for tooth/gum pain. Resident #5 (R5) was admitted to the facility with diagnoses that included multiple sclerosis, hypertension, diabetes, depression, osteopenia, neurogenic bladder and cognitive communication deficit. The MDS dated [DATE] assessed R5 as cognitively intact. On 8/20/24 at 2:22 p.m., R5 was interviewed about quality care in the facility. During this interview, R5 stated she had a tooth on the lower, right side that hurt when she chewed or put pressure on it. R5 stated she was on pain medication and received Tylenol as needed for the sore tooth. R5's clinical record documented a physician's order dated 8/14/24 for Orajel every 2 hours as needed for tooth pain. R5's MAR for August 2024 was reviewed on 8/20/24 and revealed no entry or listing for the administration of Orajel. On 8/21/24 at 7:39 a.m., R5 was interviewed again about her tooth pain and if she had used the prescribed Orajel. R5 stated her tooth was not hurting this morning but she was not aware she had an order for Orajel. R5 stated she was not aware Orajel was available if needed for tooth/gum pain. On 8/21/24 at 1:40 p.m., licensed practical nurse (LPN #2) caring for R5 was interviewed about the Orajel order. LPN #2 stated the resident was on scheduled pain medication and was administered Tylenol as needed for pain. LPN #2 reviewed R5's MAR and stated she did not see an order for Orajel. LPN #2 stated she was not aware that Orajel was an option R5's tooth/gum pain. LPN #2 stated when medication orders were received, the nurse taking the order was supposed to send the order to pharmacy and add the medication to the MAR. On 8/21/24 at 3:04 p.m., the nurse consultant (administration #3) was interviewed about R5's Orajel order. The nurse consultant stated the nurse faxed the order to pharmacy but did not record the medication on the MAR. The nurse consultant stated the medication was received from pharmacy, was available in the cart but nursing failed to list the medicine on the MAR. This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately label three medications out of 41 opportunities during the medication pass and pour observations. 1. The medication Provera administered to Resident #11 (R11) during a medication pass observation was not labeled with a dosage. 2. Phenytoin sodium extended release 100 mg administered to Resident #8 (R8), and Atenolol/Chlorthalidone 50-25 mg administered to Resident #20 (R20) were not labeled with a dosage and had incomplete medication name. The findings include: 1. The medication Provera administered to Resident #11 (R11) during a medication pass observation was not labeled with a dosage. A medication pass observation was conducted on 8/21/24 at 7:58 a.m., with licensed practical nurse (LPN #1) administering medications to Resident #11. Among the medications administered was Provera. Observation of the multi-medication pill pack did not evidence a dosage for the Provera. LPN #1 also reviewed the pill packet and agreed there was no indication of the dosage and verbalized that the order is for 10 milligrams (MG) of Provera. The medication (Provera) was then verified with the physicians order documenting Provera 10 mg tab daily. Future daily doses of Provera was also reviewed and also did not indicate the dosage on the packaging. On 8/21/24 at 9:16 a.m. an interview with a pharmacist (other staff, OS #2) via phone was conducted. After explaining the concern, OS #2 verbalized that he was also a supervisor and would look into the concern and call back. On 8/21/24 at 9:48 a.m. the director of nursing (DON) was made aware of the concern. The DON said she was going to remove all of the medication in question and reach out to the pharmacy. On 8/21/24 at 9:55 a.m. OS #2 called and verified the dosage should be on the label and had been cut off (missing from the packaging), and that the software company that creates the labels would have to be notified in order to fix the problem. On 8/21/24 at 4:30 p.m. the above information was presented to the administrator and nurse consultant. No other information was provided prior to exit conference on 8/22/24. 21875 2. A medication pass observation was conducted on 8/21/24 at 8:05 a.m., with licensed practical nurse (LPN) #3 administering medications to Resident #20 (R20). A medication administered to R20 was from a sealed pharmacy pouch labeled atenolol/chlorthalido. There was no dosage listed on the pharmacy label for this medication. R20's clinical record documented a physician's order dated 7/19/21 for Tenoretic (atenolol/chlorthalidone) 50-25 milligrams with instructions to take once daily for hypertension. A medication pass observation was conducted on 8/21/24 at 8:19 a.m., with LPN #3 administering medications to Resident #8 (R8). A medication was administered to R8 from a sealed pharmacy pouch labeled, Phenytoin Sodium Exten. There was no dosage printed on the label for this medication. R8's clinical record documented a physician's order dated 7/9/24 for Dilantin (phenytoin) extended release 100 mg with instructions to take one capsule twice per day for seizures. On 8/21/24 at 8:30 a.m., LPN #3 that administered the medications with no dose labeling was interviewed. LPN #3 stated she had not noticed the missing dose information on the above medication labels. LPN #3 stated she assumed the medication dose was correct since it came from the pharmacy. On 8/21/24 at 9:00 a.m., the registered nurse (RN #2) caring for R8 and R20 was interviewed. RN #2 reviewed medications supplied in the cart for R8 and R20 and stated the labels for the two medications questioned did not have a dose listed on the label. RN #2 stated she was not aware the pharmacy labels for the phenytoin and Tenoretic did not include a dose and the labels looked like the printing was incomplete. On 8/21/24 at 9:54 a.m., the facility's consultant pharmacy supervisor (other staff #2) was interviewed about the pharmacy labels printed with no dosage. After reviewing, the pharmacy supervisor stated the dose for medicines should be printed on the label along with the complete medication name. The pharmacy supervisor stated the label printing was a software issue and needed to be adjusted so that complete prescribing information was printed on the labels. The facility's policy titled Medication Administration (undated) documented regarding medication labeling guidelines, .All prescription medications and all non-prescription medications not in the original manufacturer's package shall be dispensed in an approved container. Each container shall have at least the following information contained on the label .trade and/or generic name of the medication .directions for use .First and last name of the resident .date of dispensing .Strength/concentration of the medication . This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide dental services for two of twenty-one residents in the survey sample (Residents #5 and #21). The findings include: 1. Resident #5, with a physician's order for dental services, had not been referred or seen by a dentist. Resident #5 (R5) was admitted to the facility with diagnoses that included multiple sclerosis, hypertension, diabetes, depression, osteopenia, neurogenic bladder and cognitive communication deficit. The MDS dated [DATE] assessed R5 as cognitively intact. On 8/20/24 at 2:22 p.m., R5 was interviewed about quality of care in the facility. R5 was observed at this time with multiple missing teeth and visible teeth with broken edges and dark areas. R5 stated she had a tooth on the lower, right side that hurt when she chewed or put pressure on it. R5 stated she had taken medication for the tooth but had not seen a dentist. R5's clinical record documented the resident was seen by the nurse practitioner (NP) on 4/12/24 and assessed with a right lower molar abscess. The NP prescribed the antibiotic Augmentin for 10 days for treatment of the infection. The NP documented on 4/12/24, .Refer to dentist if possible . Nursing notes dated 4/24/24 documented, .Writer has phoned multiple practices last week and this week to try to find a dentist that is taking new patients, that will also accept resident's insurance, and accommodate resident via stretcher. Writer has had no success finding a provider thus far .NP made aware. Writer plans to call back next month to try to get an appt. [appointment] for resident . R5's clinical record documented no provision of dental services for R5 following this attempt to schedule an appointment. R5 had ongoing assessments by the NP and nursing with no further dental issues noted until 8/9/24. A nursing note dated 8/9/24 documented the NP was notified that the resident complained of tooth pain. The NP ordered the antibiotic Augmentin 875-125 milligrams twice per day for 10 days in response to the tooth pain. The NP assessed R5 on 8/14/24 and entered an order stating, Please try [and] get her in to dentist to have abscessed tooth extracted . R5's clinical record revealed no evidence of dental referral or scheduled appointment in response to the 8/9/24 order. On 8/21/24 at 11:43 a.m., the social worker (other staff #1) was interviewed about dental services for R5. The social worker stated, As far as I know, we were unable to find a dentist that will take her [R5]. The social worker stated the resident required a stretcher during transport and the facility had been unable to locate a dentist that accommodated the stretcher. The social worker stated they currently had no dentist that provided services in-house. The social worker stated there were dentists available that accepted Medicaid, but the stretcher created a problem. On 8/21/24 at 2:18 p.m., the administrator was interviewed about dental services for R5. The administrator stated, We've struggled getting anyone to help. The administrator stated they got a contract approved for a provider to come to the facility and then the provider stated they had no dentist in the area to provide services. The administrator stated there were local Medicaid providers, but they were unable to manage stretcher-bound residents. The administrator stated, We've been trying to get appointments and have been unsuccessful. On 8/21/24 at 2:41 p.m., the NP (other staff #4) that assessed/treated R5 was interviewed about dental care. The NP stated she treated R5 earlier in the year (April 2024) for an infection of the right, lower molar. The NP stated the infection cleared with the antibiotics and there had been no further issues until recently. The NP stated the resident was ordered the dental referral because she likely had an abscessed tooth. The NP stated she had successfully managed the infection and pain with medication but that the tooth most likely needed extraction to resolve the issue long-term. The NP stated she was aware there had been difficulty finding dental providers but again stated the resident needed to see a dentist for resolution of the tooth issue. R5's plan of care (revised 1/9/24) documented the resident had oral/dental health problems due to aging and multiple comorbidities. Interventions to prevent infection and maintain oral/dental health included, Follow therapeutic regime for resolution of infection .Observe for and notify physician of s/sx [signs/symptoms] or oral/dental problems needing attention . This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey. 2. Resident #21 (R21) had no dental care for extractions as recommended by an oral surgeon consultant. Resident #21 (R21) was admitted to the facility with diagnoses that included psychosis, mood disorder, anxiety, depression, stroke, vascular dementia, colitis, aphasia, dysphagia, chronic obstructive pulmonary disease, and heart failure. The MDS dated [DATE] assessed R21 with moderately impaired cognitive skills. R21's clinical record documented an oral surgery consultation dated 4/24/23 regarding cavities and mobile teeth. The oral surgery consultation report dated 4/24/23 documented, carious and mobile teeth, however no signs of acute infection. Patient will need to be seen for evaluation by general dentist to come up with restorative plan prior to us extracting any necessary teeth .Please have patient evaluated by general dentist to come up with treatment plan .Our surgical treatment plan include: Extraction of multiple teeth in an or [operating room] setting . R21's clinical record documented no general dentist services provided in response to the consultation. On 8/21/24 at 11:51 a.m., the social worker (other staff #1) was interviewed about any dental referral or services for R21 following the oral surgery consultation. The social worker stated she was not aware the R21 needed to see a dentist or had been recommended to see a dentist. The social worker stated R21 transported in a wheelchair and that if needed, staff could accompany the resident to appointments and assist with transfer to a dental chair. The social worker stated nobody had asked her about getting a dental appointment for R21. On 8/21/24 at 2:18 p.m., the administrator was interviewed about dental services. The administrator stated, We've struggled getting anyone to help. The administrator stated they got a contract approved for a provider to come to the facility and then the provider stated they had no dentist in the area to provide services. The administrator stated, We've been trying to get appointments and have been unsuccessful. On 8/21/24 at 2:44 p.m., the nurse practitioner (NP - other staff #4) that assessed/treated R21 was interviewed his dental care. The NP stated she recalled R21 being referred to an oral surgeon or dentist. The NP stated she was aware there had been difficulty with getting dental providers. The NP stated R21 had been treated in the past with antibiotics for a tooth infection and the issue was resolved with antibiotic treatment. The NP stated R21 needed to be seen by a dentist, either in-house or by an outside provider to resolve and address ongoing dental problems. R21's plan of care (revised 3/20/24) documented the resident had poor oral/dental health and had a consultation on 4/24/23 with plans for future extractions. Interventions to maintain oral/dental health included, Coordinate arrangements for dental care as needed . This finding was reviewed with the administrator and nurse consultant during a meeting on 8/21/24 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a physician ordered therapeutic diet for one resident (Resident #35-R35) in a survey sample of 21 residents. The findings included: For R35, who had experienced significant weight loss, the physician ordered the resident to receive double portions at meals, which were not provided as ordered. On 8/20/24-8/21/24, a clinical record review was conducted of R35's chart. This review revealed that R35 had an active physician order that read, Regular diet, Pureed texture, Honey consistency double portions, EMP [enriched meal program]. A review of R35's weights was conducted and noted that on 7/3/24 R35 weighed 120.2 pounds. On 8/14/24, R35 weighed 113 pounds, which was a 7.2-pound weight loss in one month. According to R35's care plan with a revision date of 5/24/24, a focus area read, State of nourishment; less than body requirement characterized by weight loss . One of the associated interventions for this care plan focus area read, Diet is regular double portions pureed with honey thick liquids. According to a progress note written by the registered dietician dated 8/20/24, it read in part, Resident noted with weight loss 5% x 30d. Diet: Pureed, EMP, HTL [honey thick liquids] with 2x portions. All food in bowls - intake ~75-100% . On 8/21/24 at 11:29 AM, R35 was observed in the dining room being fed by certified nursing assistant #1 (CNA #1). R35's food was in bowls and the bowls were observed to be half full. The tablemate, another resident at the same table also had foods in bowls which were also half full. CNA #1 was asked about R35's portion sizes. CNA #1 looked at the meal ticket and confirmed that R35 was supposed to have double portions. CNA #1 agreed that R35's portions did not appear to be double. Licensed practical nurse #1 (LPN #1) was called over to the table and confirmed that it did not appear that R35 had received double portions as ordered. On 8/21/24 at approximately 11:45 a.m., the surveyor requested that the dietary manager come to the dining room. The dietary manager was asked about R35's portion sizes and said for double portions the bowls should have been full. The surveyor accompanied the dietary manager to the kitchen and observed the tray line. Another resident was served foods in bowls and one scoop resulted in a half full bowl, which was the same that R35 had received. The dietary manager confirmed that R35 was to receive two scoops of all food items. The facility policy titled; Therapeutic Program was reviewed. The policy read in part, The consulting dietitian advises on the planning, preparation, and serving of diets as prescribed by the resident's attending physicians. No diets will be changed without a written order from the attending physician . The policy titled; Menu Policy was reviewed. The menu policy read in part, . Other specific diets will be adjusted and indicated on the individual tray card as ordered utilizing an approved diet manual . On 8/21/24, during an end of day meeting held at 4:30 p.m., the facility administrator and corporate nurse consultant were made aware of the above findings. No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to provide an accurate clinical record for one of twenty-one residents in the survey sample (Resident #49). The findings include: Resident #49's plan of care listed the resident as a DNR (do not resuscitate) and the care plan interventions regarding advance directives documented a requirement for cardiopulmonary resuscitation. Resident #49 (R49) was admitted to the facility with diagnoses that included cancer, atrial fibrillation, deep vein thrombosis, hypertension and schizoaffective mood disorder. The minimum data set (MDS) dated [DATE] assessed R49 with severely impaired cognitive skills. R49's clinical record documented a current do not resuscitate (DNR) order. R49's plan of care (revised [DATE]) listed under the Focus column that the resident was on hospice and had a DNR order. Interventions to honor the resident's advance directives documented, CPR (cardio-pulmonary resuscitation): Full Code. On [DATE] at 2:00 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about the inaccurate full code intervention for R49. RN #1 stated she reviewed/updated the care plan and changed the problem/focus area but did not change the intervention column. RN #1 stated, The intervention did not get changed. This finding was reviewed with the administrator and nurse consultant during a meeting on [DATE] at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility document review, the facility staff failed to designate a qualified infection preventionist for the facility. The findings include: On 12/15/21 at 2:00 p.m., the administrator was interviewed about the facility's designated infection preventionist. The administrator stated they currently had no staff person qualified and/or trained to be the infection preventionist. The administrator stated the previous infection preventionist was out of leave during August 2021, resigned and did not work after 9/8/21. The administrator stated they had not had an infection preventionist since 9/8/21. On 12/15/21 at 2:52 p.m., the regional nurse consultant (administration staff #3) was interviewed about an infection preventionist for the facility. The nurse consultant stated the regional vice president was actively working to fill vacancies in the facility. On 12/16/21 at 10:16 a.m., the director of nursing (DON) was interviewed about an infection preventionist. The DON stated no person was currently assigned as the infection preventionist but the quality assurance committee reviewed infections. The facility's policy titled Infection Control Preventionist (dated 3/10/20) documented, The facility will designate an Infection Control Preventionist in compliance with federal, state, or local laws .responsibilities may include .surveillance for the identification, investigation, and documentation of facility acquired infections, community acquired infections, and communicable disease outbreaks .Reviews and analyzes facility data .Reports infections and outbreaks .Makes periodic rounds to monitor infection control practices . This finding was reviewed with the administrator on 12/15/21 at 4:00 p.m.

Based on group interview, staff interview, and facility document review, the facility staff failed to ensure mail delivery to residents. Findings include: On 12/15/21 beginning at 3:00 p.m. a group interview was conducted with eleven cognitive residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). The group was asked about mail delivery in the facility, and if mail was received on Saturdays and also received unopened. The group responded No. Resident # 11 stated We haven't gotten any mail since the activity director left over a month ago. You know, it's close to Christmas, and we don't even know if we have gotten cards or anything. On 12/15/21 at approximately 4:30 p.m. the administrator was asked about the mail delivery, and for a policy. The administrator stated she would look for a policy, and was not aware residents were not having mail delivered. The policy for mail delivery in the facility stated Mail: Residents have the right to send and promptly receive mail that is unopened and have access to stationary, postage, and writing implements. Mail will be delivered to residents Monday through Saturday during regular business hours. The administrator and corporate consultant nurse were made aware of the above findings 12/16/21 at approximately 10:30 a.m. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The facility staff failed to employ staff in the following key positions: activities director and infection control preventionist; and failed to have a restorative program in place. The findings include: An onsite survey was conducted from 12/14/2021 through 12/16/2021. During the survey deficient practice was identified in the areas of residents rights and activities including F550, F565, F576, F679, and F680 which were related to the facility not employing an activities director since 11/5/2021. The survey revealed deficient practice in the area of infection control including F880, F881, F882, F883, and F887 which were related to the facility not employing an infection control preventionist since 09/08/2021. The survey revealed deficient practice in the area of quality of care including F688, related to the facility not having a restorative program in place. 1. On 12/14/2021 at 11:00 a.m., during the entrance conference the Administrator stated the facility had not employed an activity director since 11/5/2021. The Administrator stated a new activities director started on 12/6/2021; however, she quit within 2 hours of working in the facility. The administrator was asked what type of activities were being held at the facility. The Administrator stated the nurses were playing music at times, but because the facility had been on quarantine since the week of Thanksgiving due to positive Covid-19 cases, activities were put on hold. The Administrator stated that corporate was working to hire a new activity director; however, they had not located a qualified person yet due to hiring challenges in the area. On 12/15/2021 at 10:30 a.m. the Administrator was interviewed regarding the lack of activities at the facility. The Administrator stated the facility was doing the best they could. The Administrator was asked if other facility staff were being utilized to assist with the activities department. The Administrator stated, We play music at times. My social worker is new and isn't familiar with the activities program. The first couple of weeks the resident council president assisted with bingo and certain other activities, but then we had the COVID positive cases and he stopped helping with activities. The Administrator was asked if the corporate consultant was aware the facility was not providing a consistent activities program. The Administrator stated, They are working to hire someone for the position, but we just can not locate anyone in this area. On 12/15/2021 at 2:50 p.m., the regional nurse consultant (Administration Staff #3) was interviewed about the facility's lack of activities. The regional consultant stated the corporate regional vice president was working to hire a new activities director. The regional consultant stated she was not aware the residents were not receiving activities. On 12/15/2021 at 3:58 p.m., during a meeting, the above finding was discussed with Administrator, director of nursing (DON) and corporate nurse consultant. The Administrative team were interviewed about the facility's efforts to incorporate activities into daily activities. The Administrator stated, Corporate has placed an ad with Indeed and are monitoring the ad for potential applicants. The regional nurse consultant stated she had spoken with the corporate regional vice president and another facility had agreed to loan the facility an activity assistant until someone was hired. On 12/16/2021 at 1:16 p.m., the facility's medical director (OS #5) was interviewed about the lack of activities in the facility. OS #5 stated he had discussed with the Administrator that corporate was using hiring opportunities such as job fairs and online applications. OS #5 stated the area was challenged with hiring difficulties. OS #5 stated his concern was the residents may have an increase in depression related to COVID-19 restrictions and having an ongoing activities program would help reduce depression. 2. During the survey entrance, infection prevention and control program policies and procedures, including the surveillance plan, antibiotic stewardship, COVID-19, influenza and pneumonoccocal immunization, and testing and immunization records, were requested. On 12/14/2021 at 11:00 a.m., the Administrator stated the facility did not currently have a trained infection control preventionist (ICP). The Administrator stated the previous ICP was on leave of absence in August and later resigned and did not return to work as scheduled on 9/8/2021. The Administrator stated the facility had not employed an ICP since 9/8/2021. The Administrator was asked who was monitoring the facility's infection control program. The Administrator stated the director of nursing (DON) and staff development coordinator (RN #1) were handling various parts of the infection control program. The Administrator stated the infection control program was reviewed by the quality assurance (QA) committee and discussed in daily/morning meetings. On 12/15/2021 at 2:50 p.m., the regional nurse consultant (administrative staff #3) was interviewed regarding the facility's ICP position. The nurse consultant stated the corporate regional vice president was working to hire for this position. On 12/16/2021, the infection control program was reviewed including surveillance and antibiotic stewardships. The review revealed no infection surveillance data for January and February 2021; no individual resident infection reports for the period of April 2021 through November 2021, and none of the logs identified infectious organisms. Additional review of the infection control program revealed no evidence of an antibiotic stewardship program. There was no evidence of analysis or review of the antibiotics indicating if the prescribed medications met stewardship criteria. On 12/16/2021 at 10:15 a.m. the DON was interviewed about the ICP position. The DON stated currently the facility did not have an assigned trained infection preventionist. The DON was asked who was coordinating and monitoring infection control at the facility. The DON stated, We discuss infection control during our daily meetings and at the QA meetings and [RN #1] the staff development coordinator assists with infection surveillance. On 12/16/2021 at 10:16 a.m., RN #1 was interviewed about the facility's infection surveillance. RN #1 stated she was assigned to oversee the vaccination program not the infection surveillance or the antibiotic stewardship program. On 12/16/2021 at 2:30 p.m. the above findings were discussed with the Administrator, DON, and corporate nurse consultant. 3. On 12/16/2021 at 8:15 a.m. the DON was interviewed regarding who was responsible for providing restorative nursing and the location of progress notes for the restorative program. The DON stated the, our restorative certified nursing assistant (CNA) left within the last couple of months. We really don't have anyone here that is doing it. We should have relooked at the restorative program when she left and looked at the plans that were in place, modified them, referred back to therapy, it just didn't get done . On 12/16/2021 at approximately 11:55 a.m., the Administrator was interviewed regarding who reviewed restorative notes and oversaw the program to make sure it was implemented and followed. The Administrator stated, I really don't know .we don't have that many .therapy writes the plan, we discuss it in the IDT (inter-disciplinary team) .I guess it would probably be the unit manager, but we don't have one right now, so I guess it would go to the DON. The Administrator was asked when the restorative program ended. The Administrator stated, We got an email from corporate that the CNA (certified nursing assistant) doing restorative had a felony charge come back on her annual background check and had to let her go. She was terminated on 11/04/2021, we haven't done restorative since then. On 12/16/2021 at 1:16 p.m., the facility's medical director (OS #5) was interviewed and asked if he was aware the facility was not providing restorative nursing care. OS #5 stated, I know we've been trying to hire for restorative, it is a very challenging area . [Administrator] and I have talked about having therapy do more . No additional information was provided to the survey team prior to exit on 12/16/2021 at 3:30 p.m.

Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program for the facility. The findings include: There was no staff person designated as the infection preventionist during the current survey. On 12/15/21 at 2:00 p.m., the administrator stated the facility had not had a designated/qualified infection preventionist since 9/8/21. The administrator stated the registered nurse staff development coordinator (RN #1) would assist with review of the infection control program. The infection control program was reviewed on 12/16/21 and revealed no evidence of an antibiotic stewardship program. Infection tracking information was missing for January 2021 and February 2021. Three infections were listed on a tracking sheet for March 2021 but there was nothing documented regarding antibiotic use. Infection data from April 2021 through November 2021 included no individual infection reports indicating the date, resident name, diagnoses/contributing factors, nature of infection, date of onset, infectious organism, treatments implemented, requirement for precautions or any mention of meeting and/or not meeting antibiotic stewardship criteria. The infection data provided had monthly summaries documented from January 2021 through May 2021. These sheets had tally marks indicating infections in the facility by type but there were no individual resident reports to match the monthly summaries. There were monthly reports from the pharmacy documenting antibiotics prescribed listed by resident name. There was no evidence of analysis and/or review of the antibiotics indicating if the prescribed medicines met stewardship criteria. On 12/16/21 at 10:15 a.m., RN #1 was interviewed about the antibiotic stewardship program in the facility. RN #1 stated she had been asked to oversee the vaccination program but was not assigned antibiotic stewardship. RN #1 stated the pharmacy provided a monthly report indicating which residents were on antibiotics. RN #1 stated she had no information currently showing evidence the antibiotic stewardship policies were implemented. On 12/16/21 at 10:16 a.m., the director of nursing (DON) was interviewed about the infection control program including antibiotic stewardship. The DON stated no person was currently assigned to oversee the infection programs but the quality assurance committee reviewed infections. The facility's policy titled Antibiotics Stewardship (dated 3/10/20) documented, As a component of this facility's IPCP [infection prevention and control program], the antibiotic stewardship program supports the appropriate and safe use of antibiotics in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .The core elements of the Antibiotics Stewardship Program are .Utilization of the pharmacy consultant and/or other regarding the appropriate use of antibiotics .Monitoring and analysis of antibiotic use .Monitoring and/or the review of antibiotic use should occur .When a resident is new to the facility .When a resident re-enters the facility following hospitalization .During each monthly medication regimen review .The monitoring of antibiotic prescribing, use, and resistance may include .Clinical justification for antibiotic use beyond initial duration ordered .Tracking of antibiotic-resistant or other significant organisms related to antibiotic use .Adverse drug events related to antibiotic use . This finding was reviewed with the administrator and director of nursing on 12/16/21 at 2:30 p.m.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control policies for hand hygiene during a medication pass observation, failed to provide an ongoing program of infection surveillance, and failed to follow infection protocols for PPE (personal protective equipment) use for one of seventeen residents in the survey sample, Resident #34. The findings include: 1. A medication pass observation was conducted on 12/14/21 at 4:32 p.m. with licensed practical nurse (LPN #2) administering medications to three residents. LPN #2 prepared medications and administered them to Resident #15. Oral medications were administered in addition to nasal spray, [MEDICATION(S)] diskus aerosol inhaler, and eye drops. LPN #2 handled and disposed of the resident's medication and drinking cup after the resident touched the cups to her mouth. LPN #2 put on gloves prior to administering the eye drops. LPN #2 removed the gloves, left the room and discarded items in the cart trash compartment. LPN #2 did not perform hand hygiene after medication administration to Resident #15 and then prepared and administer medications to the next resident (Resident #35). On 12/14/21 at 4:40 p.m., LPN #2 was interviewed about hand hygiene between resident contact. LPN #2 stated she usually used hand sanitizer between residents when giving medications. The facility's policy titled Handwashing Procedure (dated 3/10/20) documented, .You should wash your hands .Before and after contact with residents .After coming in contact with any body fluids .After handling contaminated items . This finding was reviewed with the administrator on 12/15/21 at 4:00 p.m. 2. There was no staff person designated as the infection preventionist during the current survey. On 12/15/21 at 2:00 p.m., the administrator stated the facility had not had a designated/qualified infection preventionist since 9/8/21. The administrator stated the registered nurse staff development coordinator (RN #1) would assist with review of the infection surveillance program. The infection control program was reviewed on 12/16/21 including surveillance of infections. There was no infection surveillance data for January 2021 and February 2021. Three infections were listed on a tracking sheet for March 2021. Infection data from April 2021 through November 2021 included no individual infection reports indicating the date, resident name, diagnoses/contributing factors, nature of infection, date of onset, infectious organism, treatments implemented, requirement for precautions or any mention of meeting and/or not meeting antibiotic stewardship criteria. The infection data provided had monthly summaries documented from January 2021 through May 2021. These sheets had tally marks indicating infections in the facility by type but there were no individual resident reports to match the monthly summaries. There were monthly logs documented for October 2021 and November 2021 listing resident name, onset, symptoms, type of infection and treatment. There were no infectious organisms identified on any of the logs. The November 2021 infection log made no mention of Resident #159 who diagnosed with COVID-19 on 11/25/21. On 12/16/21 at 10:15 a.m., RN #1 was interviewed about the infection surveillance in the facility. RN #1 stated she had been asked to oversee the vaccination program but was not assigned infection tracking/surveillance. On 12/16/21 at 10:16 a.m., the director of nursing (DON) was interviewed about infection tracking. The DON stated there was no staff person currently assigned to infection control but the quality assurance committee reviewed infections. On 12/16/21 at 11:36 a.m., RN #1 was interviewed again about the infection surveillance. RN #1 reviewed the documented sheets and stated some of the information was missing and incomplete. RN #1 stated there was supposed to be individual infection sheets completed for each person with suspected infections. RN #1 stated this information was supposed to be entered onto the monthly log and a summary report completed at least quarterly for review by the quality assurance committee. The facility's policy titled Infection Control Surveillance Policy (dated 3/10/20) documented, This facility should monitor residents that display signs and symptoms of infection. The designated staff member (i.e., unit nurse, unit supervisor, RN Supervisor) should initiate an Infection Control Surveillance form (BN-2201) and inform the designated infection control preventionist and/or the Director of Nursing of this occurrence .The designated ICP [infection control preventionist] should complete the Individual Infection Control Surveillance form (BN-2201). Upon analysis, the data will be entered on the Monthly Infection Log (BN-2202) by the ICP for tracking purposes . This finding was reviewed with the administrator and director of nursing on 12/16/21 at 2:30 p.m. 3. Resident #34 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: dementia, urine retention with foley catheter, heart failure with pacemaker, and most recently with ESBL (extended spectrum beta-lactamase) in his urine requiring IV antibiotics for fourteen days (beginning 12/08/2021) with the implementation of contact precautions. Resident #34's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/05/2021. He was assessed as cognitively intact with a summary score of 15. On 12/14/2021 at approximately 10:45 a.m., Resident #34 was observed in his room. A sign on the door indicated he was on Contact Precautions. Instructions to anyone entering the room, included: Perform hand hygiene before entering and before leaving room and/or directly after leaving room; wear gloves when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated surfaces . An [MEDICATION(S)] was hanging on his door which contained gowns, gloves, red bags, masks, and other items needed for his care. On 12/15/2021 at approximately 9:35 a.m., a staff member was observed in the room with Resident #34. She was making his bed, rearranging the bedside table, and tidying up the room. She was not wearing a gown or gloves. When she exited the room she was interviewed. She identified herself as the facility social worker. She was asked what PPE (personal protective equipment) she needed to use to enter Resident #34's room. She stated, A gown and gloves. She was asked why she had not been wearing the appropriate PPE when she was in there. She stated, I don't know, I should have been .I went in to make his bed, just trying to help out, I should have had it on. On 12/15/2021 at approximately 2:30 p.m., Resident #34 was interviewed regarding life at the facility. Upon leaving the room, there was not a trash can or trash bin available to dispose of the used isolation gown and gloves. Observed from the door, which was in front of the nurse's station, staff at the nurses station was asked where the used isolation gowns were to be disposed. LPN (licensed practical nurse) #1 told one of the CNAs (certified nursing assistants) to bring a trash can to the room. A trash can without a lid or a red bag was brought to the doorway for disposal of the used items. LPN #1 stated, Ask (name of LPN #3). LPN #3 was down the hall giving medications. She was asked what was supposed to be done with used PPE. She stated, I'll show you what I do. She went to Resident #34's doorway and pointed at the red bags, I get one of these and put my things in it and tie it up. Then I go down here with the bag, she stated as she walked down the hallway to the used utility room. I open this door and I put the bag in here in that big trash bin. She pointed to a large trash can/bin with a red bag in it. She was asked why there wasn't a place in the resident's room. She stated, I don't know. The above information was discussed with the administrator and the corporate nurse consultant during an end of the day meeting on 12/15/2021. The administrator stated, She [the social worker] told me what happened. She should have been wearing her PPE. The corporate nurse consultant stated, There should have been a receptacle in the room with a red bag for disposing of the PPE. The facility policy regarding Contact Precautions, included the following but was not limited to: Utilize clean gloves when entering resident's room and during care. Remove gloves and perform hand hygiene before leaving resident area. Wear a gown when entering room and caring for the resident. Remove and dispose of gown before leaving resident room. No further information was received prior to the exit conference on 12/16/2021.

Based on observation, resident interview, group interview, staff interview and clinical record review, the facility staff failed to promote resident rights by confining residents to their rooms and not allowing communal activities for three of 17 residents in the survey sample. For over two weeks residents in the facility, including Resident #36, #158 and #37 were not allowed out of their rooms and had communal dining and activities canceled. The findings include: 1. Resident #36 was admitted to facility on 11/18/16 with a re-admission on 12/29/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #36 with moderately impaired cognitive skills. On 12/14/21 at 11:43 a.m., Resident #36 was interviewed about quality of life in the facility. Resident #36 stated, I'm tired of this room. Resident #36 stated she was no longer allowed out of her room and had to eat in her room. Resident #36 stated she liked to walk about with her walker. Resident #36 stated she thought staying in the room had something to do with COVID but she did not understand why she could not walk around. Resident #36 stated each time she went to leave her room, one of the girls at the desk told her to get back into the room. Resident #36 stated this had been going on for about two months and she was not allowed out even with her mask. Resident #36's clinical record documented no physician orders or care plan interventions regarding room confinement or any type of isolation precautions. An order signed by the physician on 12/7/21 documented, May participate in B-day parties, council meal & facility functions w/o [without] diet restrictions .May visit outside facility w/ [with] permission of responsible party if condition permits . The clinical record documented the resident was partially vaccinated against COVID-19 with the first vaccine dose administered on 8/11/21. The resident's plan of care (revised 7/22/21) documented the resident had cognitive impairment and trouble with comprehension, reasoning difficulties, little attention span and had psychosocial adjustment difficulties due to mild intellectual disability. The care plan documented, .likes to be with others socially and to feel connected with others. At times, resident will say 'Hey, hey' to get attention . Interventions for prevent social isolation and minimize anxious mood/behaviors included, Assist resident to attend activities programming or event .When resident is saying 'hey, hey', stop and ask what he/she needs and provide reassurance . The care plan listed the resident wandered about the facility with use of a walker. 2. Resident #158 was admitted to the facility on [DATE] with a re-admission on 12/2/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #158 as cognitively intact. On 12/14/21 at 11:51 a.m., Resident #158 was interviewed about quality of life in the facility. Resident #158 stated, I'm tired of sitting in this room. People in jail got more rights than we do. Resident #158 stated that residents were not allowed in the hallway or about in the facility and that had been in place for over two weeks. Resident #158 stated he was told the reason for the confinement was something to do with COVID. Resident #158 stated his roommate got COVID-19 and then he got COVID-19 despite being vaccinated. Resident #158 stated he went to another facility for ten days and returned but never had any COVID-19 symptoms. Resident #158 stated residents were not allowed to go outside, get fresh air and going to the dining room was stopped. Resident #158 stated the facility no longer had an activity director and had not had group activities in months. Resident #158 stated he wanted out of his room, to go outside, get some fresh air and be able to see other residents in the dining room. Resident #158 stated he wore his mask when out of his room. Resident #158's clinical record documented the resident was diagnosed with COVID-19 on 12/2/21 and was transferred to a sister-facility on 12/2/21 for a ten-day quarantine. The resident was readmitted to the facility on [DATE] with no orders for room confinement, isolation, quarantine or restriction of activities. The resident's readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .May visit outside facility w/ [with] permission of responsible party if condition permits . The clinical record documented Resident #158 was fully vaccinated for COVID-19 with the second dose administered on 2/8/21 and a booster dose on 10/12/21. Nursing notes documented the resident had no symptoms associated with the COVID-19 diagnosis. Resident #158's plan of care (revised 11/1/21) documented the resident was at risk and/or had COVID-19 infection. Interventions related to COVID-19 included, .Encourage resident compliance with infection control measures mask wearing when out of room . The care plan listed the resident had, Feelings of sadness, emptiness, anxiety .depression characterized by; ineffective coping, low self esteem, anxiety, little involvement in activities related to .[CONDITION(S)] [[CONDITION(S)] accident], loss of independence . Interventions to improve mood and minimize anxiety/depression included, .Encourage resident to attend group activities .Monitor and repot any changes in mental status, mood, or behaviors and notify physician .Offer activities of which resident has shown interest . On 12/14/21 at 12:00 p.m., no residents were observed in the hallway. All residents were served lunch in their rooms with no residents in the day room, dining room or sitting out on the unit. On 12/14/21 at 12:41 p.m., the administrator was interviewed about residents not allowed out of their rooms. The administrator stated on 11/25/21 two employees tested positive for COVID-19 during routine testing. The administrator stated residents were tested on [DATE] due to the outbreak and Resident #158's roommate tested positive on that day. The administrator stated Resident #158 was placed on droplet precautions on 11/25/21 since he was exposed. The administrator stated when Resident #158 tested positive on 12/2/21, he was sent to a sister-facility to quarantine for ten days. The administrator stated that since 11/25/21 the residents had been told to stay in their rooms. The administrator stated the plan was for residents to stay in their rooms and not have group activities including dining, until 12/16/21 which was 14 days after the last positive (on 12/2/21). When asked why the residents were not allowed out of their rooms since they were not on any type of transmission-based precautions, the administrator stated, I don't know. The administrator stated, We were following the old rules, keeping them in rooms for 14 days. The administrator stated they were trying to contain the spread of COVID-19 and stated there were no CDC guidelines that called for all residents to be quarantined based on the positive result on 12/2/21. The administrator stated there were ten residents in the facility unvaccinated and the remaining residents were fully vaccinated. On 12/14/21 at 4:38 p.m., licensed practical nurse (LPN #2) was observed administering medications. Resident #19 had on a mask and was standing in the doorway to his room. LPN #2 stated at this time, [Resident #19] aren't you supposed to be in that room? The resident had money in his hand and stated he wanted to get some nabs. LPN #2 stated, Wait a little bit please. LPN #2 was interviewed at this time about instructing the resident to stay in his room. LPN #2 stated the residents were on quarantine and had to stay in their rooms. On 12/15/21 at 8:15 a.m., no residents were observed in the hallway or out of their rooms on the nursing unit. LPN #3 was interviewed at this time about the room confinement and no communal dining. LPN #3 stated she was told the residents had to stay in their rooms for 14 days from the last COVID-19 positive resident. LPN #3 stated residents were supposed to stay in their rooms until 12/16/21 and that communal dining had been canceled. On 12/15/21 at 10:37 a.m., the administrator was interviewed about resident activities. The administrator stated there had been no group activities since the activity director left on 11/5/21. On 12/15/21 at 2:52 p.m., the regional nursing consultant (administration staff #3) was interviewed about the residents' room confinement and no communal dining and/or activities since 11/25/21. The regional consultant stated she was not aware the residents were on lock-down. The regional director stated the company guidance stated if residents were vaccinated, they could participate in communal dining and be out of their rooms unless they had symptoms. The regional consultant stated that guidance was provided to administrators. The regional consultant stated she recently trained all the administrators with guidance stating that visitation and communal activities could not be restricted. On 12/15/21 at 3:57 p.m., the regional consultant and administrator were interviewed about the restrictions. The regional consultant stated the decision for residents to stay in their rooms came from the facility in response to COVID-19 outbreak. The regional consultant stated the facility was trying to keep residents socially distant and residents came out of the room for therapy and showers. The regional consultant stated the restrictions started around Thanksgiving. The administrator stated the restrictions were not according to CDC guidance for management of COVID-19. On 12/16/21 at 1:25 p.m., the facility medical director (other staff #5) was interviewed by telephone about the restricted out of room activities for residents. The medical director stated he did not order or recommend resident confinement or out of room restrictions. The medical director stated he thought the directive to keep residents in their room came from corporate. The facility's policy titled Guidelines for Dining and Communal Activities (dated 5/11/21) documented, .Previously, restrictions issued by the CDC [Centers for Disease Control and Prevention] and CMS [Centers for Medicare & Medicaid Services] had limited options for group activities. Now, with some limited exceptions outlined below, communal dining and activities are encouraged for the mental and social well-being of residents so long as there are no factors that put residents at risk for contracting COVID-19 . The policy documented concerning communal dining, .If all participating residents are fully vaccinated dining and other group activities may occur without social distancing and without face masks .If a resident is unvaccinated, or not fully vaccinated, chooses to participate in communal activities, then all residents, regardless of vaccination status, must wear a mask and socially distance, except for eating .The facility may not discriminate against fully vaccinated, unvaccinated, or not fully vaccinated residents, but may accommodate reasonable requests by the Resident Council and/or a specific patient or group or patients . These findings were reviewed with the administrator on 12/15/21 at 2:19 p.m. The administrator stated at this time that there was no CDC guidance to keep residents in their rooms in response to the recent COVID-19 positive staff/residents. The administrator stated, We were just scared of COVID spreading. It was not CDC guidance. The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 9/10/21) documents, Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. HCP [health care personnel] caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) .Fully vaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested .Fully vaccinated residents and residents with [CONDITION(S)]-CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority . (1) (1) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. Centers for Disease Control and Prevention. 12/18/21. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 3. Resident # 37 was admitted to the facility 12/15/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was a quarterly assessment dated [DATE] and had Resident # 37 coded as cognitively intact with a score of 15 out of 15. On 12/14/21 beginning at 11:00 a.m. during initial tour of the facility, there were no residents observed in the halls or in the dining room. Upon entering Resident # 37's room, when asked how she was doing, she stated Well, I'd be a lot better if I could get out of this room for a bit. Resident # 37 stated, There was a case of COVID, and they [facility staff] told us we had to stay in our rooms. If I am in my wheelchair and get close to the doorway, one of the workers hollers at me to get back in my room. No visitors, including singing groups like we used to have, are allowed in the building. A meal observation was conducted on 12/14/2021 at approximately 12:30 p.m. on the 300 unit of the facility. All residents were observed dining in their rooms, no residents were observed in the dining room. One of the staff members who was passing out trays was asked why all the residents were eating in their rooms. She stated, We are on quarantine until Thursday (12/16/2021). We had a COVID positive resident so now everyone has to stay in their rooms for fourteen days no one is going to the dining room until then. On 12/15/21 beginning at 3:00 p.m. a group interview was conducted with eleven cognitive residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). All the residents stated the same information as provided by Resident # 37. The group stated We have to stay in our rooms .we can't go out of our room because of the quarantine rule, and so all there is to do is watch TV and get fat. On 12/15/21 at approximately 4:30 p.m. the administrator confirmed the resident's statements. She stated due to fears of spreading COVID, residents were restricted to their rooms until 12/16/21 when the fourteen days were completed. The administrator stated she was not aware residents did not have to stay in their rooms, or that visitors could come in. No further information was provided prior to the exit conference.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to obtain laboratory tests as ordered by the physician for one of three residents in the survey sample (Resident #1). Resident #1 had a free [MEDICATION NAME] level performed when the physician ordered a total [MEDICATION NAME] level. Resident #1's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased when his [MEDICATION NAME] levels were already high after the free [MEDICATION NAME] level was miscommunicated to the physician as a total [MEDICATION NAME] level. A follow up [MEDICATION NAME] level ordered by the physician was not obtained. The increased dosage caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in hospitalization for treatment of [REDACTED]. The resident experienced a laceration to his left eyebrow region, ligament injury to the left pinky finger, a laceration to the right middle finger, several bruises/abrasions to his knees and swelling of his face due to repeated falls associated with toxic effects from the high [MEDICATION NAME] levels. The findings include: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills. This MDS assessed Resident #1 as always continent of bowel/bladder and to require supervision with set up help only for transfers, dressing and toileting. Resident #1's clinical record documented a physician's order dated 3/3/17 for [MEDICATION NAME] chew 100 mg (milligrams) to be given twice per day and an order dated 3/3/17 for [MEDICATION NAME] chew 50 mg to be given at 2:00 p.m. each day for treatment/prevention of [MEDICAL CONDITION]. The record documented a physician's order dated 11/15/17 for a [MEDICATION NAME] level to be obtained on 11/16/17. A lab report dated 11/18/17 documented the resident's [MEDICATION NAME] (free) level on 11/16/17 was high at 2.5 mg/L (milligrams per liter) as compared to the reference range of 1.0 to 2.0 mg/L. A nurse documented notification to the physician of the lab results. A telephone order was documented on 11/18/17 increasing Resident #1's [MEDICATION NAME] dosage to 200 mg twice per day and 100 mg at be given at 2:00 p.m. each day in response to the lab test. This order also included instructions to repeat the resident's [MEDICATION NAME] level on 11/24/17. A nursing note dated 11/18/17 documented, (Physician) informed of resident [MEDICATION NAME] level 2.5, order given to give [MEDICATION NAME] 200 mg by mouth every morning and every evening and to give 100 mg by mouth at 2 pm daily. [MEDICATION NAME] level to be checked next week, placed in lab book to check 11/24/17. The order for the increased [MEDICATION NAME] doses was inaccurately entered on the resident's November 2017 medication administration record (MAR). The order for [MEDICATION NAME] 200 mg twice per day was not added to the MAR until 11/26/17. Resident #1 continued to be administered [MEDICATION NAME] 100 mg twice per day from 11/18/17 through 11/25/17. The resident's 2:00 p.m. dose of [MEDICATION NAME] was increased from 50 mg to 100 mg starting on 11/18/17 as ordered. The twice per day 100 mg doses of [MEDICATION NAME] were stopped on 11/25/17 and starting on 11/26/17 the resident was administered [MEDICATION NAME] 200 mg twice per day. The resident's total daily dose of [MEDICATION NAME] progressed as follows: prior to 11/18/17 received 250 mg per day; 11/18/17 through 11/25/17 was given 300 mg per day; 11/26/17 until discharge on [DATE] was given 500 mg per day. The clinical record documented no repeat [MEDICATION NAME] level on 11/24/17 as ordered by the physician. The clinical record documented increased falls for Resident #1 in November 2017 as the [MEDICATION NAME] doses increased. The resident had experienced only one prior fall (on 9/9/17) from January through October of 2017. The resident experienced six falls in November 2017 prior to being sent to the emergency roiagnom on [DATE] following the third fall that day (11/28/17) resulting in a laceration above his left eye. Nursing notes documented the following falls with injuries for Resident #1 during November 2017. 11/7/17 at 6:21 p.m. - Heard a loud noise, went to check to see, found resident in floor, on knees with bedside table overturned with resident over it .Resident has minor scratch on bridge of nose with minor bleeding from left nostril .Applied Band-Aid to bridge of nose . 11/23/17 at 7:11 p.m. - this nurse called to room by cna (certified nurses' aide) feeding residents roommate found him (Resident #1) lying on floor beside his bed with his legs over the trash can assessed no injury .assisted back to bed socks removed and skid socks applied. (sic) 11/26/17 at 1:15 p.m. - heard noise in room upon entering the room, observed resident lying on the right side at the foot of the bed, in front of w/c (wheelchair). when asked resident denied falling. laceration noted to right middle finger, cleaned and dressed. no other injuries noted at this time .bruise noted to left hand. able to move wrist and all digits. some [MEDICAL CONDITION] noted to left hand . 11/28/17 at 1:42 p.m. - Was called to residents room and was advised that resident was in floor in the bathroom .resident was sitting in floor in the bathroom with wheelchair sitting at bathroom door. Resident stated that he was attempting to go to the bathroom and got too fast .Resident stated that he was not hurt .No complaint of pain or discomfort . (sic) 11/28/17 at 4:18 p.m. - Heard loud noise .resident was sitting in the floor on roommates side of the room. Resident stated that the chair turned around on him and he fell into the floor . (sic) 11/28/17 at 9:15 p.m. - Resident found on the floor by CNA, call writer to room. Resident observed on the floor with call bell in hand bleeding from what appears to be left eye. Blood also noted to the back of head. facial swelling noted .resident responsive at time of fall and still responsive when sent to ER (emergency room ) .Sent to ER for eval (evaluation) per MD (physician) order. Resident's third fall of the day . Resident #1 was seen by the physician on 11/27/17 for evaluation of the laceration to the right middle finger that occurred on 11/26/17 and the physician note made no mention of the resident's [MEDICATION NAME] dosage. This progress note dated 11/27/17 documented, I was called over the weekend that (Resident #1) had some falls . He had several additional falls and it was the nurse's opinion that he was putting himself on the floor, not actually falling .Medication administration record is reviewed in chart .Speech is quite garbled. He is generally up in a wheelchair, but has had more falls recently . The physician's note made no mention of the resident's [MEDICATION NAME] levels, inaccurate [MEDICATION NAME] entry on the MAR or the missed [MEDICATION NAME] level lab due on 11/24/17. The facility's investigation of the [MEDICATION NAME] error was not conducted until after the resident's discharge. The investigation included documentation dated 11/29/17 stating, On 11/18/17 orders transcribed to MAR incomplete + lab work illegible on labbook no requisition filled out resulted in residents increased impairment + freq (frequent) falls resulted in resident being admitted to hospital. (sic) A physician's progress note for Resident #1 dated 11/30/17 documented, I received a call from (director of nursing), informing me that several weeks ago I was called about a lab result. I was told the patient's [MEDICATION NAME] Level was very low and I asked if the patient was actually receiving and taking his prescribed dose of 100 mg bid (twice per day). She said he was taking it regularly. I ordered a significant increase in dose and a follow-up [MEDICATION NAME] level, but the order was not taken off and the lab was not done until the patient went to the hospital ER (emergency room ) . Resident #1's emergency room report dated 11/28/17 documented the resident was diagnosed upon arrival with [MEDICATION NAME] toxicity due to an abnormally high [MEDICATION NAME] level. The ER report lab report dated 11/28/17 documented Resident #1's [MEDICATION NAME] level as a critical value measuring 40.6 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The resident was diagnosed with [REDACTED]. The ER history and physical report dated 11/28/17 documented, Pt (patient) arrives to the ED (emergency department) with multiple injuries. Pt has bandaged laceration to the right middle finger. Bruising to the left hand. abrasion under the chin and both knees. Abrasion to the back of the left ear as well as left eye. EMS (emergency medical services) states that nurse states the pts speech is normally slurred however it has worsened tonight .Lab called to report abnormal Dilanton ([MEDICATION NAME]) of 40.6 . The report documented the laceration above the resident's left eye as superficial and measured 1.5 centimeters in length. The note documented the resident had . a deep abrasion on the right middle finger that appears to be old . also has contusion/hematoma of the entire left hand .is able to make a fist with the right hand and the middle finger flexes against resistance, but there is a deep laceration at the PIP (proximal interphalangeal) joint which extends into the joint capsule and the finger can be hyperextended at the PIP joint. The wound will be cleaned, finger splinted and antibiotics given . The resident was admitted to the hospital with [REDACTED]. The laceration above the resident's left eye was cleansed and closed with skin glue. An orthopedic consultation report dated 11/30/17 documented, evidently was admitted with superficial injuries after reported multiple falls . With these falls, apparently, had some other injuries contusion to his face with a 2 cm laceration to the left lateral eyebrow area that was managed in the emergency room . He also apparently had both knees with abrasions, but function intact .attention to the right hand x-rays demonstrated no acute [MEDICAL CONDITION] finger .The wound was not repaired. It was a traverse laceration approximately of 2 cm across the volar (palm) aspect of the proximal interphalangeal joint . Since the wound is at least a good 48 hours post injury, this will heal secondarily requiring no sutures . A physician consultation report dated 12/3/17 documented, .He (Resident #1) was admitted with falls and several orthopedic injuries. This appears to have been secondary to [MEDICATION NAME] toxicity . The resident remained hospitalized from [DATE] until 12/8/17. The hospital discharge summary dated 12/8/17 listed the resident's primary [DIAGNOSES REDACTED]. This summary report documented, .He (Resident #1) presented to the hospital with reported multiple falls at the local nursing home resulting in multiple abrasions and bruises as well as a 1.5 cm simple laceration to the left lateral eye brow region .His [MEDICATION NAME] level was checked and it was found to be significantly elevated at 32 (on 11/29/17) (reference range is 10 - 20) . He was admitted with [MEDICATION NAME] toxicity. His gait instability was likely related to this. [MEDICATION NAME] was discontinued and levels were checked until it trended back close to normal . Further review of Resident #1's clinical record revealed no physician's order for a free [MEDICATION NAME] level. Resident #1's plan of care (revised 7/26/17) documented prior to November the resident required minimal assistance with activities of daily living. This care plan stated the resident had potential for injury due to history of [MEDICAL CONDITION]. Interventions for [MEDICAL CONDITION] prevention included, Administer medications as ordered by the physician .Monitor for adverse side effects of medication, i.e., headache, drowsiness, [MEDICAL CONDITION], anxiety depression, [MEDICAL CONDITION], blurred vision, diplopia (double vision), dizziness, numbness, ataxia (poor muscle coordination), tremor, nausea, vomiting, diarrhea, gingival [MEDICAL CONDITION], and rash and notify physician for evaluation and intervention .Obtain and monitor serum anticonvulsant medication levels as ordered and notify physician of results . The nurse that communicated the resident's [MEDICATION NAME] lab test on 11/18/17 to the physician and inaccurately entered the [MEDICATION NAME] order on the MAR was not available for interview as she no longer worked at the facility. On 1/3/18 at 2:00 p.m. the licensed practical nurse (LPN #1) that worked on Resident #1's living unit was interviewed. LPN #1 stated Resident #1 routinely propelled himself around the facility and was alert and active. LPN #1 stated prior to November 2017 the resident had no history of frequent falls and the resident was able to make his needs known. On 1/3/18 at 2:15 p.m. the resident's physician was interviewed about the diagnosed [MEDICATION NAME] toxicity and associated injuries related to increased falls. The physician stated he was called by the nurse working on 11/18/17 and advised that the resident's [MEDICATION NAME] level was 2.5. The physician stated he had ordered a regular [MEDICATION NAME] level and not a free [MEDICATION NAME] level. The physician stated the normal range for regular [MEDICATION NAME] was 10 to 20 so he understood the resident's [MEDICATION NAME] level was low. The physician stated he asked the nurse if the resident had been taking his current dose of [MEDICATION NAME] as ordered and the nurse advised that the resident was routinely taking medications as ordered. The physician stated the nurse never told him that the lab result of 2.5 was a free [MEDICATION NAME] level so he thought the result was a regular [MEDICATION NAME] level. The physician stated the normal ranges were very different for a free [MEDICATION NAME] (1.0 to 2.0) as compared to a regular [MEDICATION NAME] level (10.0 to 20.0). The physician stated he understood the [MEDICATION NAME] level of 2.5 to be very low so he ordered an increase in the [MEDICATION NAME]. The physicians stated, I doubled what he (Resident #1) was on which was already high. The physician stated there was a miscommunication about the lab result that resulted in the toxicity. When asked if the resident's increased falls in November 2017 were related to the [MEDICATION NAME] toxicity, the physician stated, That's certainly possible. The physician stated [MEDICATION NAME] toxicity could cause loss of balance and visual changes. The physician stated Resident #1 may have not been able to report or verbalize any visual changes associated with the excess [MEDICATION NAME] levels. The physician also stated he had ordered a follow up [MEDICATION NAME] level (due on 11/24/17) and that lab was never done. The physicians stated he was not aware of the [MEDICATION NAME] toxicity until the emergency room findings on 11/28/17 were reported to the facility on [DATE]. On 1/3/18 at 2:40 p.m. the administrator and director of nursing (DON) were interviewed about the [MEDICATION NAME] error with Resident #1. The administrator stated she was made aware of the [MEDICATION NAME] toxicity when adult protective services came to the facility on [DATE] and advised them of the emergency room findings of 11/28/17. The administrator stated the resident did not have a history of frequent falls and the pattern of falls in November 2017 was not typical for Resident #1. The administrator stated when the physician gave the order for the [MEDICATION NAME] level it was entered into the lab system as a free [MEDICATION NAME] level instead of a total [MEDICATION NAME]. The administrator stated this nurse also transcribed the [MEDICATION NAME] order of 11/18/17 wrong onto the resident's medication administration record. The administrator stated there was miscommunication of the lab result on 11/18/17 with the physician thinking the 2.5 level reported was a total [MEDICATION NAME] level instead of a free [MEDICATION NAME] level. The DON stated on 11/26/17 a nurse performing a monthly review of the MAR and physician orders found the [MEDICATION NAME] error listed inaccurately on Resident #1's MAR. The DON stated when this discrepancy was found on 11/26/17 the MAR was corrected and the resident started getting a total of 500 mg of [MEDICATION NAME] per day as originally ordered by the physician on 11/18/17. When asked if the physician was notified when this error was found on 11/26/17 so that [MEDICATION NAME] levels could have been re-checked, the DON had no response. Concerning the repeat [MEDICATION NAME] level ordered and scheduled to be done on 11/24/17, the DON stated this lab test was not done. The DON stated it was listed on the lab sheet but the lab employees stated the entry was illegible so they did not draw blood or complete the test. On 1/4/18 at 10:45 a.m. the DON displayed the options in their lab entry system for [MEDICATION NAME] levels. The DON stated there were three options in the computer system for [MEDICATION NAME]. The options included a [MEDICATION NAME] level, [MEDICATION NAME] Free + total and [MEDICATION NAME] Free. The DON stated if a regular [MEDICATION NAME] level was ordered the nurses should have selected option 1 [MEDICATION NAME] level and not [MEDICATION NAME] Free. The DON stated, There is a big difference in the results. The facility's undated policy titled Medication Administration stated, .The attending physician shall be notified immediately of all significant medication errors .No medication shall be administered unless the nurse is familiar with the pharmacology of the drug, its potential toxic effects and contraindications .Any deviation from the following principles shall be considered a medication error .To the right resident .Administration of the right medication .In the right dose .by the right route .By the right method .At the right time . The Nursing 2017 Drug Handbook on pages 1171 through 1173 described [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to prevent and treat [MEDICAL CONDITION]. This reference lists adverse effects of [MEDICATION NAME] to include decreased coordination and muscle control, mental confusion, slurred speech, dizziness, headache, blurred vision, nausea, vomiting and [MEDICAL CONDITION]. This reference lists nursing considerations for [MEDICATION NAME] administration to include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms per milliliter). The therapeutic range of free [MEDICATION NAME] is 1 to 2 mcg/mL .Alert: Doubling the dose doesn't double the level but may cause toxicity. Consult pharmacist for specific dosing recommendations . (1) These findings were reviewed with the administrator and DON on 1/4/18 at 10:30 a.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to follow professional standards of care for one of three residents in the survey sample (Resident #1). A) An abnormal [MEDICATION NAME] level lab result was inaccurately communicated to the physician. Resident #1's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased when his levels were already high in response to the miscommunicated lab test result. The increased dosage caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in hospitalization for treatment of [REDACTED]. The resident experienced a laceration to his left eyebrow region, ligament injury to the left pinky finger, a laceration to the right middle finger, several bruises/abrasions to his knees and swelling of his face due to repeated falls associated with toxic effects from the high [MEDICATION NAME] levels. There was no evidence of any questioning or verification of the order that increased the resident's [MEDICATION NAME] when a lab result indicated [MEDICATION NAME] levels were already high. In addition, the resident's [MEDICATION NAME] order was inaccurately transcribed onto the medication administration record (MAR) resulting in [MEDICATION NAME] administered for eight days not according to the order. B) Nurses also failed to document and communicate a thorough assessment of Resident #1's laceration to his right middle finger at the time of injury on 11/26/17. The laceration was later assessed by the emergency roiagnom on [DATE] as deep, extending to the joint capsule and as beyond the time frame for sutures. The findings include: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills. This MDS assessed Resident #1 as always continent of bowel/bladder and to require supervision with set up help only for transfers, dressing and toileting. A) Resident #1's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased when his levels were already high in response to a miscommunicated lab test result. The increased dosage caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in hospitalization for treatment of [REDACTED]. The resident experienced a laceration to his left eyebrow region, ligament injury to the left pinky finger, a laceration to the right middle finger, several bruises/abrasions to his knees and swelling of his face due to repeated falls associated with toxic effects from the high [MEDICATION NAME] levels. There was no evidence of any questioning or verification of the order that increased the resident's [MEDICATION NAME] when the lab result indicated [MEDICATION NAME] levels were already high. In addition, the resident's [MEDICATION NAME] order was inaccurately transcribed onto the medication administration record (MAR) resulting in [MEDICATION NAME] administered for eight days not according to the order. Resident #1's clinical record documented a physician's order dated 3/3/17 for [MEDICATION NAME] chew 100 mg (milligrams) to be given twice per day and an order dated 3/3/17 for [MEDICATION NAME] chew 50 mg to be given at 2:00 p.m. each day for treatment/prevention of [MEDICAL CONDITION]. The record documented a physician's order dated 11/15/17 for a [MEDICATION NAME] level to be obtained on 11/16/17. A lab report dated 11/18/17 documented the resident's [MEDICATION NAME] (free) level on 11/16/17 was high at 2.5 mg/L (milligrams per liter) as compared to the reference range of 1.0 to 2.0 mg/L. A nurse documented notification to the physician of the lab results. A telephone order was documented on 11/18/17 increasing Resident #1's [MEDICATION NAME] dosage to 200 mg twice per day and 100 mg at be given at 2:00 p.m. each day in response to the lab test. This order also included instructions to repeat the resident's [MEDICATION NAME] level on 11/24/17. A nursing note dated 11/18/17 documented, (Physician) informed of resident [MEDICATION NAME] level 2.5, order given to give [MEDICATION NAME] 200 mg by mouth every morning and every evening and to give 100 mg by mouth at 2 pm daily. [MEDICATION NAME] level to be checked next week, placed in lab book to check 11/24/17. The order for the increased [MEDICATION NAME] doses was inaccurately entered on the resident's November 2017 medication administration record (MAR). The order for [MEDICATION NAME] 200 mg twice per day was not added to the MAR until 11/26/17. Resident #1 continued to be administered [MEDICATION NAME] 100 mg twice per day from 11/18/17 through 11/25/17. The resident's 2:00 p.m. dose of [MEDICATION NAME] was increased from 50 mg to 100 mg starting on 11/18/17 as ordered. The twice per day 100 mg doses of [MEDICATION NAME] were stopped on 11/25/17 and starting on 11/26/17 the resident was administered [MEDICATION NAME] 200 mg twice per day. The resident's total daily dose of [MEDICATION NAME] progressed as follows: prior to 11/18/17 received 250 mg per day; 11/18/17 through 11/25/17 was given 300 mg per day; 11/26/17 until discharge on [DATE] was given 500 mg per day. The clinical record documented no repeat [MEDICATION NAME] level on 11/24/17 as ordered by the physician. The clinical record documented increased falls for Resident #1 in November 2017 as the [MEDICATION NAME] doses increased. The resident had only one prior fall (on 9/9/17) from January through October of 2017. The resident experienced six falls in November 2017 prior to being sent to the emergency roiagnom on [DATE] following the third fall that day (11/28/17) resulting in a laceration above his left eye. Nursing notes documented the following falls with injuries for Resident #1 during November 2017. 11/7/17 at 6:21 p.m. - Heard a loud noise, went to check to see, found resident in floor, on knees with bedside table overturned with resident over it .Resident has minor scratch on bridge of nose with minor bleeding from left nostril .Applied Band-Aid to bridge of nose . 11/23/17 at 7:11 p.m. - this nurse called to room by cna (certified nurses' aide) feeding residents roommate found him (Resident #1) lying on floor beside his bed with his legs over the trash can assessed no injury .assisted back to bed socks removed and skid socks applied. 11/26/17 at 1:15 p.m. - heard noise in room upon entering the room, observed resident lying on the right side at the foot of the bed, in front of w/c (wheelchair). when asked resident denied falling. laceration noted to right middle finger, cleaned and dressed. no other injuries noted at this time .bruise noted to left hand. able to move wrist and all digits. some [MEDICAL CONDITION] noted to left hand . 11/28/17 at 1:42 p.m. - Was called to residents room and was advised that resident was in floor in the bathroom .resident was sitting in floor in the bathroom with wheelchair sitting at bathroom door. Resident stated that he was attempting to go to the bathroom and got too fast .Resident stated that he was not hurt .No complaint of pain or discomfort . (sic) 11/28/17 at 4:18 p.m. - Heard loud noise .resident was sitting in the floor on roommates side of the room. Resident stated that the chair turned around on him and he fell into the floor . (sic) 11/28/17 at 9:15 p.m. - Resident found on the floor by CNA, call writer to room. Resident observed on the floor with call bell in hand bleeding from what appears to be left eye. Blood also noted to the back of head. facial swelling noted .resident responsive at time of fall and still responsive when sent to ER (emergency room ) .Sent to ER for eval (evaluation) per MD (physician) order. Resident's third fall of the day . Resident #1 was seen by the physician on 11/27/17 for evaluation of the laceration to the right middle finger that occurred on 11/26/17 and the physician's note made no mention of the resident's [MEDICATION NAME] dosage. This progress note dated 11/27/17 documented, I was called over the weekend that (Resident #1) had some falls . He had several additional falls and it was the nurse's opinion that he was putting himself on the floor, not actually falling .Medication administration record is reviewed in chart .Speech is quite garbled. He is generally up in a wheelchair, but has had more falls recently . The physician's note made no mention of the resident's [MEDICATION NAME] levels, inaccurate [MEDICATION NAME] entry on the MAR or the missed [MEDICATION NAME] level lab due on 11/24/17. The facility's investigation of the [MEDICATION NAME] error was not conducted until after the resident's discharge. The investigation included documentation dated 11/29/17 stating, On 11/18/17 orders transcribed to MAR incomplete + lab work illegible on labbook no requisition filled out resulted in residents increased impairment + freq (frequent) falls resulted in resident being admitted to hospital. (sic) A physician's progress note for Resident #1 dated 11/30/17 documented, I received a call from (director of nursing), informing me that several weeks ago I was called about a lab result. I was told the patient's [MEDICATION NAME] Level was very low and I asked if the patient was actually receiving and taking his prescribed dose of 100 mg bid (twice per day). She said he was taking it regularly. I ordered a significant increase in dose and a follow-up [MEDICATION NAME] level, but the order was not taken off and the lab was not done until the patient went to the hospital ER (emergency room ) . Resident #1's emergency room report dated 11/28/17 documented the resident was diagnosed upon arrival with [MEDICATION NAME] toxicity due to an abnormally high [MEDICATION NAME] level. The ER report lab report dated 11/28/17 documented Resident #1's [MEDICATION NAME] level as a critical value measuring 40.6 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The resident was diagnosed with [REDACTED]. The ER history and physical report dated 11/28/17 documented, Pt (patient) arrives to the ED (emergency department) with multiple injuries. Pt has bandaged laceration to the right middle finger. Bruising to the left hand. abrasion under the chin and both knees. Abrasion to the back of the left ear as well as left eye. EMS (emergency medical services) states that nurse states the pts speech is normally slurred however it has worsened tonight .Lab called to report abnormal Dilanton ([MEDICATION NAME]) of 40.6 . The report documented the laceration above the resident's left eye as superficial and measured 1.5 centimeters in length. The note documented the resident had . a deep abrasion on the right middle finger that appears to be old . also has contusion/hematoma of the entire left hand .is able to make a fist with the right hand and the middle finger flexes against resistance, but there is a deep laceration at the PIP (proximal interphalangeal) joint which extends into the joint capsule and the finger can be hyperextended at the PIP joint. The wound will be cleaned, finger splinted and antibiotics given . The resident was admitted to the hospital with [REDACTED]. The laceration above the resident's left eye was cleansed and closed with skin glue. An orthopedic consultation report dated 11/30/17 documented, evidently was admitted with superficial injuries after reported multiple falls . With these falls, apparently, had some other injuries contusion to his face with a 2 cm laceration to the left lateral eyebrow area that was managed in the emergency room . He also apparently had both knees with abrasions, but function intact .attention to the right hand x-rays demonstrated no acute [MEDICAL CONDITION] finger .The wound was not repaired. It was a traverse laceration approximately of 2 cm across the volar (palm) aspect of the proximal interphalangeal joint . Since the wound is at least a good 48 hours post injury, this will heal secondarily requiring no sutures . A physician consultation report dated 12/3/17 documented, .He (Resident #1) was admitted with falls and several orthopedic injuries. This appears to have been secondary to [MEDICATION NAME] toxicity . The resident remained hospitalized from [DATE] until 12/8/17. The hospital discharge summary dated 12/8/17 listed the resident's primary [DIAGNOSES REDACTED]. This summary report documented, .He (Resident #1) presented to the hospital with reported multiple falls at the local nursing home resulting in multiple abrasions and bruises as well as a 1.5 cm simple laceration to the left lateral eye brow region . His [MEDICATION NAME] level was checked and it was found to be significantly elevated at 32 (on 11/29/17) (reference range is 10 - 20) . He was admitted with [MEDICATION NAME] toxicity. His gait instability was likely related to this. [MEDICATION NAME] was discontinued and levels were checked until it trended back close to normal . Further review of Resident #1's clinical record revealed no physician's order at the facility for a free [MEDICATION NAME] level. Resident #1's plan of care (revised 7/26/17) documented prior to November the resident required minimal assistance with activities of daily living. This care plan stated the resident had potential for injury due to history of [MEDICAL CONDITION]. Interventions for [MEDICAL CONDITION] prevention included, Administer medications as ordered by the physician .Monitor for adverse side effects of medication, i.e., headache, drowsiness, [MEDICAL CONDITION], anxiety depression, [MEDICAL CONDITION], blurred vision, diplopia (double vision), dizziness, numbness, ataxia (poor muscle coordination), tremor, nausea, vomiting, diarrhea, gingival [MEDICAL CONDITION], and rash and notify physician for evaluation and intervention .Obtain and monitor serum anticonvulsant medication levels as ordered and notify physician of results . The nurse that communicated the resident's [MEDICATION NAME] lab test to the physician on 11/18/17 and inaccurately entered the [MEDICATION NAME] order on the MAR was not available for interview as she no longer worked at the facility. On 1/3/18 at 2:00 p.m. the licensed practical nurse (LPN #1) that worked on Resident #1's living unit was interviewed. LPN #1 stated Resident #1 routinely propelled himself around the facility and was alert and active. LPN #1 stated prior to November 2017 the resident had no history of frequent falls and the resident was able to make his needs known. On 1/3/18 at 2:15 p.m. the resident's physician was interviewed about the diagnosed [MEDICATION NAME] toxicity and associated injuries related to increased falls. The physician stated he was called by the nurse working on 11/18/17 and advised that the resident's [MEDICATION NAME] level was 2.5. The physician stated he had ordered a regular [MEDICATION NAME] level and not a free [MEDICATION NAME] level. The physician stated the normal range for regular [MEDICATION NAME] was 10 to 20 so he understood the resident's [MEDICATION NAME] level was low. The physician stated he asked the nurse if the resident had been taking his current dose of [MEDICATION NAME] as ordered and the nurse advised that the resident was routinely taking medications as ordered. The physician stated the nurse never told him that the lab result of 2.5 was a free [MEDICATION NAME] level so he thought the result was a regular [MEDICATION NAME] level. The physician stated the normal ranges were very different for a free [MEDICATION NAME] (1.0 to 2.0) as compared to a regular [MEDICATION NAME] level (10.0 to 20.0). The physician stated he understood the [MEDICATION NAME] level of 2.5 to be very low so he ordered an increase in the [MEDICATION NAME]. The physicians stated, I doubled what he (Resident #1) was on which was already high. The physician stated there was a miscommunication about the lab result that resulted in the toxicity. When asked if the resident's increased falls in November 2017 were related to the [MEDICATION NAME] toxicity, the physician stated, That's certainly possible. The physician stated [MEDICATION NAME] toxicity could cause loss of balance and visual changes. The physician stated Resident #1 may have not been able to report or verbalize any visual changes associated with the excess [MEDICATION NAME] levels. The physician also stated he had ordered a follow up [MEDICATION NAME] level (due on 11/24/17) and that lab was never done. The physicians stated he was not aware of the [MEDICATION NAME] toxicity until the emergency room findings on 11/28/17 were reported to the facility on [DATE]. On 1/3/18 at 2:40 p.m. the administrator and director of nursing (DON) were interviewed about the [MEDICATION NAME] error with Resident #1. The administrator stated she was made aware of the [MEDICATION NAME] toxicity when adult protective services came to the facility on [DATE] and advised them of the emergency room findings of 11/28/17. The administrator stated the resident did not have a history of frequent falls and the pattern of falls in November 2017 was not typical for Resident #1. The administrator stated when the physician gave the order for the [MEDICATION NAME] level it was entered into the lab system as a free [MEDICATION NAME] level instead of a total [MEDICATION NAME]. The administrator stated this nurse also transcribed the [MEDICATION NAME] order of 11/18/17 inaccurately onto the resident's medication administration record. The administrator stated there was miscommunication of the lab result on 11/18/17 with the physician thinking the 2.5 level reported was a total [MEDICATION NAME] level instead of a free [MEDICATION NAME] level. The DON stated on 11/26/17 a nurse performing a monthly review of the MAR and physician orders found the [MEDICATION NAME] error listed inaccurately on Resident #1's MAR. The DON stated when this discrepancy was found on 11/26/17 the MAR was corrected and the resident started getting a total of 500 mg of [MEDICATION NAME] per day as originally ordered by the physician on 11/18/17. When asked if the physician was notified when this error was found on 11/26/17 so that [MEDICATION NAME] levels could have been re-checked, the DON had no response. Concerning the repeat [MEDICATION NAME] level ordered and scheduled to be done on 11/24/17, the DON stated this lab test was not done. The DON stated it was listed on the lab sheet but the lab employees stated the entry was illegible so they did not draw blood or complete the test. On 1/4/18 at 10:45 a.m. the DON displayed the options in their lab entry system for [MEDICATION NAME] levels. The DON stated there were three options in the computer system for [MEDICATION NAME]. The options included a [MEDICATION NAME] level, [MEDICATION NAME] Free + total and [MEDICATION NAME] Free. The DON stated if a regular [MEDICATION NAME] level was ordered the nurses should have selected option 1 [MEDICATION NAME] level and not [MEDICATION NAME] Free. The DON stated, There is a big difference in the results. The facility's undated policy titled Medication Administration stated, .The attending physician shall be notified immediately of all significant medication errors .No medication shall be administered unless the nurse is familiar with the pharmacology of the drug, its potential toxic effects and contraindications .Any deviation from the following principles shall be considered a medication error .To the right resident .Administration of the right medication .In the right dose .by the right route .By the right method .At the right time . The Nursing 2017 Drug Handbook on pages 1171 through 1173 described [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to prevent and treat [MEDICAL CONDITION]. This reference lists adverse effects of [MEDICATION NAME] to include decreased coordination and muscle control, mental confusion, slurred speech, dizziness, headache, blurred vision, nausea, vomiting and [MEDICAL CONDITION]. This reference lists nursing considerations for [MEDICATION NAME] administration to include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms per milliliter). The therapeutic range of free [MEDICATION NAME] is 1 to 2 mcg/mL .Alert: Doubling the dose doesn't double the level but may cause toxicity. Consult pharmacist for specific dosing recommendations . (1) B) Nurses failed to document and communicate a thorough assessment of Resident #1's laceration to his right middle finger at the time of injury. The laceration was assessed by the physician on 11/27/17 as not suitable for sutures because of swelling and risk of infection due to length of time since the actual injury. The laceration was assessed at the emergency roiagnom on [DATE] as deep, extending to the joint capsule and as beyond the time frame for sutures. Resident #1's clinical record documented a nursing note dated 11/26/17 at 1:15 p.m. stating, heard noise in room upon entering the room, observed resident lying on the right side at the foot of the bed, in front of w/c (wheelchair). when asked resident denied falling. laceration noted to right middle finger, cleaned and dressed. no other injuries noted at this time .bruise noted to left hand. able to move wrist and all digits. some [MEDICAL CONDITION] noted to left hand . The note stated the physician and responsible party were notified. There was no documented assessment of the finger laceration in Resident #1's clinical record other than laceration noted to right middle finger. The nursing notes and fall incident report dated 11/26/17 documented no description indicating the exact location, length, depth or appearance of the laceration. The fall incident report dated 11/26/17 documented only, laceration noted on right middle finger . A skin condition flowsheet dated 11/27/17 documented, resident has a laceration noted to the right third finger. This assessment sheet documented no exact location, length, depth, appearance or description of the cut. A physician's progress note dated 11/27/17 documented the resident had a laceration to the palm surface of the right middle finger that had been previously dressed by nursing. This note stated, There is a laceration [MEDICATION NAME] across the palmar surface of the proximal phalanx. There is no active bleeding or drainage. The margins are separated a few mm (millimeters) due to the swelling, but no surrounding redness or sign of infection . As swelling developed the margins have separated, but were not seen under the dressing. It does not appear to be infected yet, but likely will be infected and beyond the time frame for suturing . The resident was sent to the emergency room (ER) on 11/28/17 following multiple falls. The ER report dated 111/28/17 documented, .has a deep abrasion on the right middle finger that appears to be old . is able to make a fist with the right hand and the middle finger flexes against resistance, but there is a deep laceration at the PIP (proximal interphalangeal) joint which extends into the joint capsule and the finger can be hyperextended at the PIP joint. The wound will be cleaned, finger splinted and antibiotics given . An orthopedic report dated 11/30/17 documented, .a [MEDICATION NAME] laceration approximately of 2 cm (centimeters) across the volar (palm) aspect of the proximal interphalangeal joint .Since the wound is at least a good 48 hours post injury, this will heal secondarily requiring no sutures . On 1/3/18 at 2:15 p.m. the resident's physician was interviewed about Resident #1's right middle finger laceration. The physician stated a nurse called him and advised him the resident cut his finger during a fall on 11/26/17. The physician stated he was not made aware of the degree or depth of the laceration. The physician stated when he evaluated the laceration the next day on 11/27/17 the edges of the wound were separated and swelling was present. The physician stated since the laceration was a day old it was too late to put in sutures due to a risk for infection. On 1/3/18 at 2:40 p.m. the director of nursing (DON) was interviewed about a documented, thorough assessment of Resident #1's finger laceration. The DON reviewed the nursing note and wound treatment record and stated there was no documentation describing the laceration other than it was on the right middle finger. The DON stated a thorough description of the laceration should have been included in the clinical record, on the wound flow sheet and communicated to the physician at the time of the injury. The DON stated the depth, length and extent of Resident #1's right middle finger laceration was not known by what was documented in the notes. The nurse caring for Resident #1 on 11/26/17 at the time of the injury was not available for interview as she no longer worked at the facility. The Lippincott Manual of Nursing Practice 10th edition states on pages 16 and 17 concerning standards of care, A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events .Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders that should have been question or not followed, such as orders containing medication dosage errors. (2) These findings were reviewed with the administrator and DON on 1/4/18 at 10:30 a.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017. (2) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure one of three residents in the survey sample was free from a significant medication error (Resident #1). Resident #1's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased when his [MEDICATION NAME] levels were already high in response to a miscommunicated lab test result. The increased dosage caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in hospitalization for treatment of [REDACTED]. The resident experienced a laceration to his left eyebrow region, ligament injury to the left pinky finger, a laceration to the right middle finger, several bruises/abrasions to his knees and swelling of his face due to repeated falls associated with toxic effects from the high [MEDICATION NAME] levels. The findings include: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills. This MDS assessed Resident #1 as always continent of bowel/bladder and to require supervision with set up help only for transfers, dressing and toileting. Resident #1's clinical record documented a physician's order dated 3/3/17 for [MEDICATION NAME] chew 100 mg (milligrams) to be given twice per day and an order dated 3/3/17 for [MEDICATION NAME] chew 50 mg to be given at 2:00 p.m. each day for treatment/prevention of [MEDICAL CONDITION]. The record documented a physician's order dated 11/15/17 for a [MEDICATION NAME] level to be obtained on 11/16/17. A lab report dated 11/18/17 documented the resident's [MEDICATION NAME] (free) level on 11/16/17 was high at 2.5 mg/L (milligrams per liter) as compared to the reference range of 1.0 to 2.0 mg/L. A nurse documented notification to the physician of the lab results. A telephone order was documented on 11/18/17 increasing Resident #1's [MEDICATION NAME] dosage to 200 mg twice per day and 100 mg at be given at 2:00 p.m. each day in response to the lab test. This order also included instructions to repeat the resident's [MEDICATION NAME] level on 11/24/17. A nursing note dated 11/18/17 documented, (Physician) informed of resident [MEDICATION NAME] level 2.5, order given to give [MEDICATION NAME] 200 mg by mouth every morning and every evening and to give 100 mg by mouth at 2 pm daily. [MEDICATION NAME] level to be checked next week, placed in lab book to check 11/24/17. The order for the increased [MEDICATION NAME] doses was inaccurately entered on the resident's November 2017 medication administration record (MAR). The order for [MEDICATION NAME] 200 mg twice per day was not added to the MAR until 11/26/17. Resident #1 continued to be administered [MEDICATION NAME] 100 mg twice per day from 11/18/17 through 11/25/17. The resident's 2:00 p.m. dose of [MEDICATION NAME] was increased from 50 mg to 100 mg starting on 11/18/17 as ordered. The twice per day 100 mg doses of [MEDICATION NAME] were stopped on 11/25/17 and starting on 11/26/17 the resident was administered [MEDICATION NAME] 200 mg twice per day. The resident's total daily dose of [MEDICATION NAME] progressed as follows: prior to 11/18/17 received 250 mg per day; 11/18/17 through 11/25/17 was given 300 mg per day; 11/26/17 until discharge on [DATE] was given 500 mg per day. The clinical record documented no repeat [MEDICATION NAME] level on 11/24/17 as ordered by the physician. The clinical record documented increased falls for Resident #1 in November 2017 as the [MEDICATION NAME] doses increased. The resident had only one prior fall (on 9/9/17) from January through October of 2017. The resident experienced six falls in November 2017 prior to being sent to the emergency roiagnom on [DATE] following the third fall that day resulting in a laceration above his left eye. Nursing notes documented the following falls with injuries for Resident #1 during November 2017. 11/7/17 at 6:21 p.m. - Heard a loud noise, went to check to see, found resident in floor, on knees with bedside table overturned with resident over it .Resident has minor scratch on bridge of nose with minor bleeding from left nostril .Applied Band-Aid to bridge of nose . 11/23/17 at 7:11 p.m. - this nurse called to room by cna (certified nurses' aide) feeding residents roommate found him (Resident #1) lying on floor beside his bed with his legs over the trash can assessed no injury .assisted back to bed socks removed and skid socks applied. 11/26/17 at 1:15 p.m. - heard noise in room upon entering the room, observed resident lying on the right side at the foot of the bed, in front of w/c (wheelchair). when asked resident denied falling. laceration noted to right middle finger, cleaned and dressed. no other injuries noted at this time .bruise noted to left hand. able to move wrist and all digits. some [MEDICAL CONDITION] noted to left hand . 11/28/17 at 1:42 p.m. - Was called to residents room and was advised that resident was in floor in the bathroom .resident was sitting in floor in the bathroom with wheelchair sitting at bathroom door. Resident stated that he was attempting to go to the bathroom and got too fast .Resident stated that he was not hurt .No complaint of pain or discomfort . (sic) 11/28/17 at 4:18 p.m. - Heard loud noise .resident was sitting in the floor on roommates side of the room. Resident stated that the chair turned around on him and he fell into the floor . (sic) 11/28/17 at 9:15 p.m. - Resident found on the floor by CNA, call writer to room. Resident observed on the floor with call bell in hand bleeding from what appears to be left eye. Blood also noted to the back of head. facial swelling noted .resident responsive at time of fall and still responsive when sent to ER (emergency room ) .Sent to ER for eval (evaluation) per MD (physician) order. Resident's third fall of the day . Resident #1 was seen by the physician on 11/27/17 for evaluation of the laceration to the right middle finger that occurred on 11/26/17 and the physician's note made no mention of the resident's [MEDICATION NAME] dosage. This progress note dated 11/27/17 documented, I was called over the weekend that (Resident #1) had some falls . He had several additional falls and it was the nurse's opinion that he was putting himself on the floor, not actually falling .Medication administration record is reviewed in chart .Speech is quite garbled. He is generally up in a wheelchair, but has had more falls recently . The physician's note made no mention of the resident's [MEDICATION NAME] levels, inaccurate [MEDICATION NAME] entry on the MAR or the missed [MEDICATION NAME] level lab due on 11/24/17. The facility's investigation of the [MEDICATION NAME] error was not conducted until after the resident's discharge. The investigation included documentation dated 11/29/17 stating, On 11/18/17 orders transcribed to MAR incomplete + lab work illegible on labbook no requisition filled out resulted in residents increased impairment + freq (frequent) falls resulted in resident being admitted to hospital. (sic) A physician's progress note for Resident #1 dated 11/30/17 documented, I received a call from (director of nursing), informing me that several weeks ago I was called about a lab result. I was told the patient's [MEDICATION NAME] Level was very low and I asked if the patient was actually receiving and taking his prescribed dose of 100 mg bid (twice per day). She said he was taking it regularly. I ordered a significant increase in dose and a follow-up [MEDICATION NAME] level, but the order was not taken off and the lab was not done until the patient went to the hospital ER (emergency room ) . Resident #1's emergency room report dated 11/28/17 documented the resident was diagnosed upon arrival with [MEDICATION NAME] toxicity due to an abnormally high [MEDICATION NAME] level. The ER report lab report dated 11/28/17 documented Resident #1's [MEDICATION NAME] level as a critical value measuring 40.6 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The resident was diagnosed with [REDACTED]. The ER history and physical report dated 11/28/17 documented, Pt (patient) arrives to the ED (emergency department) with multiple injuries. Pt has bandaged laceration to the right middle finger. Bruising to the left hand. abrasion under the chin and both knees. Abrasion to the back of the left ear as well as left eye. EMS (emergency medical services) states that nurse states the pts speech is normally slurred however it has worsened tonight .Lab called to report abnormal Dilanton ([MEDICATION NAME]) of 40.6 . The report documented the laceration above the resident's left eye as superficial and measured 1.5 centimeters in length. The note documented the resident had . a deep abrasion on the right middle finger that appears to be old . also has contusion/hematoma of the entire left hand .is able to make a fist with the right hand and the middle finger flexes against resistance, but there is a deep laceration at the PIP (proximal interphalangeal) joint which extends into the joint capsule and the finger can be hyperextended at the PIP joint. The wound will be cleaned, finger splinted and antibiotics given . The resident was admitted to the hospital with [REDACTED]. The laceration above the resident's left eye was cleansed and closed with skin glue. An orthopedic consultation report dated 11/30/17 documented, evidently was admitted with superficial injuries after reported multiple falls . With these falls, apparently, had some other injuries contusion to his face with a 2 cm laceration to the left lateral eyebrow area that was managed in the emergency room . He also apparently had both knees with abrasions, but function intact .attention to the right hand x-rays demonstrated no acute [MEDICAL CONDITION] finger .The wound was not repaired. It was a traverse laceration approximately of 2 cm across the volar (palm) aspect of the proximal interphalangeal joint . Since the wound is at least a good 48 hours post injury, this will heal secondarily requiring no sutures . A physician consultation report dated 12/3/17 documented, .He (Resident #1) was admitted with falls and several orthopedic injuries. This appears to have been secondary to [MEDICATION NAME] toxicity . The resident remained hospitalized from [DATE] until 12/8/17. The hospital discharge summary dated 12/8/17 listed the resident's primary [DIAGNOSES REDACTED]. This summary report documented, .He (Resident #1) presented to the hospital with reported multiple falls at the local nursing home resulting in multiple abrasions and bruises as well as a 1.5 cm simple laceration to the left lateral eye brow region .His [MEDICATION NAME] level was checked and it was found to be significantly elevated at 32 (on 11/29/17) (reference range is 10 - 20) . He was admitted with [MEDICATION NAME] toxicity. His gait instability was likely related to this. [MEDICATION NAME] was discontinued and levels were checked until it trended back close to normal . Further review of Resident #1's clinical record reveal no physician's order for a free [MEDICATION NAME] level. Resident #1's plan of care (revised 7/26/17) documented prior to November the resident required minimal assistance with activities of daily living. This care plan stated the resident had potential for injury due to history of [MEDICAL CONDITION]. Interventions for [MEDICAL CONDITION] prevention included, Administer medications as ordered by the physician .Monitor for adverse side effects of medication, i.e., headache, drowsiness, [MEDICAL CONDITION], anxiety depression, [MEDICAL CONDITION], blurred vision, diplopia (double vision), dizziness, numbness, ataxia (poor muscle coordination), tremor, nausea, vomiting, diarrhea, gingival [MEDICAL CONDITION], and rash and notify physician for evaluation and intervention .Obtain and monitor serum anticonvulsant medication levels as ordered and notify physician of results . The nurse that communicated the resident's [MEDICATION NAME] lab test to the physician on 11/18/17 and inaccurately entered the [MEDICATION NAME] order on the MAR was not available for interview as she no longer worked at the facility. On 1/3/18 at 2:00 p.m. the licensed practical nurse (LPN #1) that worked on Resident #1's living unit was interviewed. LPN #1 stated Resident #1 routinely propelled himself around the facility and was alert and active. LPN #1 stated prior to November 2017 the resident had no history of frequent falls and the resident was able to make his needs known. On 1/3/18 at 2:15 p.m. the resident's physician was interviewed about the diagnosed [MEDICATION NAME] toxicity and associated injuries related to increased falls. The physician stated he was called by the nurse working on 11/18/17 and advised that the resident's [MEDICATION NAME] level was 2.5. The physician stated he had ordered a regular [MEDICATION NAME] level and not a free [MEDICATION NAME] level. The physician stated the normal range for regular [MEDICATION NAME] was 10 to 20 so he understood the resident's [MEDICATION NAME] level was low. The physician stated he asked the nurse if the resident had been taking his current dose of [MEDICATION NAME] as ordered and the nurse advised that the resident was routinely taking medications as ordered. The physician stated the nurse never told him that the lab result of 2.5 was a free [MEDICATION NAME] level so he thought the result was a regular [MEDICATION NAME] level. The physician stated the normal ranges were very different for a free [MEDICATION NAME] (1.0 to 2.0) as compared to a regular [MEDICATION NAME] level (10.0 to 20.0). The physician stated he understood the [MEDICATION NAME] level of 2.5 to be very low so he ordered an increase in the [MEDICATION NAME]. The physicians stated, I doubled what he (Resident #1) was on which was already high. The physician stated there was a miscommunication about the lab result that resulted in the toxicity. When asked if the resident's increased falls in November 2017 were related to the [MEDICATION NAME] toxicity, the physician stated, That's certainly possible. The physician stated [MEDICATION NAME] toxicity could cause loss of balance and visual changes. The physician stated Resident #1 may have not been able to report or verbalize any visual changes associated with the excess [MEDICATION NAME] levels. The physician also stated he had ordered a follow up [MEDICATION NAME] level (due on 11/24/17) and that lab was never done. The physicians stated he was not aware of the [MEDICATION NAME] toxicity until the emergency room findings on 11/28/17 were reported to the facility on [DATE]. On 1/3/18 at 2:40 p.m. the administrator and director of nursing (DON) were interviewed about the [MEDICATION NAME] error with Resident #1. The administrator stated she was made aware of the [MEDICATION NAME] toxicity when adult protective services came to the facility on [DATE] and advised them of the emergency room findings of 11/28/17. The administrator stated the resident did not have a history of frequent falls and the pattern of falls in November 2017 was not typical for Resident #1. The administrator stated when the physician gave the order for the [MEDICATION NAME] level it was entered into the lab system as a free [MEDICATION NAME] level instead of a total [MEDICATION NAME]. The administrator stated this nurse also transcribed the [MEDICATION NAME] order of 11/18/17 wrong onto the resident's medication administration record. The administrator stated there was miscommunication of the lab result on 11/18/17 with the physician thinking the 2.5 level reported was a total [MEDICATION NAME] level instead of a free [MEDICATION NAME] level. The DON stated on 11/26/17 a nurse performing a monthly review of the MAR and physician orders found the [MEDICATION NAME] error listed inaccurately on Resident #1's MAR. The DON stated when this discrepancy was found on 11/26/17 the MAR was corrected and the resident started getting a total of 500 mg of [MEDICATION NAME] per day as originally ordered by the physician on 11/18/17. When asked if the physician was notified when this error was found on 11/26/17 so that [MEDICATION NAME] levels could have been re-checked, the DON had no response. Concerning the repeat [MEDICATION NAME] level ordered and scheduled to be done on 11/24/17, the DON stated this lab test was not done. The DON stated it was listed on the lab sheet but the lab employees stated the entry was illegible so they did not draw blood or complete the test. On 1/4/18 at 10:45 a.m. the DON displayed the options in their lab entry system for [MEDICATION NAME] levels. The DON stated there were three options in the computer system for [MEDICATION NAME]. The options included a [MEDICATION NAME] level, [MEDICATION NAME] Free + total and [MEDICATION NAME] Free. The DON stated if a regular [MEDICATION NAME] level was ordered the nurses should have selected option 1 [MEDICATION NAME] level and not [MEDICATION NAME] Free. The DON stated, There is a big difference in the results. The facility's undated policy titled Medication Administration stated, .The attending physician shall be notified immediately of all significant medication errors .No medication shall be administered unless the nurse is familiar with the pharmacology of the drug, its potential toxic effects and contraindications .Any deviation from the following principles shall be considered a medication error .To the right resident .Administration of the right medication .In the right dose .by the right route .By the right method .At the right time . The Nursing 2017 Drug Handbook on pages 1171 through 1173 described [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to prevent and treat [MEDICAL CONDITION]. This reference lists adverse effects of [MEDICATION NAME] to include decreased coordination and muscle control, mental confusion, slurred speech, dizziness, headache, blurred vision, nausea, vomiting and [MEDICAL CONDITION]. This reference lists nursing considerations for [MEDICATION NAME] administration to include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms per milliliter). The therapeutic range of free [MEDICATION NAME] is 1 to 2 mcg/mL .Alert: Doubling the dose doesn't double the level but may cause toxicity. Consult pharmacist for specific dosing recommendations . (1) These findings were reviewed with the administrator and DON on 1/4/18 at 10:30 a.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to immediately notify the physician of a medication error involving [MEDICATION NAME] for one of three residents in the survey sample (Resident #1). Dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased in response to a miscommunicated lab test result. A dosage error with the ordered [MEDICATION NAME] increase discovered on 11/26/17 was not reported to the physician. The continued [MEDICATION NAME] administration caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in hospitalization for treatment of [REDACTED]. The resident experienced a laceration to his left eyebrow region, ligament injury to the left pinky finger, a laceration to the right middle finger, several bruises/abrasions to his knees and swelling of his face due to repeated falls associated with toxic effects from the high [MEDICATION NAME] levels. The findings include: Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills. This MDS assessed Resident #1 as always continent of bowel/bladder and to require supervision with set up help only for transfers, dressing and toileting. Resident #1's clinical record documented a physician's order dated 3/3/17 for [MEDICATION NAME] chew 100 mg (milligrams) to be given twice per day and an order dated 3/3/17 for [MEDICATION NAME] chew 50 mg to be given at 2:00 p.m. each day for treatment/prevention of [MEDICAL CONDITION]. The record documented a physician's order dated 11/15/17 for a [MEDICATION NAME] level to be obtained on 11/16/17. A lab report dated 11/18/17 documented the resident's [MEDICATION NAME] (free) level on 11/16/17 was high at 2.5 mg/L (milligrams per liter) as compared to the reference range of 1.0 to 2.0 mg/L. A nurse documented notification to the physician of the lab results. A telephone order was documented on 11/18/17 increasing Resident #1's [MEDICATION NAME] dosage to 200 mg twice per day and 100 mg at be given at 2:00 p.m. each day in response to the lab test. This order also included instructions to repeat the resident's [MEDICATION NAME] level on 11/24/17. A nursing note dated 11/18/17 documented, (Physician) informed of resident [MEDICATION NAME] level 2.5, order given to give [MEDICATION NAME] 200 mg by mouth every morning and every evening and to give 100 mg by mouth at 2 pm daily. [MEDICATION NAME] level to be checked next week, placed in lab book to check 11/24/17. There was no documentation of any verification or questioning of the physician order obtained on 11/18/17 to increase Resident #1's [MEDICATION NAME] when the lab report stated the resident's [MEDICATION NAME] level was already high. The order for the increased [MEDICATION NAME] was inaccurately entered on the resident's November 2017 medication administration record (MAR). The order for [MEDICATION NAME] 200 mg twice per day was not added to the MAR until 11/26/17. Resident #1 continued to be administered [MEDICATION NAME] 100 mg twice per day from 11/18/17 through 11/25/17. The resident's 2:00 p.m. dose of [MEDICATION NAME] was increased from 50 mg to 100 mg starting on 11/18/17 as ordered. The twice per day 100 mg doses of [MEDICATION NAME] were stopped on 11/25/17 and starting on 11/26/17 the resident was administered [MEDICATION NAME] 200 mg twice per day. The resident's total daily dose of [MEDICATION NAME] progressed as follows: prior to 11/18/17 received 250 mg per day; 11/18/17 through 11/25/17 was given 300 mg per day; 11/26/17 until discharge on [DATE] was given 500 mg per day. There was no notification to the physician concerning Resident #1's [MEDICATION NAME] not administered as ordered when discovered on 11/26/17. The correction was made on the MAR without notification to the physician and the resident was administered a total of 500 mg of [MEDICATION NAME] daily starting on 11/26/17. The clinical record documented no repeat [MEDICATION NAME] level on 11/24/17 as ordered by the physician. There was no recognition or mention of the missed lab in the clinical record until after the resident's discharge to the hospital on [DATE]. The clinical record documented increased falls for Resident #1 in November 2017 as the [MEDICATION NAME] doses increased. The resident had experienced only one prior fall (on 9/9/17) from January through October of 2017. The resident experienced six falls in November 2017 prior to being sent to the emergency roiagnom on [DATE] following the third fall that day (11/28/17) resulting in a laceration above his left eye. Nursing notes documented the following falls with injuries for Resident #1 during November 2017. 11/7/17 at 6:21 p.m. - Heard a loud noise, went to check to see, found resident in floor, on knees with bedside table overturned with resident over it .Resident has minor scratch on bridge of nose with minor bleeding from left nostril .Applied Band-Aid to bridge of nose . 11/23/17 at 7:11 p.m. - this nurse called to room by cna (certified nurses' aide) feeding residents roommate found him (Resident #1) lying on floor beside his bed with his legs over the trash can assessed no injury .assisted back to bed socks removed and skid socks applied.(sic) 11/26/17 at 1:15 p.m. - heard noise in room upon entering the room, observed resident lying on the right side at the foot of the bed, in front of w/c (wheelchair). when asked resident denied falling. laceration noted to right middle finger, cleaned and dressed. no other injuries noted at this time .bruise noted to left hand. able to move wrist and all digits. some [MEDICAL CONDITION] noted to left hand . 11/28/17 at 1:42 p.m. - Was called to residents room and was advised that resident was in floor in the bathroom .resident was sitting in floor in the bathroom with wheelchair sitting at bathroom door. Resident stated that he was attempting to go to the bathroom and got too fast .Resident stated that he was not hurt .No complaint of pain or discomfort . (sic) 11/28/17 at 4:18 p.m. - Heard loud noise .resident was sitting in the floor on roommates side of the room. Resident stated that the chair turned around on him and he fell into the floor . (sic) 11/28/17 at 9:15 p.m. - Resident found on the floor by CNA, call writer to room. Resident observed on the floor with call bell in hand bleeding from what appears to be left eye. Blood also noted to the back of head. facial swelling noted .resident responsive at time of fall and still responsive when sent to ER (emergency room ) .Sent to ER for eval (evaluation) per MD (physician) order. Resident's third fall of the day . Resident #1 was seen by the physician on 11/27/17 for evaluation of the laceration to the right middle finger that occurred on 11/26/17. The physician's note made no mention of the resident's [MEDICATION NAME] dosage. This progress note dated 11/27/17 documented, I was called over the weekend that (Resident #1) had some falls . He had several additional falls and it was the nurse's opinion that he was putting himself on the floor, not actually falling . Medication administration record is reviewed in chart . Speech is quite garbled. He is generally up in a wheelchair, but has had more falls recently . The physician's note made no mention of the resident's [MEDICATION NAME] levels, inaccurate [MEDICATION NAME] administration documented on the MAR or the missed [MEDICATION NAME] level lab due on 11/24/17. The facility's investigation of the [MEDICATION NAME] error was not conducted until after the resident's discharge. The investigation included documentation dated 11/29/17 stating, On 11/18/17 orders transcribed to MAR incomplete + lab work illegible on labbook no requisition filled out resulted in residents increased impairment + freq (frequent) falls resulted in resident being admitted to hospital. (sic) A physician's progress note for Resident #1 dated 11/30/17 documented, I received a call from (director of nursing), informing me that several weeks ago I was called about a lab result. I was told the patient's [MEDICATION NAME] Level was very low and I asked if the patient was actually receiving and taking his prescribed dose of 100 mg bid (twice per day). She said he was taking it regularly. I ordered a significant increase in dose and a follow-up [MEDICATION NAME] level, but the order was not taken off and the lab was not done until the patient went to the hospital ER (emergency room ) . Resident #1's emergency room report dated 11/28/17 documented the resident was diagnosed upon arrival with [MEDICATION NAME] toxicity due to an abnormally high [MEDICATION NAME] level. The ER report lab report dated 11/28/17 documented Resident #1's [MEDICATION NAME] level as a critical value measuring 40.6 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The resident was diagnosed with [REDACTED]. The ER history and physical report dated 11/28/17 documented, Pt (patient) arrives to the ED (emergency department) with multiple injuries. Pt has bandaged laceration to the right middle finger. Bruising to the left hand. abrasion under the chin and both knees. Abrasion to the back of the left ear as well as left eye. EMS (emergency medical services) states that nurse states the pts speech is normally slurred however it has worsened tonight .Lab called to report abnormal Dilanton ([MEDICATION NAME]) of 40.6 . The report documented the laceration above the resident's left eye as superficial and measured 1.5 centimeters in length. The note documented the resident had . a deep abrasion on the right middle finger that appears to be old . also has contusion/hematoma of the entire left hand .is able to make a fist with the right hand and the middle finger flexes against resistance, but there is a deep laceration at the PIP (proximal interphalangeal) joint which extends into the joint capsule and the finger can be hyperextended at the PIP joint. The wound will be cleaned, finger splinted and antibiotics given . The resident was admitted to the hospital with [REDACTED]. The laceration above the resident's left eye was cleansed and closed with skin glue. An orthopedic consultation report dated 11/30/17 documented, evidently was admitted with superficial injuries after reported multiple falls . With these falls, apparently, had some other injuries contusion to his face with a 2 cm laceration to the left lateral eyebrow area that was managed in the emergency room . He also apparently had both knees with abrasions, but function intact .attention to the right hand x-rays demonstrated no acute [MEDICAL CONDITION] finger .The wound was not repaired. It was a traverse laceration approximately of 2 cm across the volar (palm) aspect of the proximal interphalangeal joint . Since the wound is at least a good 48 hours post injury, this will heal secondarily requiring no sutures . A physician consultation report dated 12/3/17 documented, .He (Resident #1) was admitted with falls and several orthopedic injuries. This appears to have been secondary to [MEDICATION NAME] toxicity . The resident remained hospitalized from [DATE] until 12/8/17. The hospital discharge summary dated 12/8/17 listed the resident's primary [DIAGNOSES REDACTED]. This summary report documented, .He (Resident #1) presented to the hospital with reported multiple falls at the local nursing home resulting in multiple abrasions and bruises as well as a 1.5 cm simple laceration to the left lateral eye brow region .His [MEDICATION NAME] level was checked and it was found to be significantly elevated at 32 (on 11/29/17) (reference range is 10 - 20) . He was admitted with [MEDICATION NAME] toxicity. His gait instability was likely related to this. [MEDICATION NAME] was discontinued and levels were checked until it trended back close to normal . Further review of Resident #1's clinical record revealed no physician's order at the facility for a free [MEDICATION NAME] level. Resident #1's plan of care (revised 7/26/17) documented prior to November the resident required minimal assistance with activities of daily living. This care plan stated the resident had potential for injury due to history of [MEDICAL CONDITION]. Interventions for [MEDICAL CONDITION] prevention included, Administer medications as ordered by the physician .Monitor for adverse side effects of medication, i.e., headache, drowsiness, [MEDICAL CONDITION], anxiety depression, [MEDICAL CONDITION], blurred vision, diplopia (double vision), dizziness, numbness, ataxia (poor muscle coordination), tremor, nausea, vomiting, diarrhea, gingival [MEDICAL CONDITION], and rash and notify physician for evaluation and intervention .Obtain and monitor serum anticonvulsant medication levels as ordered and notify physician of results . The nurse that communicated the resident's [MEDICATION NAME] lab test to the physician on 11/18/17 and inaccurately entered the [MEDICATION NAME] order on the MAR was not available for interview as she no longer worked at the facility. On 1/3/18 at 2:00 p.m. the licensed practical nurse (LPN #1) that worked on Resident #1's living unit was interviewed. LPN #1 stated Resident #1 routinely propelled himself around the facility and was alert and active. LPN #1 stated prior to November 2017 the resident had no history of frequent falls and the resident was able to make his needs known. On 1/3/18 at 2:15 p.m. the resident's physician was interviewed about the diagnosed [MEDICATION NAME] toxicity and associated injuries related to increased falls. The physician stated he was called by the nurse working on 11/18/17 and advised that the resident's [MEDICATION NAME] level was 2.5. The physician stated he had ordered a regular [MEDICATION NAME] level and not a free [MEDICATION NAME] level. The physician stated the normal range for regular [MEDICATION NAME] was 10 to 20 so he understood the resident's [MEDICATION NAME] level was low. The physician stated he asked the nurse if the resident had been taking his current dose of [MEDICATION NAME] as ordered and the nurse advised that the resident was routinely taking medications as ordered. The physician stated the nurse never told him that the lab result of 2.5 was a free [MEDICATION NAME] level so he thought the result was a regular [MEDICATION NAME] level. The physician stated the normal ranges were very different for a free [MEDICATION NAME] (1.0 to 2.0) as compared to a regular [MEDICATION NAME] level (10.0 to 20.0). The physician stated he understood the [MEDICATION NAME] level of 2.5 to be very low so he ordered an increase in the [MEDICATION NAME]. The physicians stated, I doubled what he (Resident #1) was on which was already high. The physician stated there was a miscommunication about the lab result that resulted in the toxicity. When asked if the resident's increased falls in November 2017 were related to the [MEDICATION NAME] toxicity, the physician stated, That's certainly possible. The physician stated [MEDICATION NAME] toxicity could cause loss of balance and visual changes. The physician stated Resident #1 may have not been able to report or verbalize any visual changes associated with the excess [MEDICATION NAME] levels. The physician also stated he had ordered a follow up [MEDICATION NAME] level (due on 11/24/17) and that lab was never done. The physician stated he was not aware of the [MEDICATION NAME] toxicity until the emergency room findings on 11/28/17 were reported to the facility on [DATE]. On 1/3/18 at 2:40 p.m. the administrator and director of nursing (DON) were interviewed about the [MEDICATION NAME] error with Resident #1. The administrator stated she was made aware of the [MEDICATION NAME] toxicity when adult protective services came to the facility on [DATE] and advised them of the emergency room findings of 11/28/17. The administrator stated the resident did not have a history of frequent falls and the pattern of falls in November 2017 was not typical for Resident #1. The administrator stated when the physician gave the order for the [MEDICATION NAME] level it was entered into the lab system as a free [MEDICATION NAME] level instead of a total [MEDICATION NAME]. The administrator stated this nurse also transcribed the [MEDICATION NAME] order of 11/18/17 inaccurately onto the resident's medication administration record. The administrator stated there was miscommunication of the lab result on 11/18/17 with the physician thinking the 2.5 level reported was a total [MEDICATION NAME] level instead of a free [MEDICATION NAME] level. The DON stated on 11/26/17 a nurse performing a monthly review of the MAR and physician orders found the [MEDICATION NAME] error listed inaccurately on Resident #1's MAR. The DON stated when this discrepancy was found on 11/26/17 the MAR was corrected and the resident started getting a total of 500 mg of [MEDICATION NAME] per day as originally ordered by the physician on 11/18/17. When asked if the physician was notified when this error was found on 11/26/17 so that [MEDICATION NAME] levels could have been re-checked, the DON had no response. Concerning the repeat [MEDICATION NAME] level ordered and scheduled to be done on 11/24/17, the DON stated this lab test was not done. The DON stated it was listed on the lab sheet but the lab employee stated the entry was illegible so they did not draw blood or complete the test. On 1/4/18 at 10:45 a.m. the DON displayed the options in their lab entry system for [MEDICATION NAME] levels. The DON stated there were three options in the computer system for [MEDICATION NAME]. The options included a [MEDICATION NAME] level, [MEDICATION NAME] Free + total and [MEDICATION NAME] Free. The DON stated if a regular [MEDICATION NAME] level was ordered the nurses should have selected option 1 [MEDICATION NAME] level and not [MEDICATION NAME] Free. The DON stated, There is a big difference in the results. The facility's undated policy titled Medication Administration stated, .The attending physician shall be notified immediately of all significant medication errors .No medication shall be administered unless the nurse is familiar with the pharmacology of the drug, its potential toxic effects and contraindications .Any deviation from the following principles shall be considered a medication error .To the right resident .Administration of the right medication .In the right dose .by the right route .By the right method .At the right time . The Nursing 2017 Drug Handbook on pages 1171 through 1173 describes [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to prevent and treat [MEDICAL CONDITION]. This reference lists adverse effects of [MEDICATION NAME] to include decreased coordination and muscle control, mental confusion, slurred speech, dizziness, headache, blurred vision, nausea, vomiting and [MEDICAL CONDITION]. This reference lists nursing considerations for [MEDICATION NAME] administration to include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms per milliliter). The therapeutic range of free [MEDICATION NAME] is 1 to 2 mcg/mL .Alert: Doubling the dose doesn't double the level but may cause toxicity. Consult pharmacist for specific dosing recommendations . (1) These findings were reviewed with the administrator and DON on 1/4/18 at 10:30 a.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on clinical record review, resident interview, and staff interview, the facility failed for one of 17 residents in the survey sample (Resident # 2) to ensure the resident had an effective pain management program. 1. Resident # 2's request for pain medication for a toothache was refused. This constituted harm. 2. The facility staff also failed to offer non-pharmacological interventions to address Resident # 2's pain. The findings include: 1. Resident # 2's request for pain medication for a toothache was refused. This constituted harm. Resident # 2 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set, with an Assessment Reference Date of 6/1/17, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 9 out of 15. Resident # 2 had the following physician order, dated 4/20/17, for scheduled pain medication: [MEDICATION NAME] 25 mcg/hr (25 micro grams per hour), change patch every 72 hours. The resident also had the following prn (as needed) physician orders, dated 4/20/17, for pain medication: Tylenol ([MEDICATION NAME]) 325 mg (milligrams) tablets, 2 = 650 mgs by mouth every four hours as needed for pain. [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet, 1 by mouth every 12 hours as needed for pain. [MEDICATION NAME] ([MEDICATION NAME]/APAP) 5-325 mg tablet, 1 by mouth daily as needed. Review of the electronic portion of Resident # 2's clinical record revealed the following Progress (Nurses) Notes entry: 7/27/17 - 11:56 p.m. Resident up at station demanding Tylenol for a 'toothache.' Explained to resident she had already taken something for pain on the previous shift. Resident became irate and screamed, 'I don't give a damn I want some more.' Explained that it was too soon for more medicine. Resident stated 'Well I'll just sit up here until I can have some more.' According to the Medication Administration Record [REDACTED]. The reason listed on the Nurse's Medication Notes portion of the MAR for the administration of the [MEDICATION NAME] was C/O (Complained of) butt hurting. At the time Resident # 2 requested the Tylenol, 11:56 p.m. according to the Nurses Note, it was approximately seven and one-half hours after the [MEDICATION NAME] was administered at 4:30 p.m. According to the July 2017 MAR, no other prn pain medication was administered to Resident # 2 on 7/27/17 between 4:30 p.m. and 11:56 p.m. At approximately 10:40 a.m. on 8/10/17, LPN # 2 (Licensed Practical Nurse), who worked on the unit where Resident # 2's room was located, was interviewed regarding the 7/27/17 Nurses Notes entry. LPN # 2 identified the nurse who wrote the note as working the evening shift, from 7:00 p.m. to 7:00 a.m. At approximately 9:00 a.m. on 8/10/17, Resident # 2 was interviewed. At the time of the interview, the resident was in her room, lying in bed. Asked if she remembered asking for pain medication at night about two weeks ago, the resident said Yes. I had a toothache and they wouldn't give me anything. Asked what she did, Resident # 2 said, I toughed it out. The resident went on to say she never did get any pain medication that night. During a meeting at 11:30 a.m. on 8/10/17, that included the Administrator, Director of Nursing, the Corporate Clinical Director, and the survey team, the failure of the staff to administer Tylenol to Resident # 2 for a reported toothache was discussed. There was no response when the Administrator, Director of Nursing, and the Corporate Clinical Director were asked why the Tylenol would not have been administered, The failure of staff to honor Resident # 2's request for pain medication for a toothache constituted harm. 2. The facility staff The facility staff also failed to offer non-pharmacological interventions to address Resident # 2's pain. Review of the electronic portion of Resident # 2's clinical record revealed the following Progress (Nurses) Notes entry: 6/7/17 - 1:47 a.m. Resident came down to station with her eyes closed up tight. C/O them hurting. PRN Tylenol given. No further c/o pain or discomfort. According to the MAR's for June and July 2017, Resident # 2 received prn Tylenol twice in June and none in July. She received [MEDICATION NAME] 11 times in June and 10 times in July. With the exception of the Nurses Note for the administration of Tylenol on 6/7/17, there were no other Nurses Notes related to the administration of prn pain medication for the months of June and July. In addition, there were no Nurses Notes to indicate the resident was offered non-pharmacological interventions to address her pain in lieu of the administration of pain medication. During a meeting at 4.00 p.m. on 8/9/17, that included the Administrator, Director of Nursing, the Corporate Clinical Director, and the survey team, the failure of the staff to off non-pharmacological interventions to address Resident # 2's pain was discussed. At 8:00 a.m. on 8/10/17, the surveyor was given a copy of the following Nurses Note: 8/9/17 - 8:01 p.m. Talked with resident and discussed possible non-pharmacological pain interventions such as massage, leg elevation, repositioning and resident refused anything stating 'That will only make my pain worse. I've tried all that myself. I've been taking pain medication for [AGE] years.' During the interview with Resident # 2 at 9:00 a.m. on 8/10/17, the use of non-pharmacological interventions to address her pain was discussed. The resident was non-responsive when asked if she would be willing to try other interventions instead of pain medication. During a meeting at 11:30 a.m. on 8/10/17, that included the Administrator, Director of Nursing, the Corporate Clinical Director, and the survey team, the failure of the staff to offer Resident # 2 non-pharmacological pain interventions and the importance of non-pharmacological interventions as a part of an effective pain management program were discussed.

Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to provide transportation services to a [MEDICAL TREATMENT] center resulting in the resident experiencing life threatening [MEDICAL CONDITION] and being admitted to the local hospital for one of 3 residents in the survey sample, Resident #1. Resident #1 was not provided transportation to his [MEDICAL TREATMENT] appointment on January 10th 2015, which resulted in the resident experiencing life threatening [MEDICAL CONDITION] and being admitted to the local hospital. Resident # 1 was scheduled to go to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The last documentation reviewed in the clinical record of the resident receiving [MEDICAL TREATMENT] was on January 6th 2015, however there was documentation present in the [MEDICAL TREATMENT] log that the resident received [MEDICAL TREATMENT] on January 8th 2015. Further review of the clinical record evidenced that Resident #1 did not receive his scheduled [MEDICAL TREATMENT] treatment on January 10th 2015. After experiencing complications from missing [MEDICAL TREATMENT], the resident had to go to the local hospital, where he was admitted and received emergency [MEDICAL TREATMENT]. Resident #1 was ordered to receive [MEDICAL TREATMENT] treatments for End Stage [MEDICAL CONDITION] three days a week The findings include: Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/15 was a 30 day assessment. The resident was assessed as a fifteen (15) for cognitive skills, independent in decision making skills and able to make needs known. On 3/10/15 at approximately 1:30 p.m., Resident #1's clinical record was reviewed to include the following: Nursing Note "1/10/15 09:14 Health Status Note Text: 0910 received call from (transport company named) stating they can not find a provider to transport to transport resident to [MEDICAL TREATMENT] , ADON (assistant director of nursing) notified." "1/10/15 Type: Health Status... Note Text: DON (director of nursing) aware or problems with transport. [MEDICAL TREATMENT] center notified. (sic)." "1/12/15 Type: Health Status...Note Text: CNA (certified nursing assistant) reported to nurse that resident wasn't feeling well, resident felt very weak, needed help with ADLs (activities of daily living), nurse assessed resident, vitals obtained...skin feel warm and wet to touch, resident was sweating at the time of assessment, denies pain at this time...MD (doctor/physician) aware resident being sent to (hospital named) for evaluation." Physician's Telephone Order "1/12/15 @ 1100 (11:00 a.m.) Send pt (patient) to ER (emergency room ) for eval (evaluation)." physician progress notes [REDACTED]. He was subsequently admitted to ward." Care Plan "Focus Date Initiated: 10/29/14...End Stage [MEDICAL CONDITION]: at risk for complications due to [MEDICAL TREATMENT]...Interventions: [MEDICAL TREATMENT] (Tue-Thurs-Sat)..." Hospital History and Physical "admitted : 1/12/15...Reason for Admission: The patient is admitted with severe [MEDICAL CONDITION] patient has had some generalized weakness with fatigue over the past several days as he was not able to attend his Saturday [MEDICAL TREATMENT] session in (city named)...The patient at this time is being admitted for emergent [MEDICAL TREATMENT]...Physical Examination: ...General: ...oriented and appears in a mild amount of distress...Labs: The patient had a BNP (Brain Natriuretic Peptide) test of greater than 5000 mg (milligrams) / ml (milliliters)....Chem 12 notable for potassium of 6.6 (normal value is 3.6 to 5.2 mmoL/L millimoles / liters)....BUN (blood urea nitrogen) 83 (normal value 6 to 20 mg/ dL)...Creatinine 13.9 (normal value 0.6 to 1.2 mg / dL in adult males)...Impression: 1. Severe [MEDICAL CONDITION], life threatening. 2. CKD ([MEDICAL CONDITION]). 3. Acute combined systolic diastolic [MEDICAL CONDITION], probable...Plan: 1. Admit to (hospital named)...3. Emergent [MEDICAL TREATMENT] using a 2 mEg (miliequivalent) / L (liter) potassium bath...6. [MEDICAL TREATMENT] renal panel in a.m. ...7. Cardiology consult for [MEDICAL CONDITION]...8. 2D echocardiogram..." A brain natriuretic peptide (BNP) test measures the amount of the BNP hormone in your blood. BNP is made by your heart and shows how well your heart is working. Normally, only a low amount of BNP is found in your blood. But if your heart has to work harder than usual over a long period of time, such as from heart failure, the heart releases more BNP, increasing the blood level of BNP. (1) On 3/10/15 at approximately 3:41 p.m., the assistant director of nursing (ADON) was interviewed regarding the "Nursing Note" in the clinical record of the resident not being transported to [MEDICAL TREATMENT] on January 10th 2015. The ADON stated, "(Transport company named dropped him from the list and there was no one available to pick him (the resident) up. We called them and then the (nurse named) called me (ADON). I told her to let the (DON named know) and she did." On 3/10/15 at approximately 3:45 p.m., the DON was interviewed regarding the "Nursing Notes and being made aware that the resident was not being transported to [MEDICAL TREATMENT] and the protocol, the DON stated, "I told (nurse named to attempt to call (another transportation company named) for transport." The DON was made aware that this information was not documented in the clinical record and if there was follow-up made from her (the DON) that this was done. The DON stated, "I assumed that she did it. No, I did not follow up." The DON was asked if the nurse called the transport company to make arrangements would the information be documented, the DON stated, "It is supposed to be." On 3/10/15 at approximately 3:50 p.m., the DON was interviewed regarding the facility's protocol for transportation. The DON stated, "Before staff was instructed to rescheduled the appointments at a later time or on a different day. The last administrator did not allow us to make arrangements he would prefer us to call and reschedule appointments to another time. He did not want to pay but now we have a policy in place where we call (transport company named) and the facility will pay for it (sic)." The DON showed this Surveyor a form to include the following: "New transportation Protocol for Critical Appointments without transportation (cancelled transports) From this day forward, anytime there is a scheduled appointment that is deemed critical, (could cause harm to resident if missed; i.e. [MEDICAL TREATMENT], any specialist consults or appts.), and transport cancels at the last minute whether it be through (transport company named) or not, we will call and set up transport through a local transport service and will pay for the transport ourselves in order to see that the resident makes it to his or her appointment. In the event that this occurs, you MUST notify the administrator immediately to inform him of this.* ***Any questions regarding whether or not an appointment is critical, please follow up with QI or ADON for questions.*** ----Critical things are not things such as: eye DR. appts., or annual checkups.-----" On 3/10/15 at approximately 3:55 p.m., the Regional Vice President stated, "This form here is to get them there on the same day. This was put in place after transport missed picking up the resident; the (administrator named) put this in place and there was a complaint filed with (transport company named)." On 3/10/15 at approximately 4:00 p.m., the ADON was interviewed regarding the last administrator's last employment at the facility. The ADON stated, "(Last administrator name) left October 14th." On 3/10/15 at approximately 4:33 p.m., during a meeting with the regional vice president, the facility consultant and the director of nursing, the DON was interviewed regarding the last administrator leaving in October of 2014 and the reason the facility did not call another transport company to transport the resident to his appointment since the "last administrator was no longer employed." The DON stated, "I don't know that was his (last administrator) rule." The DON was made aware that the last administrator's rules did not apply to the resident's after his employment was terminated in October of 2014 and this incident happened January 10th 2015; the Regional Vice President stated, "I agree that's why we now have a system in place to prevent this from happening again." On 3/10/15 at approximately 4:47 p.m., Resident #1's family member was called in regards to the above findings. The family member stated that they were not aware of the above until the resident called from the hospital on Tuesday January 13th. Resident #1 was not available for an interview due to being out at [MEDICAL TREATMENT]. On 3/10/15 at approximately 4:53 p.m., the nurse, who was a Licensed Practical Nurse and will be identified as LPN #1 was interviewed regarding the above findings, LPN #1 stated, "(Transport company named) would pick (Resident named) up around 8:30 or 9:00 (a.m.). I looked in the room and he was still there. I called (transport company named) and there is a prompt for 'where's my ride?' I found out that transport had been canceled so I called (ADON named) and (DON named) and then I called (another transport company named), which is also a provider for (transport company named) (that did not show up). I was told they did not have a driver. I went in the room and I told the patient he would not be going due to transport issues and if at anytime he felt bad to come to me and I would send him to the ER; he said he felt fine. I checked on him and he said he felt fine." LPN #1 was asked if any of this was documented; LPN #1 stated, "I did not document it; it was probably a lot going on, that was my mistake. LPN #1 was asked if the family was notified to see if they could transport the resident or to inform that transport could not be obtained, LPN #1 stated, "He is his own RP (responsible party/person)." LPN #1 further stated, "I called the DON back and informed her that there was no driver to transport the resident to [MEDICAL TREATMENT] and she stated 'just keep check on him if he show signs send him to the ER.(sic).' When interviewed and asked if there was anything in place in the event transport was not available to pick up a resident for an appointment, LPN #1 stated, "No, we have been having problem with (transport company named for a while). We have something in place now that if the appointment is not far away we can call (transport company named) and pay out of pocket. Now he (the resident) is locally; he is not going to (City) named." On 3/10/15 at approximately 5:31 p.m., during the meeting with the regional vice president, the regional consultant and the director of nursing, the DON was interviewed regarding the back up transport company and it being a provider for the transport company that they are currently having "problems" with; the DON stated (transport company named) is the only local transport service that is contracted through (transport company named)." The DON was asked if the companies did not have drivers, as before, was there a system in place. The DON stated, "No." The regional vice president intervened and stated, "If there is no driver, then we will go through (transport company named) and if they do not have a driver then we will send the resident to the ER." 1. WebMD.com (2015, March) Heart Failure Center-WebMD Retrieved from http://www.webmd.com/heart-disease/heart-failure/default.htm. 2. http://www.nlm.nih.gov/medlineplus/ency/article/ 9.htm High potassium level is a problem in which the amount of potassium in the blood is higher than normal. The medical name of this condition is [MEDICAL CONDITION]. Potassium is needed for cells to function properly. You get potassium through food. The kidneys remove excess potassium in the urine to keep a proper balance of this mineral in the body. If your kidneys are not working well, they may not be able to remove the proper amount of potassium 3. http://www.nlm.nih.gov/medlineplus/[MEDICAL TREATMENT].html When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant you will need a treatment called [MEDICAL TREATMENT]. There are two main types of [MEDICAL TREATMENT]. Both types filter your blood to rid your body of harmful wastes, extra salt, and water. [MEDICAL TREATMENT] uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. Peritoneal [MEDICAL TREATMENT] uses the lining of your abdomen, called the peritoneal membrane, to filter your blood

Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the physician and the emergency contact / family member of a missed appointment to the [MEDICAL TREATMENT] center resulting in the resident experiencing life threatening [MEDICAL CONDITION] and being admitted to the local hospital for one of 3 residents in the survey sample, Resident #1. Resident #1's physician was not aware that the resident was not provided transportation to [MEDICAL TREATMENT] on January 10th 2015, which resulted in the resident experiencing life threatening [MEDICAL CONDITION] and being admitted to the local hospital. Resident # 1 was scheduled to go to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The last documentation reviewed in the clinical record of the resident receiving [MEDICAL TREATMENT] was on January 6th 2015, however there was documentation present in the [MEDICAL TREATMENT] log that the resident received [MEDICAL TREATMENT] on January 8th 2015. Further review of the clinical record evidenced that Resident #1 did not receive his scheduled [MEDICAL TREATMENT] treatment on January 10th 2015. After experiencing complications from missing [MEDICAL TREATMENT], the resident had to go to the local hospital, where he was admitted and received emergency [MEDICAL TREATMENT]. Resident #1 was ordered to receive [MEDICAL TREATMENT] treatments for End Stage [MEDICAL CONDITION] three days a week The findings include: Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/15 was a 30 day assessment. The resident was assessed as a fifteen (15) for cognitive skills, independent in decision making skills and able to make needs known. On 3/10/15 at approximately 1:30 p.m., Resident #1's clinical record was reviewed to include the following: Nursing Note "1/10/15 09:14 Health Status Note Text: 0910 received call from (transport company named) stating they can not find a provider to transport to transport resident to [MEDICAL TREATMENT] , ADON (assistant director of nursing) notified." "1/10/15 Type: Health Status... Note Text: DON (director of nursing) aware or problems with transport. [MEDICAL TREATMENT] center notified. (sic)." "1/12/15 Type: Health Status...Note Text: CNA (certified nursing assistant) reported to nurse that resident wasn't feeling well, resident felt very weak, needed help with ADLs (activities of daily living), nurse assessed resident, vitals obtained...skin feel warm and wet to touch, resident was sweating at the time of assessment, denies pain at this time...MD (doctor/physician) aware resident being sent to (hospital named) for evaluation." Physician's Telephone Order "1/12/15 @ 1100 (11:00 a.m.) Send pt (patient) to ER (emergency room ) for eval (evaluation)." physician progress notes [REDACTED]. He was subsequently admitted to ward." Care Plan "Focus Date Initiated: 10/29/14...End Stage [MEDICAL CONDITION]: at risk for complications due to [MEDICAL TREATMENT]...Interventions: [MEDICAL TREATMENT] (Tue-Thurs-Sat)..." Hospital History and Physical "admitted : 1/12/15...Reason for Admission: The patient is admitted with severe [MEDICAL CONDITION] patient has had some generalized weakness with fatigue over the past several days as he was not able to attend his Saturday [MEDICAL TREATMENT] session in (city named)...The patient at this time is being admitted for emergent [MEDICAL TREATMENT]...Physical Examination: ...General: ...oriented and appears in a mild amount of distress...Labs: The patient had a BNP (Brain Natriuretic Peptide) test of greater than 5000 mg (milligrams) / ml (milliliters)....Chem 12 notable for potassium of 6.6 (normal value is 3.6 to 5.2 mmoL/L millimoles / liters)....BUN (blood urea nitrogen) 83 (normal value 6 to 20 mg/ dL)...Creatinine 13.9 (normal value 0.6 to 1.2 mg / dL in adult males)...Impression: 1. Severe [MEDICAL CONDITION], life threatening. 2. CKD ([MEDICAL CONDITION]). 3. Acute combined systolic diastolic [MEDICAL CONDITION], probable...Plan: 1. Admit to (hospital named)...3. Emergent [MEDICAL TREATMENT] using a 2 mEg (miliequivalent) / L (liter) potassium bath...6. [MEDICAL TREATMENT] renal panel in a.m. ...7. Cardiology consult for [MEDICAL CONDITION]...8. 2D echocardiogram..." A brain natriuretic peptide (BNP) test measures the amount of the BNP hormone in your blood. BNP is made by your heart and shows how well your heart is working. Normally, only a low amount of BNP is found in your blood. But if your heart has to work harder than usual over a long period of time, such as from heart failure, the heart releases more BNP, increasing the blood level of BNP. (1) On 3/10/15 at approximately 3:41 p.m., the assistant director of nursing (ADON) was interviewed regarding the "Nursing Note" in the clinical record of the resident not being transported to [MEDICAL TREATMENT] on January 10th 2015. The ADON stated, "(Transport company named) dropped him from the list and there was no one available to pick him (the resident) up. We called them and then the (nurse named) called me (ADON). I told her to let the (DON named know) and she did." On 3/10/15 at approximately 3:45 p.m., the DON was interviewed regarding the "Nursing Notes and being made aware that the resident was not being transported to [MEDICAL TREATMENT] and the protocol, the DON stated, "I told (nurse named to attempt to call (another transportation company named) for transport." The DON was made aware that this information was not documented in the clinical record and if there was follow-up made from her (the DON) that this was done. The DON stated, "I assumed that she did it. No, I did not follow up." The DON was asked if the nurse called the transport company to make arrangements would the information be documented, the DON stated, "It is supposed to be." On 3/10/15 at approximately 3:50 p.m., the DON was interviewed regarding the facility's protocol for transportation. The DON stated, "Before staff was instructed to rescheduled the appointments at a later time or on a different day. The last administrator did not allow us to make arrangements he would prefer us to call and reschedule appointments to another time. He did not want to pay but now we have a policy in place where we call (transport company named) and the facility will pay for it (sic)." The DON showed this Surveyor a form to include the following: "New transportation Protocol for Critical Appointments without transportation (cancelled transports) From this day forward, anytime there is a scheduled appointment that is deemed critical, (could cause harm to resident if missed; i.e. [MEDICAL TREATMENT], any specialist consults or appts.), and transport cancels at the last minute whether it be through (transport company named) or not, we will call and set up transport through a local transport service and will pay for the transport ourselves in order to see that the resident makes it to his or her appointment. In the event that this occurs, you MUST notify the administrator immediately to inform him of this.* ***Any questions regarding whether or not an appointment is critical, please follow up with QI or ADON for questions.*** ----Critical things are not things such as: eye DR. appts., or annual checkups.-----" On 3/10/15 at approximately 3:55 p.m., the Regional Vice President stated, "This form here is to get them there on the same day. This was put in place after transport missed picking up the resident; the (administrator named) put this in place and there was a complaint filed with (transport company named)." On 3/10/15 at approximately 4:00 p.m., the ADON was interviewed regarding the last administrator's last employment at the facility. The ADON stated, "(Last administrator name) left October 14th." On 3/10/15 at approximately 4:33 p.m., during a meeting with the regional vice president, the facility consultant and the director of nursing, the DON was interviewed regarding the last administrator leaving in October of 2014 and the reason the facility did not call another transport company to transport the resident to his appointment since the "last administrator was no longer employed." The DON stated, "I don't know that was his (last administrator) rule." The DON was made aware that the last administrator's rules did not apply to the resident's after his employment was terminated in October of 2014 and this incident happened January 10th 2015; the Regional Vice President stated, "I agree that's why we now have a system in place to prevent this from happening again." On 3/10/15 at approximately 4:47 p.m., Resident #1's family member was called in regards to the above findings. The family member stated that they were not aware of the above until the resident called from the hospital on Tuesday January 13th. Resident #1 was not available for an interview due to being out at [MEDICAL TREATMENT]. On 3/10/15 at approximately 4:53 p.m., the nurse, who was a Licensed Practical Nurse and will be identified as LPN #1 was interviewed regarding the above findings, LPN #1 stated, "(Transport company named) would pick (Resident named) up around 8:30 or 9:00 (a.m.). I looked in the room and he was still there. I called (transport company named) and there is a prompt for 'where's my ride?' I found out that transport had been canceled so I called (ADON named) and (DON named) and then I called (another transport company named), which is also a provider for (transport company named) (that did not show up). I was told they did not have a driver. I went in the room and I told the patient he would not be going due to transport issues and if at anytime he felt bad to come to me and I would send him to the ER; he said he felt fine. I checked on him and he said he felt fine." LPN #1 was asked if any of this was documented; LPN #1 stated, "I did not document it; it was probably a lot going on, that was my mistake. LPN #1 was asked if the family was notified to see if they could transport the resident or to inform that transport could not be obtained, LPN #1 stated, "He is his own RP (responsible party/person)." LPN #1 further stated, "I called the DON back and informed her that there was no driver to transport the resident to [MEDICAL TREATMENT] and she stated 'just keep check on him if he show signs send him to the ER.(sic).' When interviewed and asked if there was anything in place in the event transport was not available to pick up a resident for an appointment, LPN #1 stated, "No, we have been having problem with (transport company named for a while). We have something in place now that if the appointment is not far away we can call (transport company named) and pay out of pocket. Now he (the resident) is locally; he is not going to (City) named." On 3/10/15 at approximately 5:31 p.m., during the meeting with the regional vice president, the regional consultant and the director of nursing, the DON was interviewed regarding the back up transport company and it being a provider for the transport company that they are currently having "problems" with; the DON stated (transport company named) is the only local transport service that is contracted through (transport company named)." The DON was asked if the companies did not have drivers, as before, was there a system in place. The DON stated, "No." The regional vice president intervened and stated, "If there is no driver, then we will go through (transport company named) and if they do not have a driver then we will send the resident to the ER." 1. WebMD.com (2015, March) Heart Failure Center-WebMD Retrieved from http://www.webmd.com/heart-disease/heart-failure/default.htm. 2. http://www.nlm.nih.gov/medlineplus/ency/article/ 9.htm High potassium level is a problem in which the amount of potassium in the blood is higher than normal. The medical name of this condition is [MEDICAL CONDITION]. Potassium is needed for cells to function properly. You get potassium through food. The kidneys remove excess potassium in the urine to keep a proper balance of this mineral in the body. If your kidneys are not working well, they may not be able to remove the proper amount of potassium 3. http://www.nlm.nih.gov/medlineplus/[MEDICAL TREATMENT].html When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant you will need a treatment called [MEDICAL TREATMENT]. There are two main types of [MEDICAL TREATMENT]. Both types filter your blood to rid your body of harmful wastes, extra salt, and water. [MEDICAL TREATMENT] uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. Peritoneal [MEDICAL TREATMENT] uses the lining of your abdomen, called the peritoneal membrane, to filter your blood

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure three of 24 residents were free from unnecessary medications. (Residents #10, #9, and #13). 1a. Resident #10 was sent to the emergency room (ER) due to an injury sustained from an assisted fall on 12/20/12. When Resident #10 returned to the facility on [DATE] the facility failed to determine when Resident #10 received pain medication from the ER visit. Subsequently the facility staff administered her scheduled pain medication and the resident became unresponsive. 1b. Resident #10 was documented as having an effective pain management program, yet was administered the [MEDICATION NAME] opioid pain medication, [MEDICATION NAME] with no indication for use. Resident #10 subsequently became unresponsive. Emergency Medical Services administered the medication, [MEDICATION NAME], without result in the facililty, and transcutaneous pacing (providing the heart electrical stimulus to maintain cardiac output until underlying issue resolved) was administered while in route to the hospital. The emergency room (ER) provided the IV medication, [MEDICATION NAME] ([MEDICATION NAME] - a medication to reverse the effects of an opioid overdose). 2. The facility staff failed to provide Resident #9 with non-pharmacological interventions, or adequate indication for the use of the antipsychotic medication, [MEDICATION NAME]. 3. Resident #13 was medicated with [MEDICATION NAME] due to a new [DIAGNOSES REDACTED]. The findings include: 1. Resident #10 was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 1/28/13 assessed the resident with a brief interview for mental status (BIMS) score of 12 out of 15, meaning the resident was minimally cognitively impaired. The clinical record was reviewed from 5/6/13 through 5/8/13. a. The electronic progress notes documented the following: "12/20/12 at 11:45 a.m. - assisted fall to floor c/o pain in rt (right) knee. (Physician) notified of resident fall. resident was assisted to get in chair c/o knee giving out, medical transport called (sic)." "12/20/13 at 12:37 p.m. - to ER per medical transport." "12/20/12 at 21:43 (9:43 p.m.) - Back to facility @ (at) 1630 (4:30 p.m.) MD ordered to continue same scheduled pain meds taken prior to ER visit." "12/21/12 at 01:11 (1:11 a.m.) - went in room resident unresponsive, bluish grey color noted to mouth and nose. md made aware order given to send out 911 called for transfer. v/s (vital signs) 90/57 (BP) - 57% (oxygen saturation) - 95 (pulse) - 24 (respirations). nonrebreather mask placed on for low sats (oxygen). sats up to 99%." "12/21/12 at 01:25 (1:25 a.m.) - 911 in for transfer to er." The 12/12 physician's orders [REDACTED].= 10 mg po (by mouth) Q (every) 4 hours W.A (while awake) (pain)" with administration times of "12 A (midnight), 4A (4:00 a.m.), 8A (8:00 a.m.), 12N (12:00 p.m. - noon), 4P (4:00 p.m.), 8P (8:00 p.m.)." O2 @ 2L/M (liters per minute) via NC (nasal cannula) PRN (when needed) for O2 sats < (less than) 90%." The 12/12 medication administration record (MAR) documented "[MEDICATION NAME] 5 mg Give 2 = 10 mg po Q4 hours (symbol) W.A. (pain)" The date of 12/20/12 indicated resident #10 received her scheduled doses at 4:00 p.m, and 8:00 p.m. The midnight (12:00 a.m.) dose was held according the nurse's initials circled on the front of the MAR and documentation "12/21/12 at 12a - [MEDICATION NAME] held sent to ER." Other scheduled medications Resident #10 received at 8:00 p.m. included [MEDICATION NAME] 50 mg, [MEDICATION NAME] XR 150 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 900 mg, and Trazadone 150 mg. At 10:00 p.m., Resident #10 received [MEDICATION NAME] 1 mg. A prn order for oxygen showed no documentation for oxygen being administered on 12/20/12 or 12/21/12. The resident's O2 sats on the 7-3 shift were documented on the front of the MAR except for the days of 12/20/12 and 12/21/12. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 1017 as an opiod [MEDICATION NAME] with clinical indications for moderate to severe pain. Adverse reactions of the central nervous system include dizziness, light-headedness, physical dependence, sedation, somnolence (drowsiness or sleepiness). [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 783 as an anticonvulsant with clinical indications for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Adverse reactions of the central nervous system include dizziness and somnolence. [MEDICATION NAME] XR is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 1389 as an SSRI antidepressant with clinical indications for depression, anxiety, panic disorder, social anxiety disorder and hot flashes. Adverse reactions of the central nervous system include dizziness and somnolence. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 144 as an antipsychotic with clinical indications for [MEDICAL CONDITIONS], major [MEDICAL CONDITION], and irritability with autism. Adverse reactions to the central nervous system include dizziness and somnolence. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 641 as an anticonvulsant with clinical indications for [MEDICAL CONDITION], postherpetic neuralgia, diabetic [MEDICAL CONDITION], vasomotor symptoms in women with [MEDICAL CONDITION] and postmenopausal women. Adverse reactions to the central nervous system include dizziness, fatigue and somnolence. Trazadone is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 1358 as an antidepressant with clinical indications for deperssion, [MEDICAL CONDITION] and migraine prevention. Adverse reactions to the central nervous system include drowsiness, dizziness, fatigue, confusion and [MEDICAL CONDITION]. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 94 as an anxiolytic with clinical indications for anxiety and panic disorders. Adverse reactions to the central nervous system include dizziness, confusion, drowsiness, sedation, somnolence and fatigue. No records from the hospital ER for the dates of 12/20/12 and 12/21/12 were located in the paper clinical record. The thinned clinical record was reviewed on 5/7/13. Discharge instructions dated 12/21/12 documented "Additional follow up instructions - Discharge Instructions - Confusion" with generic instructions. The bottom of the forms documented "print date: 12/21/2012 01:48 - Confidential Medical Records - Page 1 of 4." The pages in the record went to "Page 3 of 4." A facility "Transfer/Discharge Report" with a transfer date of 12/21/12 at 0120 (1:20 a.m.) documented the resident's vital signs "90/57 (blood pressure), 57% (O2 sat), 95 (pulse), 24 (respirations). On 5/7/13 at 2:15 p.m., the medical records staff was asked for the ER records for 12/21/12. On 5/7/13 at 3:10 p.m., this surveyor was provided with the faxed ER record for 12/21/12. The "Emergency Department Chart" documented "Arrival date 12/21/12 01:37 (1:37 a.m.)...Chief Complaint - Altered LOC (levels of consciousness) in patient with chronic problems...Triage - Per rescue squad, PT (patient) was unresponsive at the nursing home and oxygen sats were initially low, PT moved to their stretcher and woke up and sats increased with O2 (oxygen), PT seen in the ER [DATE] for a fall...Clinicial History of Present Illness - (Resident name) was found by SNF staff hypoxic and confused. The patient has a knee injury, for which she is receiving narcotic pain medication. This patient is currently receiving medication which could be playing a role in sedation and confusion...Progress Notes - Update note: Pt is awake and at baseline at present. She wears supplemental O2 PRN and with the narcotic pain medication, I think she became oversedated and got hypoxic. After administration of O2 by EMS (emergency medical services), her alteration in mental status resolved immediately. Will d/c to the SNF (skilled nursing facility) with instructions that the patient should use her supplemental O2 while taking narcotic pain medications." The bottom of the pages documented "Print date: 12/21/2012 02:48 - Confidential Medical Records - Page 1 of 7." The pages in the record went to "Page 7 of 7." On 5/7/13 at 3:15 p.m., the administrative team were made aware of concerns regarding resident being unresponsive and need for hospital records during a meeting with the survey team. This surveyor asked for any investigation the facility had done regarding the resident's episodes of unresponsiveness. The director of nurses stated that she would ask the medical records person about the records. On 5/8/13 at 8:10 a.m., the medical records staff was asked for the hospital records for the 12/20/12 ER visit as well as the 12/21/12 and 1/17/13 hospital visits, which include the ER visits. The medical records staff stated that she had put a request in yesterday at the hospital for the 12/21/12 and 1/17/13 "but it was after 5:00 p.m., so I will check on that now." On 5/8/13 at 10:15 a.m., the hospital records for 12/20/12 were provided to this surveyor. The "Emergency Department Chart" documented the following: "Arrival Date: 12/20/12 at 12:38 p.m." The exam documented "...Exam over the right anterior knee demonstrates a mild to moderate amount of swelling...consistent with a mild to moderate sprain/strain." "Drug Orders - [MEDICATION NAME] inj (injection) 2 mg IM (intramuscular) completed by 13:51 (1:51 p.m.); [MEDICATION NAME] 4 mg Im completed by 13:51; [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ([MEDICATION NAME]) 1 tab oral completed by 15:04 (3:04 p.m.)." "Discharge Prescriptions - [MEDICATION NAME] bit/[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) Oral Tablet 5-500 mg 1 tablet(s) Oral Every 4 Hours Special Instructions: prn pain Printed 14:04 (2:04 p.m.)." The bottom of the pages documented "Print date: 12/20/2012 16:30 - Confidential Medical Records - Page 1 of 9." The pages in the record went to "Page 9 of 9" The fax consisted of 13 pages, which also included the results of the resident's knee x-ray and demographic face sheet from the hospital. On the website drugs.com, the adverse reactions for [MEDICATION NAME] include shallow breathing, slow heartbeat, feeling lightheaded, [MEDICAL CONDITION], confusion, [MEDICAL CONDITION], dizziness and drowsiness. (www.drugs.com/[MEDICATION NAME].html) On 5/8/13 at 10:35 a.m., this surveyor asked the administrative team about this record and why they did not have it in the clinical record. This surveyor asked about the [MEDICATION NAME] that the resident received form the ER and then the scheduled [MEDICATION NAME] about an hour later at the facility. The director of nurses stated "we do not always get the information from the hospital, just the discharge information." The vice president for the facility asked "Why didn't we have that?" The surveyor advised the administrative team of concerns of resident's two episodes of unresponsiveness. 1b. Further review of the clinical record evidenced a "Short Stay Transfer/Discharge Summary Orders" with a "fax date of 4/29/13." This documented "Final [DIAGNOSES REDACTED]." The document had a faxed date of "4/29/13 3:22:19 PM - Page 2/002." The electronic progress notes documented the following: "1/11/13 at 21:42 (9:42 p.m.) - Resident had large formed bm (bowel movement) 3-11 shift." "1/13/13 at 21:21 (9:21 p.m.) - Resident lying in bed resting quietly after recent incident. vs (vital signs) 110/78 (blood pressure), 82 (pulse), 99.1 (temperature), 92 - O2 (oxygen saturation percentage), 17 (respirations). No injuries noted. Equal strength in upper & (and) lower extremities. No distress noted @ (at) present time." "1/14/13 at 01:19 (1;19 a.m.) - asleep in bed arouses easily. no c/o pain or discomfort from earlier incident." "1/14/13 at 09:56 (9:56 a.m.) - Resident oob (out of bed) to motorized wheelchair at this time; alert, oriented to person, place, and time; resident has been very pleasant thus far denying any pain or discomfort in the lower right extremity from previous incident; resident's skin was assessed from wear of imobilizer; skin integrity intact, no brusing or swelling noted to area; no redness noted." "1/14/13 at 11:41 (11:41 a.m.) - orthopedic office notified this nurse that immobilizer that was placed to right lower extremity may be removed at this time; also stated that resident may return to clinic as needed." "1/15/13 at 03:50 (3:50 a.m.) - resident refused mom (milk of magnesia) for no bm in 3 days. prn [MEDICATION NAME] tabs given, abd (abdomen) soft and nondistended. bs (bowel sounds) x (times) 4 quads (quadrants). no c/o pain or discomfort." "1/15/13 at 21:16 (9:16 p.m.) - [MEDICATION NAME] Supp. (suppository) given for no BM in three days. abdomen soft and non distended, active bowel sounds in all quads. MD aware." "1/16/13 at 06:54 (6:54 a.m.) - resident had 1 small formed bm this am." "1/17/13 at 05:34 (5:34 a.m.) - @ 0315 (3:15 a.m.) resident asleep in bed, resp. even and nonlabored. hob (head of bed) elevated, o2 in use.no signs of pain or distress noted. call bell in reach." "1/17/13 at 07:02 (7:02 a.m.) - @400 resident asleep in bed, resp. even and nonlabored. HOB elevated. O2 in use. No signs of pain or distress noted." "1/17/13 at 07:13 (7:13 a.m.) - @0450 (4:50 a.m.) unable to wake resident, unresponsive to verbal/tactile stimuli, skin cool and clammy, resp. shallow and irregular @ 16/min.Pulse weak& thready @ 43/min. O2 sats renging from 78%-83% with O2 in use. Unable to obtain B/P in left or right arm. Accu (accucheck), 161. Fentyl patch removed, 911 & MD notified." "1/17/13 at 07:21 (7:21 a.m.) - 0510 (5:10 a.m.) rescue arrived to facility. attempt to notify rp no answer, unable to leave voicemail, d/t (due to) mailbox full. 2nd contact notified and made aware and stated she would try and get in touch with rp. don (director of nurses)/admin. (administrator) notified." "1/17/13 at 07:39 (7:39 a.m.) - @ 0515 (5:15 a.m.)-ER notified of pending arrival, report given to ER nurse." No hospital records were located in the clinical record. The physician's verbal orders documented "1/14/13 - May d/c immobilizer to right lower extremity at this time May return to orthopedic office PRN (when needed)." "1/15/13 - Fentyl Patch 50 mcg (micrograms) ([MEDICATION NAME]) - apply 1 patch q (every) 72 hours (symbol) forpain..." The physician's verbal orders did not contain any orders to change Resident #10's [MEDICATION NAME] order. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.pages 576 - 580 as an opioid [MEDICATION NAME] with clinical indications for general anesthetic; regional anesthesia; to induce and maintain anesthesia; postoperative pain, restlessness, tachypnea (heart rate over 100 beats per minute), and emergence [MEDICAL CONDITION]; preoperative medication; to manage persistent, moderate to severe chronic pain in opioid-tolerant patients who require around-the-clock opioid [MEDICATION NAME] for an extended time; and to manage [MEDICAL CONDITION] pain in patients already receiving and tolerating an opioid. Adverse reactions to the central nervous system include dizziness, confusion and sedation. Adverse reactions to the cardiovascular system include arrythmias (irregular heart beat), and [MEDICAL CONDITION] (low blood pressure). Adverse reactions to the respiratory system include respiratory depression, apnea (no breathing), and dyspnea (difficulty breathing). Drug-drug interactions include, but are not limited to, other opioid [MEDICATION NAME]: may cause additive effects. Use together cautiously. Reduce dosages of these drugs and reduce [MEDICATION NAME] dose by one-fourth to one-third. Contraindications and cautions include, but are not limited to, use with caution in patients with [DIAGNOSES REDACTED]s, [MEDICAL CONDITION], decreased respiratory reserve, potentially compromised respirations, hepatic or [MEDICAL CONDITION], or cardiac bradyarrhythmias; use with caution in the elderly or debilitated patients. Nursing considerations include, but are not limited to, when converting a patient from another opioid, determine the initial [MEDICATION NAME] dosage with great care; overestimating the dose could be dangerous or fatal. Available forms of [MEDICATION NAME]es are 12.5 mcg, 25 mcg, 50 mcg, 75 mcg, or 100 mcg of drug per hour. The "Pain Management Log for the Resident Able to Self-Report" documented the resident's pain rating level at a 1 to a 2 from 1/2/13 to 1/16/13. There was no documentation after 1/16/13 at 8:00 p.m. The 1/13 physician's orders [REDACTED]. of 12MN (12:00 a.m. - midnight), 4AM (4:00 a.m.), 8AM (8:00 a.m.), 12N (12:00 p.m. - noon), 4PM (4:00 p.m.), and 8PM (8:00 p.m.). No PRN pain medications were ordered for any breakthrough pain for Resident #10. The 1/13 medication administration record (MAR) documented "Fentyl ([MEDICATION NAME]) patch 50 mcg apply one patch q 72 hours (symbol) for p 7-3 (7-3 shift)" with the nurse's initials written in the 1/16/13 date for administration. The 1/13 MAR also documented that the Resident #10 received [MEDICATION NAME] 10mg on 1/16/13 at 12MN, 4AM, 8AM, 12N, 4PM, 8PM. Some of the other medications that Resident #10 was administered at 8:00 p.m. included [MEDICATION NAME] 50 mg, [MEDICATION NAME] XR 150 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 900 mg, and Trazadone 150 mg. At 10:00 p.m., Resident #10 received [MEDICATION NAME] 1 mg. On 1/17/13 at 12MN, Resident #10 received her scheduled dose of [MEDICATION NAME] 10 mg. A physician's visit dated 1/2/13 documented a history that included "more recently, the patient suffered a fall and an injury to the right lower leg. She states it hurts at times." Under the section "Physical Exam" documented "Show a brace on the right lower leg to just above the knee. There is apparent tenderness of the right knee to palpation. No discoloration could be seen from the area under the brace...Assessment: 1. Condition is stable. The patient continues to complain of some nervousness at times...Plan: We will continue present therapy as ordered." A physician's visit dated 1/22/13 documented no information regarding the resident's incident of unresponsiveness and transfer to the local hospital'sER on [DATE] at 4:50 a.m. or subsequent ICU admittance and discharge back to the facility on [DATE] at 6:25 p.m. The care plan documented "Focus - Actual Pain/Chronic related to Depression, [MEDICAL CONDITIONS]/general discomfort - Date Initiated: 4/24/12...Goals - Pain will be resolved within 1 hour of intervention as voiced by resident through next review date - Date Initiated: 4/24/12, Target Date: 5/9/13...Interventions - acknowledge presence of pains and discomfort. Listen to resident's concerns; Administer pain medication as per MD orders and note the effectiveness; Anticipate resident's need for pain relief and respond appropriately; Document/Report complaints & non-verbal signs of pain; Encourage resident and/or family to request pain medication before pain becomes severe; Monitor vitals per facility protocol; Monitor and document charecteristics of pain: location, severity, frequency, precipitating factors, etc.; Monitor for side effects of pain medication such as constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and/or falls. Notify physician of potential side effects; Monitor for signs/symptoms of non-verbal pain such as changes in breathing, grunting, moans, yelling out, mood/behavior changes; sad expressions, crying, clenched teeth, grimacing, tenseness, rigidity of body/limbs. Report to nurse; Notify physicain if pain management is not effective; Obtain and monitor labs as ordered and notify physician of results; pain assessment for establishment of effective pain management program; Encourage to reposition regularly and prn." All the interventions documented an initiated date of 4/24/12. A 2/11/13 pharmacist's medication regimen review documented "Difficult to obtain all the information needed. The discharge summary is not on the chart for [DATE] acute care stay." On 5/7/13 at 2:00 p.m., licensed practical nurse (LPN) #2 was asked about the resident's episodes of being unresponsive, showing her the documentation. LPN #2 stated "I was not working during the times she was unresponsive. I didn't know about them (sic)." When asked about the [MEDICATION NAME] order, LPN #2 stated " I don't know why it was ordered (sic)." On 5/7/12 at 2:34 p.m., the attending physician was asked about the order for the [MEDICATION NAME]. The MD stated "the nurses must have said having pain, that is what I ordered (sic). On 5/7/13 at 3:15 p.m., the administrative team were made aware of concerns regarding resident being unresponsive and need for hospital records during a meeting with the survey team. This surveyor asked for any investigation the facility had done regarding the resident's episodes of unresponsiveness. The director of nurses stated that she would ask the medical records staff about the records. On 5/8/13 at 8:10 a.m., the medical records staff was asked for the hospital records for the 12/20/12 ER visit as well as the 12/21/12 and 1/17/13 hospital visits, which include the ER visits. The medical records person stated that she had put a request in yesterday at the hospital for the 12/21/12 and 1/17/13 "but it was after 5:00 p.m., so I will check on that now." On 5/8/13 at 10:20 a.m., this surveyor spoke with the pharmacy director. This surveyor advised the pharmacy director the need to speak to the consulting pharmacist for the facility. The pharmacy director stated that he would get a message to the facility's consulting pharmacist and that she would call this surveyor. On 5/8/13 at 10:30 a.m., the medical record staff provided this surveyor with the hospital records for Resident #10's hospital visit 1/17/13. The records documented "History and Physical - Primary Admitting Diagnoses: [REDACTED]. 2. status [REDACTED]. Altered mental status with unresponsiveness secondary to #2. 4. Acute [MEDICAL CONDITION]. 5. Urinary tract infection. 6. Acute [MEDICAL CONDITION]. 7. Indeterminate troponin...History of Present Illness: (Resident name, age, and race) female from (facility) who presents today to our emergency department after being found by nursing home staff to be unresponsive. EMS was called to the scene where they found a significantly bradycardic (heart rate below 60 beats per minute) patient with [MEDICAL CONDITION]. She was given [MEDICATION NAME] on the scene without response and therefore placed on pacing pads and brought to our emergency department. Further workup in our emergency room revealed the patient to have [MEDICATION NAME] ([MEDICATION NAME]) patch which was promptly removed and further review from the nursing home relates that this patch was placed yesterday. The patient was given 2 mg of [MEDICATION NAME] in our emergency department with good response. The patient became much more alert and was talking to thee emergency room staff within one minute of [MEDICATION NAME] administration. Her blood pressure and pulse are subsequently improved as did her oxygen saturation. She will be admitted to our hospital to the ICU (intensive Care Unit) for further evaluation...Consultation - [MEDICAL CONDITION]. History of Present Illness: was admitted to service (cardiac) earlier today after being transferred from (facility) where she was found to be unresponsive after starting a 50 mcg [MEDICATION NAME]. She was noted by EMS to be cool and clammy and per (facility) documentation of no blood pressure could be ascertain. Her pulse rate was 44 per minute. Her oxygen saturation was in the 80's. EMS reports indicate that her respirations were quite shallow and the patient was unresponsive. Pupils were noted to be dilated and slow to react. EMS noted a heart rate of 36 per minute. [MEDICATION NAME] 0.5 mg was given and pacing pads were placed on the patient. The patient was transcutaneously paced on route to the emergency room . blood pressure in the ambulance was 80 systolic with a persistent heart rate of 26 per minute prior to transcutaneous pacing. In the emergency room the initial blood pressure was 96/73 with a pulse rate of 69 per minute. Oxygen saturation was 92% on five liters nassal cannula oxygen. The patient was treated with [MEDICATION NAME] ([MEDICATION NAME]) intravenously as well as intravenous fluids and became more responsive." On 5/8/13 at 10:35 a.m., this surveyor advised the administrative team about the concerns for Resident #10's two episodes of unresponsiveness. On 5/8/13 at 11:30 a.m., this surveyor requested the facility's policy regarding pain management/documentation. On 5/8/13 at 11:35 a.m., the director of nurses brought this surveyor a green folder and stated this was the prior director of nurses investigation. Inside the green folder was three audit tools dated 1/18/13, 1/22/13, 1/28/13; two inservice trainings with 11 names without signatures; a 1/21/13 assessment of resident's observed with change of condition; a 1/22/13 review of progress notes and communication board for resident's with changes of condition; and a copy of the 1/7/13 ER visit with a fax date of 5/7/13. On 5/8/13 at 12:58 p.m., this surveyor asked the director of nurses if there was anything else from the green folder that this surveyor needed to see. The director of nurses stated "this was the prior director of nurses investigation. I will look to see if there is anything else." On 5/8/13 at 1:15 p.m., this surveyor received the facility's policy titled "Pain Management Policy and Procedure" which documented "When routine pain management has been initated, the resident's level of pain will be assessed every shift using the Pain Management Log. This log will be used until it is determined that the plan of treatment is effective. A consistent pain rating of 2 or below for 2 weeks is evidence of effective pain management." On 5/8/13 at 2:35 p.m., this surveyor advised the administrative team that the pain management record log was blank after the date of 1/16/13. The director of nurses advised this surveyor that according to their policy, if the pain level is reported at a two or lower for two weeks, the form did not need to be filled out anymore. No other information was provided to this surveyor prior to the exit conference on 5/8/13. On 5/9/13 at 12:30 p.m, the facility's consulting pharmacist returned the call to this surveyor. The pharmacist stated that her director gave her the message from 5/8/13 that this surveyor wanted to speak with her regarding the resident. This surveyor asked the pharmacist about her documentation about the missing discharge information from Resident #10's 1/17/13 acute hospital stay. The pharmacist advised this surveyor that she had "requested that information 2/13, 3/13, and 4/13 and has yet to see anything." When asked about the [MEDICATION NAME] at 50 mcg and no prn pain medication for breakthrough pain, the pharmacist stated "normally we would see a prn medication of 5 mg for breakthrough pain." The pharmacist then asked what the resident's pain level was at, to which this surveyor read her the documentation from the pain management log. The pharmacist stated "I should be able to review the record, including the hospital record during my next review. I really cannot say why the [MEDICATION NAME] 50 mcg patch was ordered." 2. Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 1/24/13 coded the resident with a brief interview for mental status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. The clinical record was reviewed from 5/7/13 to 5/8/13. The 4/13 physician's orders [REDACTED]. "[MEDICATION NAME] 50 mg 1 by mouth twice daily for [MEDICAL CONDITION] anxiety" with an order date of 2/5/13. "[MEDICATION NAME] 50 mg 1 by mouth daily for depression" with an order date of 2/6/13. A physician's visit note dated 2/5/13 documented "History: The nurses report that the patient has periods of heightened anxiety where he begins to yell and curse at the nursing staff at irregular intervals. Assessment: 1. Periods increased anxiety intermingled with periods of apparent depression. Plan: 1. We will give [MEDICATION NAME] 50 mg b.i.d. (twice a day) and monitor. 2. We will continue other medications as ordered." The progress notes documented the following: "1/15/13 at 05:49 (5:49 a.m.) - resident refused to have routine labs drawn, attempted x (times) 2. will report to oncoming shift." "1/30/13 at 08:00 (8:00 a.m.) - Resident noted to be very aggressive with staff and other residents, cursing, yelling. Attempted redirection. This has been resident's behavior several times this week. MD made aware, see new orders." "2/2/13 at 07:42 (7:42 a.m.) - resident refused to have lab drawn for a [MEDICATION NAME] level this am.reported to 1st shift nurse." "2/4/13 at 06:05 (6:05 a.m.) - Resident refused x2 offered blood to be obtained for ordered lab [MEDICATION NAME] level." "2/4/13 at 10:16 (10:16 a.m.) - Resident refused [MEDICATION NAME] level. Started yelling at this nurse stating 'you ain't getting nothing from me, now get out of here'. MD made aware." "2/5/13 at 06:04 (6:04 a.m.) - resident refused labs to be obtained x2 offered." "2/5/13 at 15:03 (3:03 p.m.) - refused to allow staff x2 separate nurses to draw [MEDICATION NAME] level today." "2/6/13 at 06:38 (6:38 a.m.) - Resident refused to have ordered labs drawn." "2/6/13 at 7:37 (7:37 a.m.) - Requested to draw labs X2. Resident stated 'I am trying to sleep can't you see'. Refused labs. MD aware." "2/8/13 at 04:52 (4:5

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure one of 19 residents (Resident #8) was free from unnecessary drugs, in excessive dose, and for excessive duration and did not adequately monitor for adverse consequences. The facility staff failed to adequately monitor for adverse reactions and failed to ensure the Resident # 8 was free of unnecessary medications. As a result Resident # 8 was found unresponsive and sent to the ED (emergency department) where the resident was diagnosed with [REDACTED]. Findings include: Resident # 8 was admitted to the facility originally on 10/04/10, with the most current readmission on 04/05/11. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment, dated 08/31/12. Resident # 8 was assessed as having a cognitive score of "2", which indicated the resident was severely impaired in daily decision making skills. The resident was also assessed as requiring extensive to total assistance for most ADL's (activities of daily living). Additionally, the resident was assessed as having pain frequently, with a pain intensity rating of "2" (on a scale of 0-10). A significant change MDS assessment was reviewed, dated 06/08/12 for comparison. Resident # 8 was assessed as having a cognitive score of "4" and was assessed as requiring extensive to total assistance for most ADL's. Resident # 8 was also assessed on this MDS as having pain frequently with a pain intensity rating of "2" (on a scale of 0-10) Resident # 8 was observed on 10/01/12 at 2:50 p.m., the resident was resting in bed, supine, with eyes closed. During clinical record review on 10/02/12 at approximately 8:00 a.m., a partial set of hospital discharge instructions (dated 05/29/12) for Resident # 8 were observed in the progress notes section. The instructions stated that, "...you have been treated for [REDACTED]. The May 2012 POS (physician's orders [REDACTED]. Nursing notes were reviewed for the month of May 2012 and revealed the following: 05/02/12-3:39 a.m.-"Resident in room in bed confused. Asking where she was and when she was going back to her room." 05/02/12-5:28 a.m.-"resident having periods of increased confusion..." 05/08/12-10:00 a.m.-"Resident complained of nausea, no vomiting..." 05/08/12-2:30 p.m.-"Resident complained of nauseous and feeling "sick all over." MD made aware..." 05/08/12-6:38 p.m.-"Resident feeling nausea and leg pain. She was crying and saying she wanted to go to the hospital. MD aware said to send her to ER." 05/09/12-12:10 a.m.-"Resident returned...medicated with scheduled pain med with effective results..." 05/11/12-12:26 p.m.-"Resident vomited X (times) 1. MD aware new order for GI (gastrointestinal) consult." 05/17/12-1:00 p.m.-"Resident...confused about time and date. Lethargic and having trouble remembering what she should be doing. Doctor advised to send to ER..." 05/21/12-6:08 a.m.-"Resident very confused." 05/29/12-3:04 p.m.-"CNA reported to nurse that she could not awaken resident...could not get resident to respond...taken to ER..." 05/29/12-7:30 p.m.-"Resident returned from ER with a [DIAGNOSES REDACTED]. MD notified and an order was given to D/C (discontinue) [MEDICATION NAME]." The physician's progress notes were then reviewed. A physician's progress note dated 05/29/12, documented: "...The nurses report that she was found in her room, lying in bed, unresponsive to physical or verbal stimuli...Altered mental state...We will send the patient to the emergency room for evaluation since she is unresponsive...signature of physician." On 10/02/12 at approximately 10:50 a.m., Resident # 8's closed clinical record was requested from the DON (director of nursing). The closed clinical record was presented shortly thereafter and reviewed. Additional physician's orders [REDACTED]. On May 22nd, 2012 four (4) separate physician's orders [REDACTED]. 1. 05/22/12 "...Decrease [MEDICATION NAME] 5-325 to (1) tab PO (by mouth) q 6 h(every 6 hours) prn (as needed)...signature of physician." 2. 05/22/12 "Order clarification [MEDICATION NAME] 5-325 (2) tablets every 6 hours while awake for pain. per doctors orders..." 3. 05/22/12 "D/C (discontinue) [MEDICATION NAME] 5-325 (1) tab PO q 6 h prn pain per doctors orders..." 4. 05/22/12 "D/C [MEDICATION NAME] 5-325 tab (2) tabs every 6 hours by mouth for pain..." According to the last physician's orders [REDACTED]. On 05/25/12 a physician's orders [REDACTED]. Resident # 8's MARs (medication administration records) were reviewed for the month of May 2012 and revealed that Resident # 8 received the following medications: [REDACTED] The physician's orders [REDACTED]. The resident continued to receive the medication. On 05/22/12 Resident # 8 received a total of: [MEDICATION NAME] 2 mg, [MEDICATION NAME] (5/325 mg each tab) 6 tabs total= 30/1950 (30 mg of [MEDICATION NAME]/1950 mg of Tylenol) and also received [MEDICATION NAME] (muscle relaxer) 8 mg. According to the MAR (medication administration record) Resident # 8 received [MEDICATION NAME] 2 mg, [MEDICATION NAME] 8 mg, and [MEDICATION NAME] (5/325 mg each tab) 8 tabs total= 40/2600 (40 mg of [MEDICATION NAME]/2600 mg of Tylenol) each day on 05/23, 05/24, and 05/25/12. On 05/26, 05/27, 05/28/12, Resident # 8 received [MEDICATION NAME] 3 mg, [MEDICATION NAME] (5/325 mg each tab) 8 tabs (40/2600mg total) and [MEDICATION NAME] 8 mg each day. On May 29th, Resident # 8 received [MEDICATION NAME] 2 mg and [MEDICATION NAME] (5/325 mg each tab) 2 tabs (10/650mg total) and [MEDICATION NAME] 8 mg each day. Resident # 8's CCP (comprehensive care plan) in effect for May 2012 was reviewed and documented: "...observe and report changes in cognitive status that are significant to MD...Meds as ordered...Assess and/or monitor for anxiety behavioral symptoms and notify MD for needed interventions...Monitor for any significant changes in cognitive status such as increased confusion or drowsiness, or unsteadiness and notify MD as needed...Monitor moods and behaviors per facility protocol..pain assessment to establish effective pain management, document per policy characteristics of pain such as frequency, duration, location, severity and notify MD as needed for any change in meds, document any non-verbal indicators of pain such as grimacing or crying, document effectiveness of pain meds and notify MD if pain med is not effective..." On 10/02/12 at approximately 1:15 p.m., the administrator and DON (director of nursing) were made aware of concerns regarding the amount of narcotic/sedating medication Resident # 8 received and the visit to the emergency roiagnom on [DATE], which diagnosed the resident as having a narcotic overdose. The DON stated that she would have to look at the chart and review, because she could not recall at that time. The hospital discharge summary was requested at this time. The DON stated that she did not know if they (the facility) had that information, but would look. A policy on pain (assessment/interventions) was requested at this time. The DON stated, "...we don't have a policy on pain or monitoring pain..." The DON was asked if type of investigation had been completed, the DON stated, "No." "Pain Management Logs" for Resident # 8 were reviewed at this time for the month of May 2012. One sheet was observed, the start date was May 3 and the end date was May 15th. This log did not cover the entire month of May and did not include all doses of pain medication administered to Resident # 8. Another pain management log was reviewed dated May 26th through May 29th, this log did not include all doses of pain medication, did not provide results of the medication or any side effects of the medication. On 10/02/12 at 4:35 p.m., LPN (Licensed Practical Nurse) # 1 was interviewed regarding Resident # 8. LPN # 1 stated that she was the nurse coming on duty that day for the 3-11 shift. The LPN stated that nothing unusual was given to her in report regarding Resident # 8 that day. LPN # 1 stated that around 4:00 p.m. a CNA reported to her that she could not wake Resident # 8, that the resident was unresponsive. LPN # 1 further stated that she checked Resident # 8 over had another nurse come in and check the resident as well. LPN # 1 stated that the Medical Director was in the building at the time and that he was called to the room and he ordered for the resident to be sent out. On 10/03/12 the DON and the ADON (assistant director of nursing) were interviewed in a meeting with the survey team at 11:30 a.m. The DON and ADON were asked what was being done for Resident # 8 regarding managing her pain. The DON stated that they (the facility) were trying to get her pain under control and that they (the facility) gradually increased her pain medications and "...they (the medications) caught up with her..." The DON stated that we were monitoring her. The DON was asked how they were monitoring the resident, the DON stated we, "...document in the nurse's notes..." When asked what non-pharmacological interventions were used for Resident # 8, the DON stated that we (the facility) communicated with the family and the Medical Director. The DON stated that we spoke with the Medical Director about "anything else we can do" for her. The DON and ADON were asked at this time if they felt like the resident's pain had been or was being managed. The DON stated, "No." The ADON agreed with the DON and nodded her head "no." The DON stated that, there aren't any pain clinics in our community. The ADON stated, "We do make suggestions to him (Medical Director) and the resident was in therapy. The ADON and DON were made aware of the therapy notes for the month of May that documented the resident was not attending therapy due to pain and sickness. The hospital records for Resident # 8 were presented at this time for May 29th, 2012. Nursing notes were reviewed from June 2012 up to present for Resident # 8 and documented the following: 06/04/12-"Resident lying in be calling help help me... 06/07/12-"Resident noted to be crying most of shift off and on stating that her legs are hurting from her knees down..." 06/08/12-"...Significant change...decline in ADLs Is total assist for ADLs and is no longer transferring self...Has complaints of pain...Has increased tearful moods..." 06/16/12-"Resident complained of her leg hurting..." 06/17/12-"...left leg...still hurt some." 06/22/12-"Noted in bed yelling...very confused and agitated. Stated she was making bread all night and needed thread to sew up her feet and that her feet were killing her. Resident also disrobing...MD aware..." 06/27/12-"Resident having hallucination and delusion (sic)..." 06/27/12-"...having difficulty swallowing, stated that her throat hurts, very lethargic, falling asleep while eating...MD aware..." 06/30/12-"Resident in bed talking loudly to herself. Calling Ms. Berta. Resident given prn [MEDICATION NAME]. This did not help..." Nursing notes through out the month of July, August and September (2012) revealed that the resident continued to have complaints of pain, as well as increased confusion with episodes of hallucinations and delusional type of behaviors. On 10/03/12 at 1:45 p.m., the MD (Medical Director) (Resident # 8's attending physician) was interviewed via telephone by the survey team. The Medical Director stated that the resident had chronic pain in her legs, nurses were reporting that she was crying/yelling out night and day. The MD also stated that with the continued behavior, gradually the medications were increased. The MD was made aware of the of review of the multiple physician's orders [REDACTED]. The MD voiced that he had not reviewed the MARs and was not aware of what the resident received during that time (May 2012) and stated, "I was meaning to look at the chart." The MD stated that we (the facility) would keep increasing until she was pain free then back off. The MD was asked what other interventions were attempted. The MD stated, "Other things." The MD was asked specifically what "other things" had been attempted, the MD stated, "Medications." The MD stated, that they (the facility) couldn't figure out the etiology of her pain, that she had arthritis, but it "didn't seem arthritis would cause that much pain." The MD was asked what was being done to manage the resident's pain. The MD stated we sent her to a rheumatologist and to the orthopedic but could not figure out where the pain was coming from. The MD was asked if he felt like Resident # 8's pain was being effectively managed. The MD stated that she was put on a new medication last week and that seemed to be working. The MD was asked if pain management resources had been considered. The MD stated, "People don't send nursing home patients to a pain clinic." The MD was asked why couldn't nursing home patients be seen for pain management; the MD stated, "I've never heard of that, have you?" Pharmacy recommendations were reviewed and documented: "06/16/12 Resident found unresponsive on May 29th and went to ER where narcotic overdose was diagnosed . Her narcotics had been adjusted multiple times just prior. Do we have measures in place to prevent this from happening again?...signature of MD 06/26/12" The MD signed this sheet but did not "agree", "disagree", or "other", no measures were addressed regarding this pharmacy recommendation. The MD was informed of the serious concerns regarding Resident # 8's pain, the large amounts of pain medication the resident was receiving and that the resident was continuing to have pain, as well as having increased confusion with [MEDICAL CONDITION] and hallucinations. The resident's current (comprehensive care plan) CCP was reviewed and documented: "...Administer medications as ordered by the physician...notify physician if pain management is not effective...pain assessment for establishment of effective pain management program..." The hospital records documented: "The pt. presents with confusion and being unresponsive. The pt. given [MEDICATION NAME] and became responsive...PT WAS ONLY RESPONSIVE TO PAINFUL STIMULI UPON ARRIVAL. 1 MG [MEDICATION NAME] GIVEN EN ROUTE TO THE ED PER RESCUE PT IMMEDIATELY BEGAN COMING AROUND..." No further information or documentation was provided prior to the exit conference to evidence that Resident # 8's pain was effectively managed or appropriately monitored to prevent untoward side effects.