Every finding on record at Binger Nursing and Rehabilitation

Based on observation and interview, the facility failed to accommodate resident preferences of handwashing water temperatures for 1 (#10) of 4 resident sinks temped. The director of nursing identified 33 residents resided in the facility. Findings: On 04/16/25 at 12:59 p.m., Resident #10's hot water faucet handle was turned on and the water temperature reached 105.9 degrees F. An annual resident assessment, dated 04/09/25, showed the cognition for Resident #10 was moderately impaired. On 04/16/ at 12:58 p.m., Resident #10 stated, It's as cold as can be. On 04/16/25 at 12:55 p.m., the maintenance director stated some rooms take longer to heat/warm than others. On 04/16/25 at 1:20 p.m., the maintenance director stated to wash their hands it didn't need to be too hot.

Based on observation, record review, and interview, the facility failed to provide privacy curtains for three (#1, 3, and #4) of four sampled residents reviewed for enteral nutrition. The DON/RN reported four residents resided in the facility with enteral nutrition. Findings: The Enteral Tube Feeding via Syringe (Bolus) policy, read in part, If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them they may now enter the room. On 01/22/25 at 1:45 p.m., LPN #1 was observed administering enteral nutrition to Resident #3 and did not provide privacy from their roommate Resident #4. LPN #1 was asked why they did not use privacy curtains and they stated they did not have a privacy curtain to separate the two residents. They were asked if Resident #1 had a privacy curtain. They stated they did not have a privacy curtain. On 01/22/25 at 2:05 p.m., DON/RN was asked about privacy curtains for Resident #1, 3, and #4. They observed the residents' rooms and agreed the rooms did not have privacy curtains. They reported it was the facility policy to have curtains.

Based on record review and interview, the facility failed to obtain routine laboratory values per physician orders for two (#14 and #25) of five sampled residents reviewed for laboratory results. The administrator identified 37 residents resided in the facility. Findings: An undated Laboratory Services policy, read in part, Labs will only be obtained when ordered by the doctor, physician assistant, nurse practitioner, or clinical nurse specialist. 1. Resident #14 had diagnoses which included unspecified atrial fibrillation, essential hypertension, and unspecified dementia. A physician order, dated 04/17/23, documented to obtain labs every six months in May and November for CBC, CMP, lipids, and prealbumin. The resident's clinical record documented no lab results for May 2024. On 10/28/24 at 9:30 a.m., the DON reported it looked like the labs were missed in May 2024. On 10/28/24 at 9:50 a.m., the DON reported they did not have any labs in May. They reported the orders were in the laboratory system for Resident #14's labs to be drawn in November. 2. Resident #25 had diagnoses which included dementia with Lewy Bodies, Parkinson's, and essential hypertension. A physician order, dated 04/12/23, documented to obtain labs every six months in May and November for CBC, CMP, lipids, and PSA. The resident's clinical record documented no lab results for May 2024. On 10/28/24 at 11:44 a.m., the IP nurse reported Resident #25's labs for May 2024, were not in the clinical record and reported they thought after a year the order dropped out of the computer laboratory.

Based on observation and interview, the facility failed to ensure food and garbage from the kitchen were disposed of properly. The administrator identified 37 residents resided in the facility. Findings: The administrator reported the facility had no policy regarding food and garbage disposal in the kitchen. On 10/22/24 at 7:25 a.m., three large trash cans without lids were observed in the kitchen and two plungers were observed under the dishwashing sink. On 10/28/24 at 11:13 a.m., flies were observed near the back door inside the kitchen area. The dietary manager reported the garbage disposal had been broken for several months which caused the sink to get plugged. They reported a plunger had to be used to unstop it. The dietary manager reported food was disposed of in trash cans which caused them to be very heavy and hard to empty. The dietary manager reported the food in the trash can attracted flies. On 10/28/24 at 11:50 a.m., the administrator reported corporate was aware the garbage disposal in the kitchen was broken and had chosen to not replace it at this time. On 10/28/24 at 1:00 p.m., two large gray uncovered trash cans were observed with filled black trash bags of garbage inside of both. The uncovered trash cans were swarmed with flies. The trash had not been transported to the facility's large metal garbage containers.

Based on observation, record review, and interview, the facility failed to ensure an adequate call light system for 16 residents who resided on the 400 hall. The Resident Census and Conditions of Residents form, dated 08/16/23, documented 37 residents resided in the facility. Findings: On 08/16/23 at 10:30 a.m., the 400 hall was toured. Numerous residents reported the call light system had been non-working since 07/30/23. Residents were observed to have small tins with some beads and a couple of pennies inside to use as rattles in place of call lights. The residents reported the rattles didn't work because the aides couldn't hear them and no one came when they rattled them. On 08/16/23 at 11:15 a.m., Resident #26 reported he shook the rattle all the time but no one ever came. On 08/16/23 at 11: 23 a.m., Resident #33 reported they didn't even use the rattle because the staff couldn't hear it. On 08/16/23 at 11:30 a.m., Resident #25 reported they used the rattle but staff couldn't hear it and it did no good to use it. On 08/16/23 at 11:35 a.m., Resident #21 reported staff couldn't hear it so they didn't get any help. On 08/16/23 at 11:39 a.m., Resident #13 reported they did not have a way to contact staff. On 08/16/23 at 11:43 a.m., Resident #15 reported they did not have a call device and stated they just yelled out for staff. On 08/16/23 at 11:00 a.m., LPN #1 reported they asked for bells but they got the tins instead. The LPN reported they were doing 15 minute rounds in the beginning but no one was doing that now. On 08/16/23, the surveyor observed hall 400 from 11:00 a.m. to 12:00 p.m. The surveyor did a continuous rattle for ten minutes with one of the resident's tins. No aides came to the hall until 11:57 a.m. On 08/16/23 at 12:00 p.m., CNA #1 reported they were doing two-hour rounding. On 08/16/23 at 12:30 p.m., the maintenance manager reported the call light system went down on 07/30/23. He reported they had to outsource it to be fixed and no one had come to make the repairs. He stated he texted the people who were expected to do the repairs and they replied it would be 08/24/23 before they could come to fix it. On 08/16/23 at 2:40 p.m., Resident #4 was observed to have a paddle-stick with a rattle taped to it on the bedside table. The resident reported staff couldn't hear it so they went around the corner to get help from staff. On 08/17/23, the DON provided the 15-minute rounding sheets for 07/30/23, 07/31/23, 08/01/23, 08/02/23, 08/04/23, and 08/07/23. There were none provided for 08/08/23 though 08/16/23. The DON reported the facility did not have a policy for call lights. The DON reported 11 of the 16 residents on the 400 hall were dependent residents. On 08/21/23 at 3:30 p.m., the DON reported they had ordered bells but they had not come in until that morning. She reported when the call lights went out they started the 15-minute rounding but it fell by the wayside. The DON stated they restarted the 15-minute rounding the day the surveyors arrived. The DON reported the tin rattles were not as effective for a call light system as they should have been.

Based on record review and interview, the facility failed to transmit an MDS discharge assessment, within 14 days following a discharge, for one (#31) of two residents sampled for discharges. The Resident Census and Conditions of Residents form, dated 08/16/23, documented 37 residents resided in the facility. Findings: The MDS Assessment Coordinator policy, not dated, read in part, .A Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS) . On 08/17/23 at 02:52 p.m., the assessment coordinator reported Resident #31 admitted on [DATE] and discharged on [DATE]. The assessment coordinator reported they thought Resident #31 would stay in the facility for awhile, but the resident went back home on hospice shortly after admission. A document titled, MDS 3.0, not dated, read in part, .Record submitted Late: This submission date is more than 14 days after . On 08/17/23 at 03:54 p.m., the assessment coordinator reported they had re-submitted the discharge MDS assessment and it came back as accepted, but it was late. They reported it was accepted today on 08/17/23, but they had no documentation to indicate the assessment was accepted previously.

Based on record review, observation, and interview, the facility failed to ensure oxygen was administered per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator reported 37 residents resided in the facility. Findings: 1. Resident #15 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment documented the resident required oxygen therapy. The resident's care plan did not address oxygen therapy. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/30/22 at 9:31 a.m., the resident's oxygen was observed to be at 3 lpm per nasal cannula. On 08/30/22 at 1:28 p.m., the resident's oxygen was observed to be at 3.5 lpm per NC On 08/31/22 at 3:09 p.m., the oxygen was observed to be set on 4 lpm. The charge nurse observed the setting and reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident # 22 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Physician Order, dated 02/01/22, documented, Oxygen - May have O2 at 2 liters via NC as needed to maintain sats above 90%. The resident's Care Plan, documented Oxygen at 2 liters via NC as needed to maintain sats above 90% . An MDS assessment, dated 06/19/22, documented the resident was cognitively intact. On 08/30/22 at 10:06 a.m., the resident was observed in bed, receiving O2 via nasal cannula. The O2 concentrator was set at 3 LPM. On 08/31/22 at 3:30 p.m., the resident was observed during wound care, receiving O2 via NC at a rate of 3 LPM. The resident reported she had not asked any staff to adjust the setting of her O2 and was unaware of what it was to be set on. On 08/31/22 at 3:40 p.m., the Charge Nurse reported resident #22's oxygen rate should be set at 2 liters and she had not adjusted the level on her shift. The charge nurse reported residents oxygen should be checked each shift. She reported in-service education would be done with staff to ensure only licensed nursing staff adjusted O2 flow rates. On 09/01/22 at 8:35 a.m., the resident was observed in bed, receiving O2 via NC at 3 LPM. At 08:45 a.m., an interview with CNA #1 and CNA #2 was conducted, both reported they check residents O2 sats and assist with putting on O2 tubing if needed. The CNA's reported they only turn the O2 concentrator on and off, they are not allowed to adjust the flow rate. At 09:40 a.m., LPN #2 reported that she does not check residents' oxygen flow rate on the day shift unless there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At 10:10 a.m., LPN #1 reported the facility did not have an oxygen policy.

Based on record review, observation, and interview the facility failed to notify the physician of a significant weight loss for one (# 36) of four residents reviewed for nutritional needs. The facility Resident Census and Conditions of Residents report documented two residents with unplanned weight loss. The Administrator reported a resident census of 37. Findings: Resident #36 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 07/15/22, documented the resident's cognition was intact and required supervision with eating and all activities of daily living. A care plan, dated 07/29/22, documented the resident received a regular diet and was able to feed self after tray was set up, and significant weight gain or loss > 5 lbs. would be reported to the physician. A dietician recommendation form dated 08/27/22 for Resident #36 documented weight loss of 10% (13 lbs.) and included interventions to be added to the resident's diet to prevent further weight loss. There was no documentaton located in Resident #36 chart to indicate the physician had been notified of the the 13 pound (10%) weight loss. On 08/31/22 at 10:47 a.m., LPN #1 reported the physician was in-house today, and is in agreement with the dietician's recommendations. The LPN provided the physician's new orders and reported no documentation was found where the physician had been previously notified of the resident's weight loss.

Based on record review and interview, the facility failed to inform resident families and/or representatives by 5:00 p.m. the next calendar day of testing positive for COVID-19 for five (#5, 10, 12, 23, and #27) of five residents reviewed for notification. The Administrator reported 37 residents resided in the facility. Findings: The Monthly Infection Control Log, dated July 2022, documented five residents (#5, 10, 12, 23, and #27) tested positive for COVID-19 on 07-31-22. Review of the residents' clinical records documented no notification was made to families and/or representatives of the resident's positive COVID-19 test. On 08/31/22 at 12:04 p.m., the IP reported no documentation was found that the families and/or representatives of the residents that tested positive for COVID-19 on 07/31/22 had been notified by 5:00 p.m. the following day. On 08/31/22 at 3:30 p.m., the IP reported residents and their families and/or representatives are made aware the facility is in outbreak when the first resident or staff member tests positive for COVID-19. The IP reported resident families and/or representatives should be contacted again if the resident has a positive COVID-19 test and is put on isolation precautions.

Based on record review, observation, and interview, the facility failed to ensure all staff were fully vaccinated for Covid-19 and to implement additional precautions of wearing N95 masks, as recommended by the CDC, intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for Covid-19. The Administrator reported 37 residents currently resided in the facility. Findings: The facility policy Covid-19 Vaccination Policy, dated 01/19/22, read in parts, .All staff must be vaccinated by March 15, 2022, or will be placed on unpaid leave until fully vaccinated .Employees that are granted medical or religious exemption or have delayed immunization for reason outlined in the regulation will be required to wear N95 masks at all time and adhere to the core principles. On 04/05/22 upon entrance to the facility and throughout the investigation all staff were observed wearing surgical masks, no staff were observed wearing N95 masks. The Administrator reported no positive Covid in the facility and not residents in quarantine at this time. The formCovid-19 Staff Vaccination Status for Providers, dated 04/05/22, documented 25 staff members were granted vaccination exemptions, and two staff members were partially vaccinated. On 04/06/22 at 2:00 p.m., the IP reported CNA #1 and CNA #2 were partially vaccinated for Covid-19: 1. CNA # 1 had Covid-19 Pfizer vaccination dose #1 on 11/29/21 and should have gotten the 2nd dose in December 2021. The IP reported CNA #1 had been reminded of being past due but had not followed through with the 2nd dose and had still been allowed to work. The IP reported CNA #1 had not been placed on leave without pay per the facility's policy but gave no reason why when asked. 2. CNA #2 had received dose #1 of the Moderna Covid-19 vaccination on 02/09/22 and should have gotten the 2nd dose in March 2022. The IP reported CNA #2 had been reminded she was overdue and was going to get it 04/06/22. The IP reported CNA #2 had not been placed on leave without pay per the facility's policy but gave no reason why when asked. On 04/06/22 at 2:35 p.m., CMA #1 was observed to bring a resident in a wheelchair back into the facility from smoking, wearing a surgical mask. CMA #1 reported not having an N95 mask and had not been told that she needed to wear one. CMA #1 reported having a granted exemption for the Covid vaccination and was wearing a surgical mask. On 04/06/22 at 2:40 p.m., CNA #3 was observed wearing a surgical mask. CNA #3 reported only wearing a surgical mask and could not recall being told wear an N95 mask since not being vaccinated for Covid-19. CNA #3 reported as having a Covid-19 vaccination exemption. On 04/06/22 at 3:00 p.m., the DON reported staff that are not fully vaccinated for Covid should be wearing a N95 mask in the facility.

Based on observation, interview, and record review, it was determined the facility failed to keep an accounting ledger of residents' personal funds for three (#15, #28, and #47) of three residents reviewed for trust funds. The facility identified 12 residents with resident trust fund accounts. Findings: A facility policy documented .To protect each Resident's fund, the facility: Shall maintain and allow each resident or his/her legal guardian or representative access to a written record of all financial arrangements and transactions involving the individual resident's funds. Shall provide each resident, or his/her representative, with a written itemized statement ., of all financial transactions involving the resident's funds. Trust Fund account records were reviewed for residents #15, #28, and #47. There were no documented ledgers and/or itemized statements for the residents personal funds held in the trust account. On 07/12/21 at 1:22 p.m., the facility ADM reported residents or their POA were provided a statement each month for the residents' trust fund account. She reported the resident's personal funds were debited from the resident's trust fund and placed in petty cash. She reported the resident provided her a list of items to purchase and she would use petty cash to purchase it. The money was kept in her office separated for each resident. She reported not having any kind of accounting system to track the transactions, or an itemized statement, and stated she only kept the receipts. She reported some receipts had both the resident's items and the facility items on the same receipt as one transaction instead of being separated. She reported she was the only employee that had access to the petty cash and when the resident brought her a list they looked to see how much money the resident had available by counting the cash with the resident. On 07/12/21 at 1:27 p.m., the ADM reported she did not have receipts for all cash transactions. On 07/12/21 at 2:29 p.m., resident #15 reported when he needed items, he gave a list to the ADM and she would make the purchase. He reported he had not received a statement for his trust fund account or personal funds. He stated he would ask the ADM how much money he had and she would tell him. On 07/12/21 at 3:59 p.m., the ADM reported resident #15 currently had $20 in his personal fund. She reported that monthly trust fund statements had not been sent for June and July 2021, and there was no documentation of statements being submitted to residents or their representative. On 07/12/21 at 4:05 p.m., interviews were conducted with residents with trust fund accounts. An additional five residents (#9, #11, #17, #19, and #37) reported they had never received a statement for their trust fund account. He reported he had to go to the ADM's office and ask how much money he had available. The POA for resident #37 was interviewed and reported she had not received any trust fund statements from the facility. On 07/13/21 at 11:08 a.m., the POA for resident #15 was interviewed and reported the facility had emailed her the receipts the previous day that she had requested back in June 2020. She reported she had concerns with not receiving itemized quarterly statements for the resident's trust fund or personal fund account.

Based on interview and record review, it was determined the facility failed to provide an advanced beneficiary notice, describing charges for covered and non-covered services, for three (#18, #26, and #46) of three residents reviewed for Skilled Nursing Facility Advance Beneficiary Notice. The administrator reported 20 residents had received skilled nursing services in the past six months. Findings: A review of the clinical records for residents' #18, 26, and #46 contained no documentation they were provided an ABN when they were discharged from skilled therapy services with days remaining. On 07/07/21 at 10:44 a.m., three advanced beneficiary notices (ABN's) were requested for resident #18, 26, and #46. The facility failed to provide the ABN's for the residents. 07/08/21 at 11:16 a.m., the assessment coordinator was interviewed and reported the documents had not been completed as required.

Based on observation, interview, and record review, it was determined the facility failed to identify the need to monitor or obtain laboratory results for one (#27) of three residents with daily glucose monitoring and potential complications related to chronic health conditions. Findings: Resident #27 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~Atorvastatin Calcium (cholesterol reducing medication) 80 mg (milligram) tablet by mouth at bedtime; ~Fenofibrate (cholesterol reducing medication) 145 mg tablet by mouth daily; ~Finger stick blood sugar monitoring before meals and at bedtime; ~Ozempic (glucose medication) 2 mg/1.5 ml, inject 1 mg subcutaneous once weekly on Tuesday. A care plan, dated 03/17/21, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The documented interventions included to observe labs when ordered and to notify the physician. The care plan also addressed the residents chronic kidney disease and had the following interventions: ~monitor labs and report to the physician as needed; ~monitor for increased [CONDITION(S)] and any signs or symptoms of fluid overload and report it to the physician. The clinical record was reviewed and contained no lab results or any indication of monitoring as indicated by the care plan. A quarterly assessment, dated 06/17/21, documented the resident was severely impaired with cognition. On 07/08/21 at 10:30 a.m., the resident was observed to participate in the resident council meeting. On 07/12/21 at 2:32 p.m., the DON stated she just notified the physician to fax the resident's laboratory results drawn at the hospital on 01/20/21 to the facility. 07/13/21 at 10:17 a.m., the DON was asked about the process to ensure laboratory results were provided and/or obtained to monitor the resident. She stated they had a nurse come in and set the labs up under the treatment tab in the computer and the system would identify when labs were due. The DON was asked when she discovered labs were being missed. She stated it was recognized the previous month and they had been trying to catch up.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with limited range of motion received services or devices to increase, maintain, or prevent further decline in range of motion for one (#22) of one resident reviewed for limited range of motion. The facility reported 26 residents with limited mobility. Findings: Resident #22 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/24/21, documented the resident was non-verbal, did not ambulate, and required total assistance of staff for all activities of daily living. A care plan, dated 05/05/21, documented the resident required assistance of two staff and a lift for transfer, and had limited range of motion to upper and lower extremities. The care plan did not document splints or devices were used for the resident's limited range of motion. On 07/08/21 at 8:15 a.m., CNA #1 and CNA #2 were observed to transfer the resident with a lift. The resident was observed to open forefinger and thumb to hold the bar during transfer. The resident did not open her hand. The staff members were interviewed and did not know of any devices used for the hands to prevent decline in function. At 08:46 a.m., the resident was observed in the dining room with total assistance of staff with the meal. The resident did not open her hands, and was observed only opening her forefinger and thumb. At 11:33 a.m., the physical therapy assistant (PTA) #1 was interviewed and reported the resident had been referred to PT on 04/13/21 for an evaluation. The record documented no physical therapy was indicated. At 11:43 a.m., an interview with LPN #1 reported the resident had been on the restorative program and no splints or hand rolls had been used for the resident's hands. At 11:45 a.m., the DON was interviewed and reported she had not seen the resident with any hand devices and agreed she might benefit from them. She stated she would provide hand rolls immediately. At 12:15 p.m., hospice RN #2 was interviewed and reported the resident was admitted to hospice in 2018 and had no splints or other devices ordered for her hands.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from the use of unnecessary [CONDITION(S)] medications for one (#27) of five residents reviewed for unnecessary medications. The facility failed to evaluate the resident for use of a PRN (as-needed) [CONDITION(S)] medication beyond 14 days. Findings: Resident #27 was admitted to the facility on [DATE] and had diagnoses which included [CONDITION(S)], unspecified dementia without behavioral disturbance, diabetes mellitus without complications, and anxiety. A care plan, dated 03/17/21, documented the resident was administered [CONDITION(S)] drugs daily and to consult with the pharmacist for potential gradual dose reduction. The medication regimen review (MRR), dated 05/21/21, documented the physician agreed to discontinue the as-needed [MEDICATION(S)] on 06/10/21, because the resident was not taking the medication. A new order was written for as-needed [MEDICATION(S)] on 06/15/21. A physician's order documented [MEDICATION(S)] tab 0.25 mg (milligrams) as needed by mouth once daily for anxiety with a start date of 06/15/21. Routine [MEDICATION(S)], give 0.25 mg one by mouth twice daily, at 08:00 and 20:00. A quarterly assessment, dated 06/17/21, documented the resident was severely impaired with cognition. The assessment documented the resident received anti-anxiety medication seven of seven days previous. On 07/08/21 at 10:30 a.m., the resident was observed when she participated in the resident council meeting. On 07/12/21 at 2:10 p.m., the DON was asked about an extension or the end date for the PRN [MEDICATION(S)]. The DON reported she thought it was two weeks. She was asked to submit documentation from the physician for a rationale to extend past 14 days. The DON reviewed the paper chart and the electronic record and found no rationale to extend the medication.

Based on observation, interview, and record review, it was determined the facility failed to obtain laboratory blood tests per physician orders, for one (#28) of five residents reviewed for routine laboratory orders. The facility reported 43 residents resided in the facility. Findings: Resident #28 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/21/21, documented the resident received insulin injections during the last 7 days. The care plan, dated 6/22/21, documented to obtain HGBA1C (a blood test that measures blood sugar over a period of time) blood draw every 3 months, September, December, March, and June. The care plan documented to report laboratory (lab) results to the medical doctor and follow up as indicated. The clinical record was reviewed and documented no A1C laboratory blood test obtained for December 2020, March 2021, or June 2021. On 07/12/21 at 2:52 p.m., the director of nurses reviewed the clinical record and reported the ordered labs had not been scheduled and were not obtained per physician orders.

Based on record reviews and interviews, it was determined the facility failed to notify the physician when a resident experienced changes in condition for one (#1) of three sampled residents reviewed with changes in condition. The administrator identified 34 residents who resided in the facility. Findings: A facility policy titled, Change in a Resident's Condition or Status, documented: .Our facility shall promptly notify the resident, his or her attending physician .of changes in the resident's medical .condition . Policy Implementation .The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .A significant change in the resident's physical/emotional/mental condition .A need to alter the resident's medical treatment significantly .Instructions to notify the physician of changes in the resident's condition .The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated initiated on 08/07/18, documented the resident was incontinent of bowel and bladder. The care plan identified an intervention was to observe the resident for signs/symptoms of a UTI (urinary tract infection) such as pain, burning, increased temperature, increased back pain and foul smelling urine. The care plan identified the resident had a history of [REDACTED]. A nurse's progress note, dated 08/08/19 at 3:19 a.m., documented the resident had an extremely large amount of off-white color puss (pus) like discharge from his penis. His urine had a very strong odor and was dark amber in color. The progress note was authored by LPN (licensed practical nurse) #4. There was no documentation the resident's physician was contacted. A nurse's progress note, dated 08/08/19 at 2:23 p.m., documented the resident had copius (sic) amounts of discharge. His bladder was tender and distended to palpitation. The LPN documented she straight catheterized the resident and flushed his bladder. The resident had 1000 ml of dark yellow, cloudy urine with sediment and a foul odor. The resident stated his abdomen felt better following the straight catheterization. The progress note was authored by LPN #1. A nurse's progress note, dated 08/08/19 at 9:53 p.m., documented the resident's urine remained cloudy and dark with a foul odor present. The resident was afebrile. A nurse's progress note, dated 08/09/19 at 12:41 p.m., documented a new physician's orders [REDACTED]. The progress note was authored by LPN #1. The nurse's progress note, dated 08/09/19 at 12:41 p.m., was completed 33 hours after the resident began exhibiting signs/symptoms of a urinary tract infection and [MEDICAL CONDITION]. There was no documentation the physician was notified of ongoing concerns during this period of time. A nurse's progress noted, dated 08/11/19 at 12:13 p.m., was signed by LPN #5. The note documented the physician's orders [REDACTED]. LPN #5 documented immediate thick, yellow urine return noted with gravity flow into the collection bag. A nurse's progress note, dated 08/11/19 at 9:09 p.m., documented the resident's indwelling urinary catheter was observed and had amber colored urine with small clots. There was no documentation the resident's physician was notified the resident had clots in his catheter Nurse's progress notes, dated 08/12/19 through 08/13/19, documented the resident continued to pass blood clots in his urinary catheter for an additional 33 hours. His urine was cloudy. The resident complained the catheter burned at times. The progress notes were signed by LPN #1, 2, and #4 There was no documentation the physician was notified the resident had been passing blood clots in his urine for over 41 hours. A laboratory report, dated 08/14/19 at 1:35 p.m., documented the UA was collected. The laboratory report documented (Named Physician #1) was notified of the results on 08/14/19 at 7:00 p.m. The laboratory test was not obtained until six days after the physician's orders [REDACTED]. The UA results were as follows: moderate blood and small leukocytes. The urine microscopic results documented the specimen was positive for erythrocytes (red blood cells), leukocytes and bacteria. The urine specimen was sent for culture and sensitivity testing. A nurse's progress note, dated 08/16/19 at 10:57 p.m., documented the resident's urine was amber colored, thick consistency and pus was present. LPN #2 flushed the resident's catheter with normal saline. He remained afebrile. There was no documentation the resident's physician was notified his urine was thick and contained pus. A nurse's progress note, dated 08/18/19 at 10:43 a.m., documented the previous nurse who worked the 10:00 p.m. to 6:00 a.m. shift notified her (LPN #6) the resident had dark red colored output in the urinary catheter bag all of the previous shift. LPN #6 documented she assessed the resident's catheter and there was approximately 200 ml of dark red colored output and clots in the catheter tubing. LPN #6 documented the resident refused to allow her to assess the catheter any further and requested to go to the ER (emergency room ) for evaluation and treatment. There was no documentation the physician was notified the resident had started to pass blood and clots in his urine again and had requested to be sent to the ER. emergency room records, dated 08/18/19, documented the resident was evaluated and treated for [REDACTED]. The resident presented with blood in his urinary catheter. emergency room records, dated 08/18/19 at 1:23 p.m., documented the resident was administered [MEDICATION NAME] (an antibiotic) for a UTI. A laboratory test for culture and sensitivity, dated 08/19/19, documented the final results of the culture were positive for greater than 100,000 cfu/ml (colony forming units per milliliter) of Proteus Mirabilis (a bacteria). A nurse's progress note, dated 08/19/19 at 11:33 a.m., documented the resident had returned to the facility and the physician visited the resident and was aware of blood in foley (urinary catheter) bag. The progress note documented the first time the facility staff documented the physician was notified the resident had blood in his urinary catheter. A nurse's progress note, dated 09/25/19 at 3:47 a.m., signed by LPN #4 documented the resident had bright red blood noted around head of penis and urethra, in catheter tubing dark red blood noted with large amounts of clots, UA bag contains dark red blood tinged urine. A nurse's progress note, dated 09/28/19 at 9:58 p.m., documented the resident's urine was clear and yellow. There was no documentation the resident's physician was notified the resident had a new onset of bleeding around his penis and blood clots in his urine. A nurse's progress note, dated 01/09/20 at 5:43 a.m., signed by LPN #2 was reviewed. The note documented the resident was very confused and hallucinating. The resident's urine was dark with sediment and blood in it. The resident complained of flank pain and had a fever of 100.5 F. The resident was administered Tylenol. The physician was contacted and provided an order for [REDACTED].>A nurse's progress note, dated 01/11/20 at 4:06 a.m., was signed by LPN #2. The note documented the resident's urine was still dark cherry colored due to blood. Blood was also coming from penis around catheter. There was no documentation the resident's physician was notified he had a new onset of bleeding coming from his penis. On 02/25/20 at 8:59 a.m., LPN #1 was asked if the resident's physician should have been notified when the resident experienced a new onset of abdominal pain, bladder distention and cloudy urine with sediment. She stated the resident experienced cloudy urine and sediment quite often. She stated staff would encourage the resident to drink more fluids. She stated she had called and emailed the physician many times about the resident. She stated she had been instructed by the nurses and DON she needed to document her communication with the physician better. She stated she had been informed by the nurses and DON she needed to notify the physician every time the resident experienced symptoms. She was asked what could the signs and symptoms indicate. She said, Even though it may be something that happens a lot, it's not normal for him. Could be infection. She was asked to review her nurse's note from 08/08/19 at 2:23 p.m. She acknowledged she documented the resident had copious discharge, bladder pain and distention and his urine was cloudy with sediment and a foul odor. She confirmed the copious discharge was coming from the resident's penis. She acknowledged the resident's symptoms had been going on since the previous shift, 11 hours prior to her note. She then stated she observed the documented symptoms at the beginning of her shift (6:00 a.m. to 2:00 p.m.) She was asked if she had any concerns related to the resident's symptoms. She stated yes. She stated something not normal was going on. She was asked if she notified the resident's physician. She stated she was sure she had, but didn't know for 100 percent. She stated the physician should have been notified of the resident's symptoms. She verified physician notification was not documented. She was asked to review her note from 08/09/19 at 12:41 p.m. She was asked when had the physician been notified of the resident's change in condition which prompted him to write new physician's orders [REDACTED]. She said, I don't know. At 9:10 a.m., LPN #1 reviewed her progress note from 08/13/19 at 2:07 p.m. She acknowledged she had documented the resident had sediment and blood clots in his urine. She was asked if she had any concern when she noted the resident had blood clots in his urine. She stated she was sure she was concerned. She reviewed progress notes from 08/11/19 at 9:09 p.m. to her progress note written two days later. She acknowledged the resident had experienced blood clots in his urine for the previous two days. She was asked if she had notified the physician. She stated she did not know if she had. She stated the physician should have been notified when the blood clots were first observed in his urine. She was asked what could a finding of blood clots in a resident's urine indicate. She stated she did not know, but it was not a normal finding. At 9:30 a.m., LPN #5 reviewed her progress note from 08/11/19 at 12:13 p.m. She acknowledged she placed the physician's orders [REDACTED]. She was asked if she notified the resident's physician that the resident's urine was thick and yellow. She stated he had a history of [REDACTED]. She acknowledged there was no documentation which indicated the resident's urine cleared soon after his catheter was placed. She then stated she would have notified the physician. She acknowledged there was no documentation of physician notification. At 9:36 a.m., LPN #3 was asked to review her progress note from 01/10/20 at 10:33 a.m. She acknowledged she documented the resident had dark bloody urine. She was asked if she notified the physician the resident continued to have blood in his urine. She stated she noticed the blood in in the resident's urine and called the physician. She acknowledged there was no documentation the physician had been notified. She stated normally she documented when she called the physician. She was asked what could blood in the resident's urine indicate. She stated blood could indicate a serious infection. At 10:54 a.m., physician #1 was asked if he was notified when the resident experienced large pus like drainage from his penis, pus in his urine and foul odorous urine, abdominal pain and bladder distention, and blood clots in his urine for 48 hours. He stated he did not recall if he was notified. He stated he would be concerned about any of the listed symptoms. He stated staff should be alert and observing residents for possible signs and symptoms of a UTI. He stated he expected to be notified by the facility staff as soon as they noticed any of the listed symptoms. He stated the symptoms could indicate the resident had a possible infection. He stated blood in the urine could also be a serious matter and he expected to be notified. At 11:09 a.m., the DON was asked what should staff do if they observed copious pus drainage from a resident's penis, pus in the urine, foul smelling urine, bladder pain and distention, and/or blood or blood clots in the urine. She stated staff should notify the physician right away. She stated if the resident's symptoms worsened she expected staff to notify the physician immediately. She stated if a resident experienced the identified symptoms this could indicate a possible infection. She stated the resident could become septic with the infection if untreated. At 1:45 p.m., LPN #2 reviewed her progress note from 08/08/19 at 9:53 p.m. She acknowledged she documented the resident's urine was still cloudy with a foul odor. She stated the resident's urine was usually pretty cloudy and sometimes had an odor. She stated the resident did not have a fever. She was asked if the resident's physician was notified when the resident experienced these symptoms. She stated the physician should have been notified when the resident experienced the symptoms. She stated if he was notified it would have been documented in her progress note. She stated she could not recall if she had notified the physician. She was asked to review her progress notes from 08/13/19 at 9:37 p.m. and 9:39 p.m. She acknowledged she documented the resident had sediment and blood clots in his urine and complained that his catheter burned at times. She was asked if her observations caused her any concern, when had the blood clots started and how was the resident monitored. She stated she was not sure when the blood clots had started. She stated sometimes if the resident's catheter got pulled he got blood clots in his urine and then his urine would clear up. She was asked if she had notified the physician the resident had blood clots in his urine. She stated in general the physician was notified for these types of changes. She stated she would have notified the physician if the blood clots had not cleared up. She was asked to review progress notes from 08/11/19 at 9:09 p.m. to her notes on 08/13/19. She acknowledged the resident had been passing blood clots in his urine since 08/11/19. She stated if it had been going on for that long the physician should have been notified. She was asked to review her progress note from 08/16/19 at 10:57 p.m. She acknowledged she documented the resident's urine was thick with pus. She was asked if the physician was notified of the change in the resident's urine. She stated the physician should have been notified, but she acknowledged there was no documentation he had been. She stated she could not recall if she had notified the physician. She stated new onset of pus in the urine could indicate the resident had an infection. She stated if the infection was left untreated the resident could become septic. She acknowledged she wrote the next progress note on 01/10/20 at 7:00 p.m. for the resident and documented the resident's urine was black, he had a fever of 99.8 F, and pain when the catheter tubing was moved. She was asked if she had notified the physician the resident had black colored urine and a temperature of 99.8 F. She stated she should have notified the physician. She was asked if she notified the physician when the resident had a new onset of bleeding from his penis which she documented in a progress note on 01/11/20 at 4:06 a.m. She stated she was not sure, but she should have. At 2:23 p.m., the DON stated she reviewed the notes on the resident during August 2019, September 2019 and January 2020. She stated she was concerned with the lack of physician notification when the resident had changes in condition. She stated she had definite concerns with the competency level of LPN #1 and #2 and those concerns needed to be addressed. She was notified there were other LPNs who documented progress notes on the resident during the time periods reviewed which included changes of condition in which the physician was not contacted. She acknowledged several staff members did not perform competently related to the care and services provided to resident #1.

Based on record reviews and interviews, it was determined the facility failed to: a. assess, monitor, and intervene when a resident exhibited changes in condition for one (#1) of three sampled residents reviewed with changes in condition; and b. implement a physician's orders [REDACTED].#1) of three sampled residents reviewed with physician's orders [REDACTED]. The administrator identified 34 residents who resided in the facility. Findings: A facility policy titled, Change in a Resident's Condition or Status, documented: .Our facility shall promptly notify the resident, his or her attending physician .of changes in the resident's medical .condition . Policy Implementation .The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .A significant change in the resident's physical/emotional/mental condition .A need to alter the resident's medical treatment significantly .Instructions to notify the physician of changes in the resident's condition .The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Resident #1 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated initiated on 08/07/18, documented the resident was incontinent of bowel and bladder. The care plan identified an intervention was to observe the resident for signs/symptoms of a UTI (urinary tract infection) such as pain, burning, increased temperature, increased back pain and foul smelling urine. The care plan identified the resident had a history of [REDACTED]. A nurse's progress note, dated 08/08/19 at 3:19 a.m., documented the resident had an extremely large amount of off-white color puss (pus) like discharge from his penis. His urine had a very strong odor and was dark amber in color. The progress note was authored by LPN (licensed practical nurse) #4. There was no documentation the physician's orders [REDACTED]. There was no documentation the resident's physician was contacted. A nurse's progress note, dated 08/08/19 at 2:23 p.m., documented the resident had copius (sic) amounts of discharge. His bladder was tender and distended to palpitation. The LPN documented she straight catheterized the resident and flushed his bladder. The resident had 1000 ml of dark yellow, cloudy urine with sediment and a foul odor. The resident stated his abdomen felt better following the straight catheterization. The progress note was authored by LPN #1. A nurse's progress note, dated 08/08/19 at 9:53 p.m., documented the resident's urine remained cloudy and dark with a foul odor present. The resident was afebrile. A nurse's progress note, dated 08/09/19 at 12:41 p.m., documented a new physician's orders [REDACTED]. The progress note was authored by LPN #1. The nurse's progress note, dated 08/09/19 at 12:41 p.m., was completed 33 hours after the resident began exhibiting signs/symptoms of a urinary tract infection and [MEDICAL CONDITION]. There was no documentation the physician was notified of ongoing concerns during this period of time. There was no documentation of any further assessment and monitoring of the resident for his ongoing change in condition. A nurse's progress note, dated 08/10/19 at 2:19 p.m., documented the resident's penis was observed and there was no discharge present. The resident remained afebrile. The nurse's progress note documented the only assessment conducted since 08/08/19 at 2:23 p.m. The assessment was not thorough and did not include the appearance of the resident's urine and palpation of the resident's bladder. A nurse's progress noted, dated 08/11/19 at 12:13 p.m., was signed by LPN #5. The note documented the physician's orders [REDACTED]. The catheter was not placed for over 47 hours after the physician's orders [REDACTED].#5 documented immediate thick, yellow urine return noted with gravity flow into the collection bag. A nurse's progress note, dated 08/11/19 at 9:09 p.m., documented the resident's indwelling urinary catheter was observed and had amber colored urine with small clots. There was no further documentation the resident was assessed and monitored and the physician was notified the resident had clots in his catheter Nurse's progress notes, dated 08/12/19 through 08/13/19, documented the resident continued to pass blood clots in his urinary catheter for an additional 33 hours. His urine was cloudy. The resident complained the catheter burned at times. The progress notes were signed by LPN #1, 2, and #4 The notes did not document the resident refused the collection of the physician ordered laboratory tests. There was no documentation which suggested the facility had attempted to obtain and/or reasons they were unable to obtain the physician's orders [REDACTED]. There was no documentation of thorough assessments and monitoring. A laboratory report, dated 08/14/19 at 1:35 p.m., documented the UA was collected. The laboratory report documented (Named Physician #1) was notified of the results on 08/14/19 at 7:00 p.m. The laboratory test was not obtained until six days after the physician's orders [REDACTED]. The UA results were as follows: moderate blood and small leukocytes. The urine microscopic results documented the specimen was positive for erythrocytes (red blood cells), leukocytes and bacteria. The urine specimen was sent for culture and sensitivity testing. Nurse's progress notes, dated 08/14/19, documented the resident's urine was cloudy and dark amber colored with a large amount of sediment. A nurse's progress note, dated 08/16/19 at 10:57 p.m., documented the resident's urine was amber colored, thick consistency and pus was present. LPN #2 flushed the resident's catheter with normal saline. He remained afebrile. There was no further documentation of a thorough assessment or further monitoring between 08/14/19 and 08/16/19. There was no documentation the resident's physician was notified his urine was thick and contained pus. A nurse's progress note, dated 08/18/19 at 10:43 a.m., documented the previous nurse who worked the 10:00 p.m. to 6:00 a.m. shift notified her (LPN #6) the resident had dark red colored output in the urinary catheter bag all of the previous shift. LPN #6 documented she assessed the resident's catheter and there was approximately 200 ml of dark red colored output and clots in the catheter tubing. LPN #6 documented the resident refused to allow her to assess the catheter any further and requested to go to the ER (emergency room ) for evaluation and treatment. There was no documentation the physician was notified the resident had started to pass blood and clots in his urine again and had requested to be sent to the ER. emergency room records, dated 08/18/19, documented the resident was evaluated and treated for [REDACTED]. The resident presented with blood in his urinary catheter. He remained afebrile. emergency room laboratory records, dated 08/18/19, documented a UA was collected and tested . The UA results were cloudy urine, three plus leukocytes and blood, two plus protein and [MEDICATION NAME] were positive. Urinary microbiology documented elevated white blood cells, red blood cells and bacteria was present. emergency room records, dated 08/18/19 at 1:23 p.m., documented the resident was administered [MEDICATION NAME] (an antibiotic) for a UTI. He was discharged in stable and nontoxic condition. A laboratory test for culture and sensitivity, dated 08/19/19, documented the final results of the culture were positive for greater than 100,000 cfu/ml (colony forming units per milliliter) of Proteus Mirabilis (a bacteria). A nurse's progress note, dated 08/18/19 at 6:20 p.m., documented the resident returned to the facility with orders for Keflex (an antibiotic). He urinary catheter remained thick with reddish brown urine. The physician was notified of the new order. A nurse's progress note, dated 08/19/19 at 11:33 a.m., documented the resident's physician visited the resident and was aware of blood in foley (urinary catheter) bag. The progress note documented the first time the facility staff documented the physician was notified the resident had blood in his urinary catheter. A nurse's progress note, dated 09/25/19 at 3:47 a.m., signed by LPN #4 documented the resident had bright red blood noted around head of penis and urethra, in catheter tubing dark red blood noted with large amounts of clots, UA bag contains dark red blood tinged urine. A nurse's progress note, dated 09/28/19 at 9:58 p.m., documented the resident's urine was clear and yellow. There was no documentation of assessment, monitoring or interventions initiated for a resident who had a new onset of bleeding around the penis and blood clots in the urine. There was no documentation the resident's physician was notified of the change in condition. A nurse's progress note, dated 01/09/20 at 5:43 a.m., signed by LPN #2 was reviewed. The note documented the resident was very confused and hallucinating. The resident's urine was dark with sediment and blood in it. The resident complained of flank pain and had a fever of 100.5 F. The resident was administered Tylenol. The physician was contacted and provided an order for [REDACTED].>A UA laboratory report, dated 01/09/20 at 7:00 a.m., documented the resident's urine was pink and cloudy. The urine was positive for large blood, moderate leukocytes and one plus bacteria. A nurse's progress note, dated 01/09/20, documented the resident's UA results were sent to (Named Physician #1) and the urine specimen had been sent for culture. A nurse's progress note, dated 01/10/20 at 4:07 a.m., signed by LPN #2 documented the next assessment was completed over 22 hours after the most recent assessment of the resident's ongoing change in condition. The resident's urine was black in color with blood in the tubing. The resident complained of pain when the tubing was moved. The resident had a fever of 99.8 F. A nurse's progress note, dated 01/10/20 at 10:33 a.m., documented the resident had dark bloody urine in his urinary catheter and abdominal pain with palpation. The resident was afebrile. A nurse's progress note, dated 01/11/20 at 4:06 a.m., was signed by LPN #2. The note documented the next assessment was completed over 17 hours after the most recent assessment of the resident's ongoing change in condition. The note documented the resident's urine was still dark cherry colored due to blood. Blood was also coming from penis around catheter. There was no documentation the resident's physician was notified he had a new onset of bleeding coming from his penis. A nurse's progress note, dated 01/11/20 at 5:15 a.m., documented a new physician's orders [REDACTED]. On 02/25/20 at 8:59 a.m., LPN #1 was asked if the resident's physician should have been notified when the resident experienced a new onset of abdominal pain, bladder distention and cloudy urine with sediment. She stated the resident experienced cloudy urine and sediment quite often. She stated staff would encourage the resident to drink more fluids. She stated she had called and emailed the physician many times about the resident. She stated she had been instructed by the nurses and DON she needed to document her communication with the physician better. She stated she had been informed by the nurses and DON she needed to notify the physician every time the resident experienced symptoms. She was asked what could the signs and symptoms indicate. She said, Even though it may be something that happens a lot, it's not normal for him. Could be infection. She was asked to review her nurse's note from 08/08/19 at 2:23 p.m. She acknowledged she documented the resident had copious discharge, bladder pain and distention and his urine was cloudy with sediment and a foul odor. She confirmed the copious discharge was coming from the resident's penis. She acknowledged the resident's symptoms had been going on since the previous shift, 11 hours prior to her note. She then stated she observed the documented symptoms at the beginning of her shift (6:00 a.m. to 2:00 p.m.) She stated she observed the resident routinely during her shift and the symptoms continued. She stated she made one entry for the entire shift at 2:23 p.m. She was asked if she had any concerns related to the resident's symptoms. She stated yes. She stated something not normal was going on. She was asked if she notified the resident's physician. She stated she was sure she had, but didn't know for 100 percent. She stated the physician should have been notified of the resident's symptoms. She verified physician notification was not documented. She was asked to review her note from 08/09/19 at 12:41 p.m. She was asked when had the physician been notified of the resident's change in condition which prompted him to write new physician's orders [REDACTED]. She said, I don't know. She acknowledged the note and corresponding physician's orders [REDACTED]. She acknowledged both were written over 33 hours since the onset of the resident's symptoms. She was asked if the interventions were timely. She said, No. She then acknowledged the physician's orders [REDACTED]. She stated she did not know why she didn't implement the physician's orders [REDACTED]. At 9:10 a.m., LPN #1 reviewed her progress note from 08/13/19 at 2:07 p.m. She acknowledged she had documented the resident had sediment and blood clots in his urine. She was asked if she had any concern when she noted the resident had blood clots in his urine. She stated she was sure she was concerned. She reviewed progress notes from 08/11/19 at 9:09 p.m. to her progress note written two days later. She acknowledged the resident had experienced blood clots in his urine for the previous two days. She was asked if she had notified the physician. She stated she did not know if she had. She stated the physician should have been notified when the blood clots were first observed in his urine. She was asked what could a finding of blood clots in a resident's urine indicate. She stated she did not know, but it was not a normal finding. She was asked to review her documentation from 08/14/19. She acknowledged she documented the physician's orders [REDACTED]. She stated she was not sure why the UA was not obtained in a timely manner. She stated she could not recall any reasons why the UA was not obtained timely. At 9:30 a.m., LPN #5 reviewed her progress note from 08/11/19 at 12:13 p.m. She acknowledged she placed the physician's orders [REDACTED]. She acknowledged the resident's urine was thick and soupy yellow. She stated she was unsure why the resident's urinary catheter was not placed soon after the order was received. She was asked if she notified the resident's physician that the resident's urine was thick and yellow. She stated he had a history of [REDACTED]. She acknowledged there was no documentation which indicated the resident's urine cleared soon after his catheter was placed. She then stated she would have notified the physician. She acknowledged there was no documentation of physician notification. At 9:36 a.m., LPN #3 was asked to review her progress note from 01/10/20 at 10:33 a.m. She acknowledged she documented the resident had dark bloody urine. She was asked if she notified the physician the resident continued to have blood in his urine. She stated she noticed the blood in in the resident's urine and called the physician. She acknowledged there was no documentation the physician had been notified. She stated normally she documented when she called the physician. She was asked what could blood in the resident's urine indicate. She stated blood could indicate a serious infection. At 10:54 a.m., physician #1 was asked if he ordered a UA with CS if indicated and a PSA, when did he expect the specimen to be obtained and sent to the laboratory. He said, Generally the next time he (the resident) voids. He was asked what concerns he would have if the laboratory testing was not obtained for several days. He stated he would be concerned because the UA was ordered to rule out possible infection. He was asked if he was notified when the resident experienced large pus like drainage from his penis, pus in his urine and foul odorous urine, abdominal pain and bladder distention, and blood clots in his urine for 48 hours. He stated he did not recall if he was notified. He stated he would be concerned about any of the listed symptoms. He stated staff should be alert and observing residents for possible signs and symptoms of a UTI. He stated he expected to be notified by the facility staff as soon as they noticed any of the listed symptoms. He stated the symptoms could indicate the resident had a possible infection. He stated blood in the urine could also be a serious matter and he expected to be notified. At 11:09 a.m., the DON acknowledged the physician's orders [REDACTED]. She was asked what should staff do if they observed copious pus drainage from a resident's penis, pus in the urine, foul smelling urine, bladder pain and distention, and/or blood or blood clots in the urine. She stated staff should notify the physician right away. She stated staff should provided ongoing assessment and monitoring of the resident until the change in condition resolved. She stated if the resident's symptoms worsened she expected staff to notify the physician immediately. She stated staff should monitor the resident at least once a shift when a change in condition was noticed. She stated if a resident experienced the identified symptoms this could indicate a possible infection. She stated the resident could become septic with the infection if untreated. At 1:45 p.m., LPN #2 reviewed her progress note from 08/08/19 at 9:53 p.m. She acknowledged she documented the resident's urine was still cloudy with a foul odor. She stated the resident's urine was usually pretty cloudy and sometimes had an odor. She stated the resident did not have a fever. She was asked if the resident's physician was notified when the resident experienced these symptoms. She stated the physician should have been notified when the resident experienced the symptoms. She stated if he was notified it would have been documented in her progress note. She stated she could not recall if she had notified the physician. She was asked to review her progress notes from 08/13/19 at 9:37 p.m. and 9:39 p.m. She acknowledged she documented the resident had sediment and blood clots in his urine and complained that his catheter burned at times. She was asked if her observations caused her any concern, when had the blood clots started and how was the resident monitored. She stated she was not sure when the blood clots had started. She stated sometimes if the resident's catheter got pulled he got blood clots in his urine and then his urine would clear up. She stated she observed the resident during her shift and he didn't have any further changes. She stated she did not document the resident was monitored for blood clots in his urine. She was asked if she had notified the physician the resident had blood clots in his urine. She stated in general the physician was notified for these types of changes. She stated she would have notified the physician if the blood clots had not cleared up. She was asked to review progress notes from 08/11/19 at 9:09 p.m. to her notes on 08/13/19. She acknowledged the resident had been passing blood clots in his urine since 08/11/19. She stated if it had been going on for that long the physician should have been notified. She was asked if she was aware the physician had ordered a UA with CS if indicated on 08/09/19 which had not yet been obtained as of her note on 08/13/19. She stated she was not aware and did not know why the UA had not been obtained. She was asked to review her progress note from 08/16/19 at 10:57 p.m. She acknowledged she documented the resident's urine was thick with pus. She was asked if the physician was notified of the change in the resident's urine. She stated the physician should have been notified, but she acknowledged there was no documentation he had been. She stated she could not recall if she had notified the physician. She stated new onset of pus in the urine could indicate the resident had an infection. She stated if the infection was left untreated the resident could become septic. She was asked to review her progress note from 01/09/20 at 5:43 a.m. She acknowledged she documented the resident was confused, hallucinating and had dark urine with sediment and blood, complained of flank pain and had a temperature of 100.5 F. She acknowledged she wrote the next progress note on 01/10/20 at 7:00 p.m. for the resident and documented the resident's urine was black, he had a fever of 99.8 F, and pain when the catheter tubing was moved. She was asked if there was any documentation the resident was monitored for an ongoing change in condition. She stated she had assessed the resident during her shifts, but did not document her assessments. She was asked if she had notified the physician the resident had black colored urine and a temperature of 99.8 F. She stated she should have notified the physician. She stated she did not because the resident's UA had been sent and the results were pending. She was asked if she notified the physician when the resident had a new onset of bleeding from his penis which she documented in a progress note on 01/11/20 at 4:06 a.m. She stated she was not sure, but she should have. At 2:23 p.m., the DON stated she had experienced concerns with LPN #1 documenting pertinent information in the past. She stated she could not recall any concerns with LPN #2. She stated she reviewed the notes on the resident during August 2019, September 2019 and January 2020. She stated she was concerned with the lack of physician notification and monitoring/interventions when the resident had changes in condition. She provided documentation for LPN #2 on hire for orientation. The staff member was provided orientation on 08/07/19 related to physician notification requirements, head to toe evaluation and assessments, and change in condition recognition and management. She was also provided orientation for urinary catheter insertion and care. She provided documentation for LPN #1 on hire for orientation. The staff member was provided orientation on 03/21/19 and 03/22/19 related to physician notification requirements and resident assessment. There was no documentation that the staff members were required to demonstrate skills or tested to determine their competency levels. She provided documentation of an in-service on 05/17/19 related to physician notification. LPN #1 did not attend the in-service training. LPN #2 was not employed at the facility at the time of the in-service training. She provided documentation of an in-service on 09/06/19 which include training related to resident status change and documentation and timely documentation. Both LPN #1 and #2 attended the in-service. She was asked if she had any concerns related to LPN #1 an LPN #2 and their competency level. She stated she had definite concerns with their competency level and those concerns needed to be addressed. She stated she had not been required to provide either of the LPNs with individual in-services or retraining. She was notified there were other LPNs who documented progress notes on the resident during the time periods reviewed which included changes of condition which were not assessed, monitored, interventions were not identified and implemented and the physician was not contacted. She acknowledged several staff members did not perform competently related to the care and services provided to resident #1.

Based on record reviews and interviews, it was determined the facility failed to ensure staff were competent and possessed the necessary skills to asssess, monitor and intervene for a resident who experienced changes in condition for one (#1) of three sampled residents reviewed who had changes in condition. The administrator identified 34 residents who resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. Nurse's progress notes, dated 08/08/19 through 08/18/19, documented entries made by several facility LPNs. The LPNs documented the resident experienced changes in condition including pus and copious amounts of discharge from his penis and in his urine, dark, cloudy and foul smelling urine with sediment, and bleeding from his penis and blood clots in his catheter. The LPNs did not document physician notification of the signs and symptoms or at one time waited 48 hours before physician notification of blood clots in the resident's catheter. When the physician was contacted, 24 hours after symptoms started he ordered a UA (urinalysis) with CS (culture and sensitivity) if indicated, a PSA (prostate specific [MEDICATION NAME] laboratory test), and an indwelling urinary catheter for [MEDICAL CONDITION]. The nursing staff did not obtain the ordered UA with CS if indicated for six days after the order was received. The ordered urinary catheter was not placed for two days after the order was received. The LPNs did not chart consistent and thorough assessments, monitoring and interventions for a resident with an ongoing change in condition. When the UA was collected, six days after the order was received, the results were: moderate blood and small leukocytes. The urine microscopic results documented the specimen was positive for erythrocytes (red blood cells), leukocytes and bacteria. The urine specimen was sent for culture and sensitivity testing. On 08/18/19, the resident was sent to the emergency room at his request, ten days after onset of his symptoms with continued dark red colored urine with blood clots. There was no documentation the physician was notified the resident had started to pass blood and clots in his urine again and had requested to be sent to the ER. emergency room records, dated 08/18/19, documented the resident was evaluated and treated for [REDACTED]. The resident presented with blood in his urinary catheter. He remained afebrile. A laboratory test for culture and sensitivity, dated 08/19/19, documented the final results of the culture were positive for greater than 100,000 cfu/ml (colony forming units per milliliter) of Proteus Mirabilis (a bacteria). A nurse's progress note, dated 08/19/19 at 11:33 a.m., documented the resident's physician visited the resident and was aware of blood in foley (urinary catheter) bag. The progress note documented the first time the facility staff documented the physician was notified the resident had blood in his urinary catheter. A nurse's progress note, dated 09/25/19 at 3:47 a.m., signed by LPN #4 documented the resident had bright red blood noted around head of penis and urethra, in catheter tubing dark red blood noted with large amounts of clots, UA bag contains dark red blood tinged urine. A nurse's progress note, dated 09/28/19 at 9:58 p.m., documented the resident's urine was clear and yellow. There was no documentation of assessment, monitoring or interventions initiated for a resident who had a new onset of bleeding around the penis and blood and blood clots in the urine. There was no documentation the resident's physician was notified of the change in condition. A nurse's progress note, dated 01/09/20 at 5:43 a.m., signed by LPN #2 was reviewed. The note documented the resident was very confused and hallucinating. The resident's urine was dark with sediment and blood in it. The resident complained of flank pain and had a fever of 100.5 F. The resident was administered Tylenol. The physician was contacted and provided an order for [REDACTED].>A UA laboratory report, dated 01/09/20 at 7:00 a.m., documented the resident's urine was pink and cloudy. The urine was positive for large blood, moderate leukocytes and one plus bacteria. A nurse's progress note, dated 01/09/20, documented the resident's UA results were sent to (Named Physician #1) and the urine specimen had been sent for culture. A nurse's progress note, dated 01/10/20 at 4:07 a.m., signed by LPN #2 documented the next assessment was completed over 22 hours after the most recent assessment of the resident's ongoing change in condition. The resident's urine was black in color with blood in the tubing. The resident complained of pain when the tubing was moved. The resident had a fever of 99.8 F. A nurse's progress note, dated 01/10/20 at 10:33 a.m., documented the resident had dark bloody urine in his urinary catheter and abdominal pain with palpation. The resident was afebrile. A nurse's progress note, dated 01/11/20 at 4:06 a.m., was signed by LPN #2. The note documented the next assessment was completed over 17 hours after the most recent assessment of the resident's ongoing change in condition. The note documented the resident's urine was still dark cherry colored due to blood. Blood was also coming from penis around catheter. There was no documentation the resident's physician was notified the he had a new onset of bleeding coming from his penis. On 02/25/20 at 8:59 a.m., LPN #1 was asked if the resident's physician should have been notified when the resident experienced a new onset of abdominal pain, bladder distention and cloudy urine with sediment. She stated the resident experienced cloudy urine and sediment quite often. She stated staff would encourage the resident to drink more fluids. She stated she had called and emailed the physician many times about the resident. She stated she had been instructed by the nurses and DON she needed to document her communication with the physician better. She stated she had been informed by the nurses and DON she needed to notify the physician every time the resident experienced symptoms. She was asked what could the signs and symptoms indicate. She said, Even though it may be something that happens a lot, it's not normal for him. Could be infection. She was asked to review her nurse's note from 08/08/19 at 2:23 p.m. She acknowledged she documented the resident had copious discharge, bladder pain and distention and his urine was cloudy with sediment and a foul odor. She confirmed the copious discharge was coming from the resident's penis. She acknowledged the resident's symptoms had been going on since the previous shift, 11 hours prior to her note. She then stated she observed the documented symptoms at the beginning of her shift (6:00 a.m. to 2:00 p.m.) She stated she observed the resident routinely during her shift and the symptoms continued. She stated she made one entry for the entire shift at 2:23 p.m. She was asked if she had any concerns related to the resident's symptoms. She stated yes. She stated something not normal was going on. She was asked if she notified the resident's physician. She stated she was sure she had, but didn't know for 100 percent. She stated the physician should have been notified of the resident's symptoms. She verified physician notification was not documented. She was asked to review her note from 08/09/19 at 12:41 p.m. She was asked when had the physician been notified of the resident's change in condition which prompted him to write new physician's orders [REDACTED]. She said, I don't know. She acknowledged the note and corresponding physician's orders [REDACTED]. She acknowledged both were written over 33 hours since the onset of the resident's symptoms. She was asked if the interventions were timely. She said, No. She then acknowledged the physician's orders [REDACTED]. She stated she did not know why she didn't implement the physician's orders [REDACTED]. At 9:10 a.m., LPN #1 reviewed her progress note from 08/13/19 at 2:07 p.m. She acknowledged she had documented the resident had sediment and blood clots in his urine. She was asked if she had any concern when she noted the resident had blood clots in his urine. She stated she was sure she was concerned. She reviewed progress notes from 08/11/19 at 9:09 p.m. to her progress note written two days later. She acknowledged the resident had experienced blood clots in his urine for the previous two days. She was asked if she had notified the physician. She stated she did not know if she had. She stated the physician should have been notified when blood clots were first observed in his urine. She was asked what could a finding of blood clots in a resident's urine indicate. She stated she did not know, but it was not a normal finding. She was asked to review her documentation from 08/14/19. She acknowledged she documented the physician's orders [REDACTED]. She stated she was not sure why the UA was not obtained in a timely manner. She stated she could not recall any reasons why the UA was not obtained timely. At 9:30 a.m., LPN #5 reviewed her progress note from 08/11/19 at 12:13 p.m. She acknowledged she placed the physician's orders [REDACTED]. She acknowledged the resident's urine was thick and soupy yellow. She stated she was unsure why the resident's urinary catheter was not placed soon after the order was received. She was asked if she notified the resident's physician that the resident's urine was thick and yellow. She stated he had a history of [REDACTED]. She acknowledged there was no documentation which indicated the resident's urine cleared soon after his catheter was placed. She then stated she would have notified the physician. She acknowledged there was no documentation of physician notification. At 9:36 a.m., LPN #3 was asked to review her progress note from 01/10/20 at 10:33 a.m. She acknowledged she documented the resident had dark bloody urine. She was asked if she notified the physician the resident continued to have blood in his urine. She stated she noticed the blood in in the resident's urine and called the physician. She acknowledged there was no documentation the physician had been notified. She stated normally she documented when she called the physician. She was asked what could blood in the resident's urine indicate. She stated blood could indicate a serious infection. At 10:54 a.m., physician #1 was asked if he ordered a UA with CS if indicated and a PSA, when did he expect the specimen to be obtained and sent to the laboratory. He said, Generally the next time he (the resident) voids. He was asked what concerns he would have if the laboratory testing was not obtained for several days. He stated he would be concerned because the UA was ordered to rule out possible infection. He was asked if he was notified when the resident experienced large pus like drainage from his penis, pus in his urine and foul odorous urine, abdominal pain and bladder distention, and blood clots in his urine for 48 hours. He stated he did not recall if he was notified. He stated he would be concerned about any of the listed symptoms. He stated staff should be alert and observing residents for possible signs and symptoms of a UTI. He stated he expected to be notified by the facility staff as soon as they noticed any of the listed symptoms. He stated the symptoms could indicate the resident had a possible infection. He stated blood in the urine could also be a serious matter and he expected to be notified. At 11:09 a.m., the DON acknowledged the physician's orders [REDACTED]. She was asked what should staff do if they observed copious pus drainage from a resident's penis, pus in the urine, foul smelling urine, bladder pain and distention, and/or blood or blood clots in the urine. She stated staff should notify the physician right away. She stated staff should provided ongoing assessment and monitoring of the resident until the change in condition resolved. She stated if the resident's symptoms worsened she expected staff to notify the physician immediately. She stated staff should monitor the resident at least once a shift when a change in condition was noticed. She stated if a resident experienced the identified symptoms this could indicate a possible infection. She stated the resident could become septic with the infection if untreated. At 1:45 p.m., LPN #2 reviewed her progress note from 08/08/19 at 9:53 p.m. She acknowledged she documented the resident's urine was still cloudy with a foul odor. She stated the resident's urine was usually pretty cloudy and sometimes had an odor. She stated the resident did not have a fever. She was asked if the resident's physician was notified when the resident experienced these symptoms. She stated the physician should have been notified when the resident experienced the symptoms. She stated if he was notified it would have been documented in her progress note. She stated she could not recall if she had notified the physician. She was asked to review her progress notes from 08/13/19 at 9:37 p.m. and 9:39 p.m. She acknowledged she documented the resident had sediment and blood clots in his urine and complained that his catheter burned at times. She was asked if her observations caused her any concern, when had the blood clots started and how was the resident monitored. She stated she was not sure when the blood clots had started. She stated sometimes if the resident's catheter got pulled he got blood clots in his urine and then his urine would clear up. She stated she observed the resident during her shift and he didn't have any further changes. She stated she did not document the resident was monitored for blood clots in his urine. She was asked if she had notified the physician the resident had blood clots in his urine. She stated in general the physician was notified for these types of changes. She stated she would have notified the physician if the blood clots had not cleared up. She was asked to review progress notes from 08/11/19 at 9:09 p.m. to her notes on 08/13/19. She acknowledged the resident had been passing blood clots in his urine since 08/11/19. She stated if it had been going on for that long the physician should have been notified. She was asked if she was aware the physician had ordered a UA with CS if indicated on 08/09/19 which had not yet been obtained as of her note on 08/13/19. She stated she was not aware and did not know why the UA had not been obtained. She was asked to review her progress note from 08/16/19 at 10:57 p.m. She acknowledged she documented the resident's urine was thick with pus. She was asked if the physician was notified of the change in the resident's urine. She stated the physician should have been notified, but she acknowledged there was no documentation he had been. She stated she could not recall if she had notified the physician. She stated new onset of pus in the urine could indicate the resident had an infection. She stated if the infection was left untreated the resident could become septic. She was asked to review her progress note from 01/09/20 at 5:43 a.m. She acknowledged she documented the resident was confused, hallucinating and had dark urine with sediment and blood, complained of flank pain and had a temperature of 100.5 F. She acknowledged she wrote the next progress note on 01/10/20 at 7:00 p.m. for the resident and documented the resident's urine was black, he had a fever of 99.8 F, and pain when the catheter tubing was moved. She was asked if there was any documentation the resident was monitored for an ongoing change in condition. She stated she had assessed the resident during her shifts, but did not document her assessments. She was asked if she had notified the physician the resident had black colored urine and a temperature of 99.8 F. She stated she should have notified the physician. She stated she did not because the resident's UA had been sent and the results were pending. She was asked if she notified the physician when the resident had a new onset of bleeding from his penis which she documented in a progress note on 01/11/20 at 4:06 a.m. She stated she was not sure, but she should have. At 2:23 p.m., the DON stated she had experienced concerns with LPN #1 documenting pertinent information in the past. She stated she could not recall any concerns with LPN #2. She stated she reviewed the notes on the resident during August 2019, September 2019 and January 2020. She stated she was concerned with the lack of physician notification and monitoring/interventions when the resident had changes in condition. She provided documentation for LPN #2 on hire for orientation. The staff member was provided orientation on 08/07/19 related to physician notification requirements, head to toe evaluation and assessments, and change in condition recognition and management. She was also provided orientation for urinary catheter insertion and care. She provided documentation for LPN #1 on hire for orientation. The staff member was provided orientation on 03/21/19 and 03/22/19 related to physician notification requirements and resident assessment. There was no documentation that the staff members were required to demonstrate skills or tested to determine their competency levels. She provided documentation of an in-service on 05/17/19 related to physician notification. LPN #1 did not attend the in-service training. LPN #2 was not employed at the facility at the time of the in-service training. She provided documentation of an in-service on 09/06/19 which include training related to resident status change and documentation and timely documentation. Both LPN #1 and #2 attended the in-service. She was asked if she had any concerns related to LPN #1 an LPN #2 and their competency level. She stated she had definite concerns with their competency level and those concerns needed to be addressed. She stated she had not been required to provide either of the LPNs with individual in-services or retraining. She was notified there were other LPNs who documented progress notes on the resident during the time periods reviewed which included changes of condition which were not assessed, monitored, interventions were not identified and implemented and the physician was not contacted. She acknowledged several staff members did not perform competently related to the care and services provided to resident #1.

Based on interviews and record reviews, it was determined the facility failed to ensure laboratory testing was obtained as ordered by the physician and in a timely manner for one (#1) of one sampled resident reviewed with physician's orders [REDACTED]. The DON (director of nurses) identified 20 residents with physician's orders [REDACTED]. The administrator identified 34 residents who resided in the facility. Findings: A facility policy titled, Laboratory Services, documented: .Labs (laboratory testing) will be obtained and reported as ordered .Labs will be ordered by the doctor . Resident #1 had [DIAGNOSES REDACTED]. Nurse's progress notes, dated 08/08/19 at 3:19 a.m., 2:23 p.m., and 9:53 p.m., documented the resident exhibited the following signs and symptoms: extremely large amount of pus like discharge from his penis, very strong urine odor, dark amber colored urine which was cloudy and contained sediment, and a tender and distended bladder. A straight catheter was utilized to empty the resident's bladder with a return of 1000 milliliters of dark cloudy, yellow urine with sediment. A physician's orders [REDACTED]. A nurse's progress note, dated 08/09/19 at 12:41 p.m., documented a new physician's orders [REDACTED]. The progress note was authored by LPN (licensed practical nurse) #1. Nurse's progress notes, dated 08/09/19 through 08/13/19, were reviewed. The notes did not document the resident refused the collection of the physician ordered laboratory tests. There was no documentation which suggested the facility had attempted to obtain or reasons they were unable to obtain the physician's orders [REDACTED]. A physician's orders [REDACTED].clarification UA c (with) CS (culture and sensitivity) if indicated (and) PSA on next lab day .Signature of Nurse Receiving Order (Named LPN #1) . There was no documentation provided by the facility which documented the reason a clarification physician's orders [REDACTED]. A laboratory report, dated 08/14/19 at 1:35 p.m., documented the UA was collected on 08/14/19 at 1:35 p.m., the specimen was received at 2:38 p.m. and the final results were completed at 2:56 p.m. The laboratory report documented (Named Physician #1) was notified of the results on 08/14/19 at 7:00 p.m. The UA results were as follows: moderate blood and small leukocytes. The urine microscopic results documented the specimen was positive for erythrocytes (red blood cells), leukocytes and bacteria. The urine specimen was sent for culture and sensitivity testing. The physician's orders [REDACTED]. This was six days after the physician's orders [REDACTED]. A laboratory report, dated 08/14/19 at 1:35 p.m., documented the specimen was collected for PSA testing at 1:35 p.m., the specimen was received by the laboratory at 2:38 p.m., and the final results were completed on 08/15/19 at 7:54 a.m. The results of the PSA test were elevated at 7.4. The documented normal reference range was less than or equal to 4.0. The report documented LPN #1 notified the physician of the results on 08/15/19 at 8:00 a.m. The physician's orders [REDACTED]. The laboratory test was not collected until two days later on 08/14/19. A laboratory test for culture and sensitivity, dated 08/19/19, documented the final results of the culture were positive for greater than 100,000 cfu/ml (colony forming units per milliliter) of Proteus Mirabilis (a bacteria). The culture and sensitivity testing was completed 10 days after the original physician's orders [REDACTED]. On 02/25/20 at 9:08 a.m., LPN #1 acknowledged she received the order from the physician on 08/09/19 for the UA with CS if indicated and for a PSA. She was asked to review the physician's clarification order she wrote on 08/14/19. She was asked why was the clarification order written. She stated she was not sure why. She said, Maybe there was an issue with getting the UA. She then acknowledged there was no documentation the resident had refused the collection of the laboratory testing or the nursing staff had difficulty obtaining the specimen. She was asked when should physician's orders [REDACTED]. She stated they should be obtained as soon as possible. At 10:54 a.m., physician #1 was asked if he ordered a UA with CS if indicated and a PSA, when did he expect the specimen to be obtained and sent to the laboratory. He said, Generally the next time he (the resident) voids. He was asked what concerns he would have if the laboratory testing was not obtained for several days. He stated he would be concerned because the UA was ordered to rule out possible infection. At 11:09 a.m., the DON was asked when should a physician's orders [REDACTED]. She stated laboratory testing should be obtained when they were ordered. She was asked to review the physician's orders [REDACTED]. She stated it was not acceptable for staff to wait for six days to collect the specimen for the ordered laboratory testing. The DON was asked to review the physician's orders [REDACTED]. She acknowledged the laboratory test was ordered to be completed on 08/12/19. She reviewed the laboratory report for the PSA test and acknowledged the specimen was not collected until 08/14/19. She stated it was not acceptable for staff to not collect the laboratory tests as ordered by the physician. The DON was asked to review the clarification physician's orders [REDACTED].#1. She stated she did not know why the LPN wrote the clarification order. She stated the order was the same as the original order written on 08/09/19.

On 10/23/14, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure assessment, monitoring, physician notification and treatment was obtained for pressure ulcers for one (#5) of two sampled residents with pressure ulcers. At 3:30 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 3:42 p.m., the administrator, director of nursing (DON), regional DON and quality assurance (QA) nurse were notified of the existence of the IJ. At 5:35 p.m., an acceptable written plan of removal was received. The facility's plan for removal, dated 10/23/2014, documented, "Binger Nursing Center 10/23/14. 1. The doctor for the identified resident (#5) will be notified regarding the current wound assessment. He has been notified on 10-23-14 at 1630. 2. A wound care consult will be scheduled for the identified resident. The wound care consultant will be here for evaluation tonight (10-23-14). Occurred at 1730. 3. Nursing staff (licensed staff) will be educated on the requirements for physician notification of changes in wounds on 10-23-14 by midnight. Those employees not able to be educated by this time will not be allowed to return to work until education is complete. 4. Nursing staff will be educated regarding the regulatory requirements for wound identification, assessment, treatment and reporting changes to the physician on 10-23-14 by 12 midnight. Those employees not able to be educated by this time will not be allowed to return to work until the education is complete. 5. The DON will monitor wounds weekly for compliance for a period of no less than 90 days. 6. New/readmissions will be reviewed to ensure continued compliance for a period of no less than 90 days. 7. Physician notification will be reviewed in the daily clinical meeting on an ongoing basis. 8. If unable to obtain orders from the PCP (primary care physician) the medical director will be notified for further instructions. 9. The wound care policy and procedure will be reviewed and updated by 10-24-14 at 12 noon. 10. The results of the audits and monitoring will be presented to the facility QA committee monthly for a period of no less than 90 days. 11. Any identified non-compliance will result in one on one education and progressive disciplinary action." On 10/24/14, three direct care staff members (LPN #1 at 11:45 a.m., LPN #3 at 3:06 p.m. and LPN #4 at 3:13 p.m.) were interviewed. All stated they had been inserviced and were able to verbalize the requirements on physician notification of changes in wounds and regulatory requirements for wound identification, assessment and treatment. The IJ was removed on 10/24/14 at 12:00 midnight, when all direct care staff had been inserviced. The deficient practice remained at a pattern, actual harm that was not an immediate jeopardy. Based on observation, record review and interview, it was determined the facility failed to ensure assessment and monitoring were performed and the physician was notified of changes; and to recieve treatment orders for pressure ulcers for one (#5) of two sampled residents with pressure ulcers. The facility failed to: ~ assess and monitor the skin of a resident identified at high risk for pressure ulcers, whose fractured leg was wrapped with an ace wrap in a hard splint for 14 days, ~ obtain clarification of a physician's orders [REDACTED]. ~ obtain post hospital orders in regard to wound care, ~ transcribe wound care orders to treatment sheets which resulted in no wound care being performed for three days and ~ notify the physician of a change in status of a resident's knee wound; the protrusion of a hard white object. The Census and Conditions report, dated 10/23/14, identified three residents with pressure ulcers. Forty-six residents resided in the facility. Findings: The policy, Change in a Resident's Condition or Status, last reviewed/revised on 04/26/11, documented, "... Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Policy Interpretation and Implementation 1. The Nurse Supervisor will notify the resident's attending physician when... b. There is a significant change in the resident's physical, mental, or psychosocial status... c. There is a need to alter the resident's treatment significantly... f. Deemed necessary or appropriate in the best interest of the resident..." The policy, Physician Services, last reviewed/revised on 04/12/12, documented, "...Policy Interpretation and Implementation 1. The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the facility..." The policy, Skin Care & Pressure Ulcer Management Program, provided by the regional DON on 10/23/14 at 5:39 p.m., documented, "SKIN CARE & PRESSURE ULCER MANAGEMENT PROGRAM Standard This Skin Care & Pressure Ulcer Management Program describes the interdisciplinary approach to managing pressure ulcers, and uses the nursing process to ensure a comprehensive review. The program relies on evidence-based treatment protocols and standards of practice that focus on two aspects of care: 1. Prevention of pressure ulcer development by promoting healing and preventing infection when breakdown occurs. 2. Treatment that uses a standardized approach to promoting healing and preventing infection when skin breakdown occurs.... Objectives Pressure ulcers are a serious concern especially in compromised residents... 1. Prevent pressure ulcers from developing in residents identified as being as risk. 2. Create care plans for residents who are at risk or have already developed pressure ulcers. 3. Identify newly acquired pressure ulcers. 4. Document the change of condition. 5. Provide standardized treatment and interventions that promote pressure ulcer healing and prevent infection. 6. Evaluate the effectiveness of interventions through the care-planning process and make changes, as necessary, to prevent development of additional pressure ulcers. 7. Provide staff education, training, and resources... SECTION 1: ASSESSMENT: IDENTIFYING RESIDENTS AT RISK OF SKIN BREAKDOWN... Time Frame: Before and during the admission process; daily, weekly, monthly and quarterly according to the MDS (minimum data set) assessment schedule; PRN (as needed)... If the resident has a pressure ulcer or other wound at the time of admission, treatment begins promptly according to physician orders... SECTION 2: PLANNING, IMPLEMENTATION, AND EVALUATION: CARE PLANNING... Time Frame: Ongoing Developing an Individualized Skin Care Plan Based on the resident's assessment, the Interdisciplinary Team develops an individualized care plan to prevent or treat skin breakdown... Weekly Evaluation A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR). The licensed nurse documents using the following equations: * "Y" = skin intact * "N" = not intact If a licensed nurse documents "N," she/he writes a note in the narrative note and wound sheet describing the area. If skin integrity is compromised, the process moves into the wound management phase. The physician and responsible party is notified, a progress note is completed and the care plan is updated with appropriate interventions... SECTION 3: THE Save Our Skin PROGRAM... Time Frame: Ongoing Identifying and Reporting Pressure Ulcers... If the licensed nurse determines that the identified area is a new skin issue, the nurse completes the investigation process described below. Investigation Process Any new skin issue is an "incident" which requires an investigation to determine the root cause. Follow these steps to investigate a skin issue: 1. Complete a Skin Risk Assessment... 2. Complete a Pain Evaluation form... 3. Complete a Pressure Ulcer Documentation Form to document the status of the pressure ulcer... 4. Notify the physician and responsible party and collaborate on a treatment order... 8. Update the care plan, as applicable... Evaluation Process When a pressure ulcer has been identified, reported, and investigated, a licensed nurse completes a thorough evaluation to determine appropriate treatment interventions and updates the resident's plan of care..." Resident #5 had [DIAGNOSES REDACTED]. Prior surgeries included a total right knee replacement. The resident assessment, dated 06/25/14, documented the resident was at risk for the development of pressure ulcers. The assessment documented she had a Stage II pressure ulcer on that date, but did not indicated where the pressure ulcer was located. The medical record documented the resident had a pressure ulcer being treated at that time on both her right ankle and right heel. An incident report, dated 09/04/14, documented the resident had a fall which involved the resident's right knee. It was documented there were no apparent injuries or redness noted. A nurse's note, dated 09/05/14 at 10:18 a.m., documented the resident complained of pain. She had a large bruise on her right knee and had swelling to her right knee through her upper thigh. Ice was applied for swelling and new orders were received to x-ray the right knee and lower leg. A nurse's note, dated 09/05/14 at 1:49 p.m., documented the resident complained of knee pain. The x-ray tech (technician) was at the facility at 1:00 p.m. to x-ray the right knee and lower leg. The x-ray tech gave a preliminary report of the right knee being broken. The physician was notified and new orders were received to send the resident to the emergency room . A nurse's note, dated 09/05/14 at 9:51 p.m., documented the resident returned to the facility with new orders to do neurovascular checks every four hours for 48 hours. The notes documented the hard splint to her right leg was intact. A physician's orders [REDACTED]." A nurse's note, dated 09/09/14 at 12:40 p.m., documented the registered nurse (RN) took off the ace wrap to assess the resident's right leg. The nurse documented there were no blisters noted to the right leg; yellowish/purplish discolorations were noted to the right knee area. A significant change assessment, dated 09/15/14, documented the resident's cognition was severely impaired, she did not ambulate and was totally dependent on staff for transfers, dressing, hygiene and bathing. The resident had one fall with major injury and was at risk of developing pressure ulcers. A care plan, initiated on 09/16/14, documented, "...Focus (Resident) has a history of falls and is at risk for falls due to cognitive status, and decline mobility 9-5-14 had a fall with a fracture... Goals...(Resident) will attempt to resume usual activities without further incident after fracture heels (sic) through the review date... Interventions...Had a fall with fracture, sent to the hospital, returned later in the evening with a splint on RLE (right lower extremity). 9-17-2014, she has an appt. (appointment) with (orthopedic surgeon) to determine further tx (treatment)..." A nurse's note, dated 09/17/14 at 12:32 p.m., documented the resident's PCP made rounds at 10:00 a.m. and there were no new orders. The PCP was aware of the resident going to see the orthopedic surgeon that day. A nurse's note, dated 09/17/14 at 4:20 p.m., documented the resident returned to the facility from the orthopedic surgeon's office and there were no new orders. The orthopedic surgeon's office visit note, dated 09/17/14, documented, "...HISTORY OF PRESENT ILLNESS: (Resident) is an [AGE] year-old female who presented to the emergency roiagnom on ,[DATE]. She had been found with a mobile x-ray to have an acute [MEDICAL CONDITION] femur. She was splinted and sent home. The patient's family felt that she was not a surgical candidate, nor did the emergency room physician, but she was seen here for "change of splint"... PHYSICAL EXAMINATION... X-rays demonstrated a [MEDICAL CONDITION] femur with 100% offset. The total knee is in satisfactory position. These are x-rays taken in the office today AP (anterior/posterior) and lateral. The radiological impression is markedly displaced fracture, periprosthetic femur... ADVISEMENT AND PLAN: The patient understands that the only option for any improvement would be surgery. The family has opted for non-surgical approach. Her splint was reapplied today. A new splint was applied anteriorly. We plan to speak with her daughter with regards to possible management..." A nurse's note, dated 09/19/14 at 9:05 a.m., documented she was unable to assess under the resident's splint on her right leg due to no orders to take the splint off. A nurse's note, dated 09/24/14 at 9:56 a.m., documented she spoke with the orthopedic surgeon concerning getting the resident up in a reclining geri-chair and to see if they could take the ace wrap off to see the right heel. Orders were received to get the resident up in her geri-chair and to take the ace wrap off twice a week, check the heel, apply skin prep and foam pad, then rewrap. The PCP was notified. A nurse's note, dated 09/24/14 at 10:41 a.m., documented the licensed practical nurse (LPN) unwrapped the right leg from the knee down to the foot. There were no open areas. Skin prep was applied to the right ankle for redness. The right leg was rewrapped. A nurse's note, dated 10/08/14 at 3:02 p.m., documented, "while doing residents treatment of [REDACTED]. resident's right ankle is red and is not open, skin prepped around area and applied foam dressing, re wrapped right leg with splint in place, faxed (PCP) in regards to this and (MDS nurse) LPN called wound care nurse and she is to come see resident on her next visit, changed order to assess right leg from twice a week to three times a week, also asked (PCP name) if we could increase pain meds, awaiting any new orders." A physician notification fax, dated 10/08/14 at 3:36 p.m., documented, "... Situation: We have orders to take splint & wraps off 2 x weekly. Today when splint was took off she has a noted .7 cm x .8 cm open area on top of (R) (right) knee that has bloody drainage and is tunneling. We have contacted wound care nurse and she is coming to do a visit. Her (R) ankle is very red but not open. Applied a Solosite & foam dressing. She is in terrible pain when we get her up and when we do anything to her leg. She only has order for [MEDICATION NAME] 5/325 (1) PO (by mouth) q (every) 8 (hours) PRN and PRN Tylenol. Any new orders?... ( physician's response, dated 10/09/14) C&S (culture and sensitivity) drainage if wound care nurse thinks its infected I'll give antibiotics before C&S return..." A physician's telephone order, dated 10/08/14, documented to change order to three times weekly and to remove ace wraps and assess for pressure ulcers, cleanse area on right ankle with normal saline and four by four, apply skin prep, apply Solosite and cover with foam dressing three times weekly and cleanse area on right knee with normal saline, four by four and cover with foam dressing. A physician's telephone order, dated 10/08/14, documented for the wound care nurse to evaluate and treat, change heel and ankle assessment to three times weekly and place Solosite disk to right outside ankle on those days. No documentation was located in the nurses' notes or on the October 2014, treatment sheets of the wound treatments. A care plan, initiated on 10/09/14, documented, "...Focus (Resident) has pressure ulcer development r/t (related to) Splint on right knee and ankle... Goals...(Resident) will have intact skin, free of redness, blisters or discoloration by/through review date... Interventions...Administer treatments as ordered and monitor for effectiveness. Follow treatments ordered by physician...Follow facility policies/protocols for the prevention/treatment of [REDACTED]. A nurse's note, dated 10/11/14 at 2:41 p.m., documented, "...resident continues to be in pain at 8/10 to right knee. Tylenol 325mg two adm (administered) po. 130pm resident wound care adm to right knee per physician orders. Resident yelling in pain with routine pain med given at noon. Wound to right knee draining bloody yellow ting (sic) drainage. Reposition right knee and rewrapped... 150pm LPN notified (Name) daughter of resident being in constant pain even with routine pain med adm. Daughter agreed to send her to have surgery...new order received and noted to send to ER (emergency room ) for eval (evaluation) at (Name) hospital..." An emergency room report, dated 10/11/14, documented, "...Musculoskeletal...Patient has what appears to be a decubitus to be (sic) medial anterior knee. Pressure to the medial thigh causes purulent drainage from the decubitus concerning for an abscess. Patient has a stage II decubitus to the right ankle/lateral malleolus with no drainage..." A hospital history and physical report, dated 10/12/14, documented, "..XXX[AGE] year-old female who sustained a distal femur fracture recently and was discharge to home with nursing home placement...She has come back with a wound over her right knee, worsening leg pain and a fever, along with a white blood cell count of 18,000. She is draining pus out of that wound over her knee which is a little concerning , because she has the obvious comminuted distal femur fracture and history of a total knee replacement, according to the medical record, with hardware in the knee. The patient is bedbound. She is nonambulatory, has a history of previous [MEDICAL CONDITION]" A hospital physician's consult note, dated 10/13/14, documented, "...seen in the office on September 17, 2014, and at that time had a [MEDICAL CONDITION] femur with 100% offset, but no significant displacement otherwise. No flexion deformity and no open wounds. The patient has been treated with just splinting since and presented to the emergency room again today...she was now found with an open wound with a white count of 18,000...They (family members) were contacted again today and (Physician) had told them the possibility that the only way she may have a chance for survival is with an AK (above knee) amputation for immediate mobilization...EXTREMITIES: Right lower extremity demonstrated a markedly deformed distal femur, but it is the proximal end of the fracture site. There is redness and drainage from this wound...CLINICAL IMPRESSION: Open fracture now with some drainage and white count of 18,000..." A nurse's note, dated 10/13/14 at 1:21 p.m., documented the resident's daughter explained due to the severity of her mother's infection they were consulting with the orthopedic surgeon about leg amputation. The PCP was to be notified of any possible surgery. A nurse's note, dated 10/14/14 at 3:25 p.m., documented an aerobic culture of the right knee with critical [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) was faxed to (hospital). A nurse's note, dated 10/15/14 at 7:49 a.m., documented the resident's daughter stated her mother would not be having surgery. The note documented the doctors at the hospital told her the mother would not make it through surgery. The daughter was told if her mother did have surgery and survived, her quality of life would not be good and it was suggested the resident go back to the nursing home and be placed on hospice. The note documented Hospice would be called after talking to the PCP. A nurse's note, dated 10/15/14 at 11:41 a.m., documented the PCP was informed of the resident's condition in the hospital and the request from the family. New orders were received for hospice to evaluate and treat when the resident returned to the facility. A hospital discharge summary, dated 10/16/14, documented, "...FINAL Diagnoses: [REDACTED]. Hospital discharge orders, dated 10/16/14, documented, "...Discharge to Nursing home with (Hospice) hospice to follow. Comfort Measures. Pt. (patient) is DNR (do not resuscitate). Give meds per med rec (reconciliation) sheet. Facility Physician to follow. Call for further orders (hand written) Diet as tolerated..." The medication reconciliation sheet, dated 10/16/14, documented all medications were discontinued. There were no orders for wound care, splint care or care of the resident's fractured bones. A nursing admission screening/history assessment, effective date 10/16/14, documented the resident's right leg was fractured below the knee. She could bear weight on her right leg and had a wound on the front of her right knee measuring 2 cm x 2 cm x 1.7 cm at a stage III, which was caused by a screw rubbing her knee and a wound on her outer right ankle measuring 2 cm x 1 cm at a stage I caused by pressure. This was electronically signed on 10/18/14. A nurse's note, dated 10/16/14 at 12:30 p.m., documented, "Resident back from hospital...new order received and noted. (Hospice) for comfort care and pain control...Right knee has open area 2 x 1.5. Pink around outer area, yellow brownish slough to top part of area, rest of open area red. Tunneling 1.7 in depth by 1.3. Clear bloody drainage. Has scab to the right of wound. No undermining. Cleansed with NSS (normal saline solution) 4x4, applied with gauze 4x4 cover with abd (abdominal) pad and tape. Re wrapped with ace wrap. No open areas to rest of skin..." A physician's orders [REDACTED]. On 10/22/14 at 2:30 p.m., the MDS nurse was interviewed. She was asked if the ace wraps were taken off to assess the resident's leg between 09/09/14 and 09/24/14. She stated they did not take the wraps off. She stated they did not obtain an order to take the ace wraps off. At 3:55 p.m., the right knee wound was observed. The DON and the hospice nurse were performing the wound care. The resident was observed in bed with her right leg positioned on a hard splint from just slightly above the knee down to the foot. A pillow was positioned under the resident's lower right leg. The ace wrap had been removed and the indentation from the ace wrap could still be seen on the resident's skin from just above her knee to her toes. A foam pad was observed on the outside of the resident's right ankle. Both the DON and the hospice nurse positioned their hands under the resident's lower leg and slowly lifted the resident's leg, which caused the knee to assume a more flexed position. The resident yelled out in pain, "Ohh, that hurts!" As long as they held her leg the resident cried out in pain. A wound was observed on the top of her right knee. When the leg was lifted, a moderate amount of serosanguinous fluid ran out of the wound and down the inner side of the resident's knee. It measured 3cm wide by 3cm long. The DON inserted a cotton tipped swab into the wound and more serosanguinous fluid ran out. The wound had a tunneling depth which measured 3cm deep. The bed of the wound was dark beefy red with stings of yellow slough covering the lateral area of the wound. A white curved shaped object was protruding from the lower aspect of the wound approximately 1/2 inch. The DON tapped the white object several times with the cotton swab. The object made a tapping sound. The DON stated she thought the object was part of a bone. She was asked if the physician had been notified about the object. She just shrugged her shoulders. The DON was asked about the hard splint. She stated there was a top half to the splint that fit down over the bottom piece which made the splint more like a cast. She stated the top edge of the splint had been rubbing on the top of the knee and they had been concerned about the development of a pressure ulcer on the knee. She was asked if they had contacted the physician about this concern. She stated she had taken over the DON position after the fracture and had not been told there was a resident with a fracture and a splint in the facility for over a week. She stated she had attempted to contact the orthopedic surgeon but he never returned her call. She stated she had called the PCP but he didn't want to give orders related to the splint and she had called the medical director but he didn't want to give orders on another physician's resident. She was asked if there was any documentation of the phone calls. She stated, "No." The DON was asked about the removal of the ace wrap on 09/09/14, without physician's orders [REDACTED]. She stated there were no open areas but the right ankle was getting pink. She was asked about the nurse's note, dated 09/19/14, which documented they were unable to view the skin because they had no orders to remove the ace wrap and splint. The DON stated they still had not received orders to be able to remove the ace wrap and the splint at that time. She was asked about the knee wound, when it was found on 10/08/14. She stated the resident's knee wound was very small when she was admitted to the hospital and returned from the hospital stay with the large knee wound. She stated she thought the wound was possibly caused by a loose screw from the past knee replacement. The DON was asked if the physician had ordered a wound consult after the resident's return from the hospital. She stated, "No." She was asked if the facility had talked with the physician about a wound consult. She stated, "No." At 3:55 p.m., the regional DON was interviewed. She was asked if the resident was seen by the wound care nurse. She stated there was an order for [REDACTED]. She stated when the resident came back from the hospital she was on hospice. At 5:30 p.m., the medical director (MD) was interviewed. He was asked if he had been contacted by the facility in regard to the resident's leg. He stated he didn't remember being contacted by the facility. The MD stated he had never heard of the resident until that day. He was the physician for the hospice service who had assumed her care. He was asked if he would be managing her wound. He stated, "No, just pain." The MD was asked if he, as the medical director, would give orders if the facility told him they were unable to get orders from a resident's PCP. He stated, "Yes. That is my job. They just have to call me." On 10/23/14 at 9:30 a.m., the QA nurse was interviewed. She was asked if there were any treatment sheets for the order on 10/08/14, to cleanse the area on the right knee with normal saline, four by fours and cover with foam dressing. At 9:45 a.m., the QA nurse stated the 10/08/14, order to cleanse the knee didn't get transcribed to the treatment sheet, so the treatments didn't get done. At 12:55 p.m., LPN #2 was interviewed. She was asked about the resident's skin assessment that she had performed on 10/04/14. She was asked if there were any indications of the development of a pressure ulcer at that time. She stated there were no indications of a pressure ulcer. She stated she didn't think her wound was a pressure ulcer but thought the screw in her knee caused the wound. The LPN was asked if the resident's right leg should have been unwrapped and her skin assessed between the dates of 09/09/14 through 09/24/14. She stated she thought she told someone but couldn't remember. She stated the MDS nurse would have been the one to take the order and or call. At 1:35 p.m., the regional DON was interviewed. She was asked if there were any readmission orders [REDACTED]. She stated there were no readmission orders [REDACTED] At 2:00 p.m., the resident's PCP was interviewed. He was asked if he had been contacted by the facility to get clarification on the order "to maintain the split to the resident's right leg continuously." He stated he would have to look at the resident's chart because he couldn't recall. The PCP stated if they would have called him in the clinic, it would have been documented. The PCP was asked if he had seen the resident's wound. He stated he had not seen the wound. He stated he wanted the orthopedic surgeon to make the decisions in regard to the wound and be involved. The PCP was asked if the facility had contacted him in regard to changing the dressing. He stated he did not recall any other requests for a different dressing change. The PCP was asked if the facility called him for a wound care consult. He stated the facility called him in regard to an open wound. He stated he told the facility to get a culture of the knee wound, before he started her on antibiotics. The PCP stated by the time they got the results she had been sent to the emergency room . He stated he has not been involved in the care of her leg since the resident came back from the hospital. The PCP stated he has not seen the resident since she's been back from the hospital.

On 10/23/14, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to notify the physician when a change in treatment was necessary; to obtain physician' orders for continued care of the resident's wound; and to notify the physician when the resident's condition began to deteriorate due to lack of necessary care for one (#5) of two sampled residents with pressure ulcers. At 3:30 p.m., the existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 3:42 p.m., the administrator, director of nursing (DON), regional DON and quality assurance (QA) nurse were notified of the existence of the IJ. At 5:35 p.m., an acceptable written plan of removal was received. The facility's plan for removal, dated 10/23/2014, documented, "Binger Nursing Center 10/23/14. 1. The doctor for the identified resident (#5) will be notified regarding the current wound assessment. He has been notified on 10-23-14 at 1630. 2. A wound care consult will be scheduled for the identified resident. The wound care consultant will be here for evaluation tonight (10-23-14). Occurred at 1730. 3. Nursing staff (licensed staff) will be educated on the requirements for physician notification of changes in wounds on 10-23-14 by midnight. Those employees not able to be educated by this time will not be allowed to return to work until education is complete. 4. Nursing staff will be educated regarding the regulatory requirements for wound identification, assessment, treatment and reporting changes to the physician on 10-23-14 by 12 midnight. Those employees not able to be educated by this time will not be allowed to return to work until the education is complete. 5. The DON will monitor wounds weekly for compliance for a period of no less than 90 days. 6. New/readmissions will be reviewed to ensure continued compliance for a period of no less than 90 days. 7. Physician notification will be reviewed in the daily clinical meeting on an ongoing basis. 8. If unable to obtain orders from the PCP (primary care physician) the medical director will be notified for further instructions. 9. The wound care policy and procedure will be reviewed and updated by 10-24-14 at 12 noon. 10. The results of the audits and monitoring will be presented to the facility QA committee monthly for a period of no less than 90 days. 11. Any identified non-compliance will result in one on one education and progressive disciplinary action." On 10/24/14, three direct care staff members (LPN #1 at 11:45 a.m., LPN #3 at 3:06 p.m. and LPN #4 at 3:13 p.m.) were interviewed. All stated they had been inserviced and were able to verbalize the requirements on physician notification of changes in wounds and regulatory requirements for wound identification, assessment and treatment. The IJ was removed on 10/24/14 at 12:00 midnight, when all direct care staff had been inserviced. The deficient practice remained at a pattern, actual harm that was not an immediate jeopardy. Based on observation, record review and interview, it was determined the facility failed to ensure the physician was notified of the change of a resident's skin status for one (#5) of two sampled residents with pressure ulcers and failed to: ~ obtain clarification of a physician's orders [REDACTED].; ~ obtain post hospital orders which included wound care and ~ notify the physician of a change in status of a resident's knee wound after assessment (a hard white protruding object). The Census and Conditions report, dated 10/23/14, identified three residents with pressure ulcers. Forty-six residents resided in the facility. Findings: The policy, Change in a Resident's Condition or Status, last reviewed/revised on 04/26/11, documented, "... Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Policy Interpretation and Implementation 1. The Nurse Supervisor will notify the resident's attending physician when... b. There is a significant change in the resident's physical, mental, or psychosocial status... c. There is a need to alter the resident's treatment significantly... f. Deemed necessary or appropriate in the best interest of the resident..." The policy, Physician Services, last reviewed/revised on 04/12/12, documented, "...Policy Interpretation and Implementation ...The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when called by the facility..." Resident #5 had [DIAGNOSES REDACTED]. Prior surgeries included a total right knee replacement. The resident assessment, dated 06/25/14, documented the resident was at risk for the development of pressure ulcers. The assessment documented she had a Stage II pressure ulcer on that date, but did not indicated where the pressure ulcer was located. The medical record documented the resident had a pressure ulcer being treated at that time on both her right ankle and right heel. An incident report, dated 09/04/14, documented the resident had a fall which involved the resident's right knee. It was documented there were no apparent injuries or redness noted. A nurse's note, dated 09/05/14 at 10:18 a.m., documented the resident complained of pain. She had a large bruise on her right knee and had swelling to her right knee through her upper thigh. Ice was applied for swelling and new orders were received to x-ray the right knee and lower leg. A nurse's note, dated 09/05/14 at 1:49 p.m., documented the resident complained of knee pain. The x-ray tech (technician) was at the facility at 1:00 p.m. to x-ray the right knee and lower leg. The x-ray tech gave a preliminary report of the right knee being broken. The physician was notified and new orders were received to send the resident to the emergency room . A nurse's note, dated 09/05/14 at 9:51 p.m., documented the resident returned to the facility with new orders to do neurovascular checks every four hours for 48 hours. The notes documented the hard splint to her right leg was intact. A physician's orders [REDACTED]." A nurse's note, dated 09/09/14 at 12:40 p.m., documented the registered nurse (RN) took off the ace wrap to assess the resident's right leg. The nurse documented there were no blisters noted to the right leg; yellowish/purplish discolorations were noted to the right knee area. A significant change assessment, dated 09/15/14, documented the resident's cognition was severely impaired, she did not ambulate and was totally dependent on staff for transfers, dressing, hygiene and bathing. The resident had one fall with major injury and was at risk of developing pressure ulcers. A care plan, initiated on 09/16/14, documented, "...Focus (Resident) has a history of falls and is at risk for falls due to cognitive status, and decline mobility 9-5-14 had a fall with a fracture... Goals...(Resident) will attempt to resume usual activities without further incident after fracture heels (sic) through the review date... Interventions...Had a fall with fracture, sent to the hospital, returned later in the evening with a splint on RLE (right lower extremity). 9-17-2014, she has an appt. (appointment) with (orthopedic surgeon) to determine further tx (treatment)..." A nurse's note, dated 09/17/14 at 12:32 p.m., documented the resident's PCP made rounds at 10:00 a.m. and there were no new orders. The PCP was aware of the resident going to see the orthopedic surgeon that day. A nurse's note, dated 09/17/14 at 4:20 p.m., documented the resident returned to the facility from the orthopedic surgeon's office and there were no new orders. The orthopedic surgeon's office visit note, dated 09/17/14, documented, "...HISTORY OF PRESENT ILLNESS: (Resident) is an [AGE] year-old female who presented to the emergency roiagnom on ,[DATE]. She had been found with a mobile x-ray to have an acute [MEDICAL CONDITION] femur. She was splinted and sent home. The patient's family felt that she was not a surgical candidate, nor did the emergency room physician, but she was seen here for "change of splint"... PHYSICAL EXAMINATION... X-rays demonstrated a [MEDICAL CONDITION] femur with 100% offset. The total knee is in satisfactory position. These are x-rays taken in the office today AP (anterior/posterior) and lateral. The radiological impression is markedly displaced fracture, periprosthetic femur... ADVISEMENT AND PLAN: The patient understands that the only option for any improvement would be surgery. The family has opted for non-surgical approach. Her splint was reapplied today. A new splint was applied anteriorly. We plan to speak with her daughter with regards to possible management..." A nurse's note, dated 09/19/14 at 9:05 a.m., documented she was unable to assess under the resident's splint on her right leg due to no orders to take the splint off. A nurse's note, dated 09/24/14 at 9:56 a.m., documented she spoke with the orthopedic surgeon concerning getting the resident up in a reclining geri-chair and to see if they could take the ace wrap off to see the right heel. Orders were received to get the resident up in her geri-chair and to take the ace wrap off twice a week, check the heel, apply skin prep and foam pad, then rewrap. The PCP was notified. A nurse's note, dated 09/24/14 at 10:41 a.m., documented the licensed practical nurse (LPN) unwrapped the right leg from the knee down to the foot. There were no open areas. Skin prep was applied to the right ankle for redness. The right leg was rewrapped. A nurse's note, dated 10/08/14 at 3:02 p.m., documented, "while doing residents treatment of [REDACTED]. resident's right ankle is red and is not open, skin prepped around area and applied foam dressing, re wrapped right leg with splint in place, faxed (PCP) in regards to this and (MDS nurse) LPN called wound care nurse and she is to come see resident on her next visit, changed order to assess right leg from twice a week to three times a week, also asked (PCP name) if we could increase pain meds, awaiting any new orders." A physician notification fax, dated 10/08/14 at 3:36 p.m., documented, "... Situation: We have orders to take splint & wraps off 2 x weekly. Today when splint was took off she has a noted .7 cm x .8 cm open area on top of (R) (right) knee that has bloody drainage and is tunneling. We have contacted wound care nurse and she is coming to do a visit. Her (R) ankle is very red but not open. Applied a Solosite & foam dressing. She is in terrible pain when we get her up and when we do anything to her leg. She only has order for [MEDICATION NAME] 5/325 (1) PO (by mouth) q (every) 8 (hours) PRN and PRN Tylenol. Any new orders?... ( physician's response, dated 10/09/14) C&S (culture and sensitivity) drainage if wound care nurse thinks its infected I'll give antibiotics before C&S return..." A physician's telephone order, dated 10/08/14, documented to change order to three times weekly and to remove ace wraps and assess for pressure ulcers, cleanse area on right ankle with normal saline and four by four, apply skin prep, apply Solosite and cover with foam dressing three times weekly and cleanse area on right knee with normal saline, four by four and cover with foam dressing. A physician's telephone order, dated 10/08/14, documented for the wound care nurse to evaluate and treat, change heel and ankle assessment to three times weekly and place Solosite disk to right outside ankle on those days. No documentation was located in the nurses' notes or on the October 2014, treatment sheets of the wound treatments. A care plan, initiated on 10/09/14, documented, "...Focus (Resident) has pressure ulcer development r/t (related to) Splint on right knee and ankle... Goals...(Resident) will have intact skin, free of redness, blisters or discoloration by/through review date... Interventions...Administer treatments as ordered and monitor for effectiveness. Follow treatments ordered by physician...Follow facility policies/protocols for the prevention/treatment of [REDACTED]. A nurse's note, dated 10/11/14 at 2:41 p.m., documented, "...resident continues to be in pain at 8/10 to right knee. Tylenol 325mg two adm (administered) po. 130pm resident wound care adm to right knee per physician orders. Resident yelling in pain with routine pain med given at noon. Wound to right knee draining bloody yellow ting (sic) drainage. Reposition right knee and rewrapped... 150pm LPN notified (Name) daughter of resident being in constant pain even with routine pain med adm. Daughter agreed to send her to have surgery...new order received and noted to send to ER (emergency room ) for eval (evaluation) at (Name) hospital..." An emergency room report, dated 10/11/14, documented, "...Musculoskeletal...Patient has what appears to be a decubitus to be (sic) medial anterior knee. Pressure to the medial thigh causes purulent drainage from the decubitus concerning for an abscess. Patient has a stage II decubitus to the right ankle/lateral malleolus with no drainage..." A hospital history and physical report, dated 10/12/14, documented, "..XXX[AGE] year-old female who sustained a distal femur fracture recently and was discharge to home with nursing home placement...She has come back with a wound over her right knee, worsening leg pain and a fever, along with a white blood cell count of 18,000. She is draining pus out of that wound over her knee which is a little concerning , because she has the obvious comminuted distal femur fracture and history of a total knee replacement, according to the medical record, with hardware in the knee. The patient is bedbound. She is nonambulatory, has a history of previous [MEDICAL CONDITION]" A hospital physician's consult note, dated 10/13/14, documented, "...seen in the office on September 17, 2014, and at that time had a [MEDICAL CONDITION] femur with 100% offset, but no significant displacement otherwise. No flexion deformity and no open wounds. The patient has been treated with just splinting since and presented to the emergency room again today...she was now found with an open wound with a white count of 18,000...They (family members) were contacted again today and (Physician) had told them the possibility that the only way she may have a chance for survival is with an AK (above knee) amputation for immediate mobilization...EXTREMITIES: Right lower extremity demonstrated a markedly deformed distal femur, but it is the proximal end of the fracture site. There is redness and drainage from this wound...CLINICAL IMPRESSION: Open fracture now with some drainage and white count of 18,000..." A nurse's note, dated 10/13/14 at 1:21 p.m., documented the resident's daughter explained due to the severity of her mother's infection they were consulting with the orthopedic surgeon about leg amputation. The PCP was to be notified of any possible surgery. A nurse's note, dated 10/14/14 at 3:25 p.m., documented an aerobic culture of the right knee with critical [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) was faxed to (hospital). A nurse's note, dated 10/15/14 at 7:49 a.m., documented the resident's daughter stated her mother would not be having surgery. The note documented the doctors at the hospital told her the mother would not make it through surgery. The daughter was told if her mother did have surgery and survived, her quality of life would not be good and it was suggested the resident go back to the nursing home and be placed on hospice. The note documented Hospice would be called after talking to the PCP. A nurse's note, dated 10/15/14 at 11:41 a.m., documented the PCP was informed of the resident's condition in the hospital and the request from the family. New orders were received for hospice to evaluate and treat when the resident returned to the facility. A hospital discharge summary, dated 10/16/14, documented, "...FINAL Diagnoses: [REDACTED]. Hospital discharge orders, dated 10/16/14, documented, "...Discharge to Nursing home with (Hospice) hospice to follow. Comfort Measures. Pt. (patient) is DNR (do not resuscitate). Give meds per med rec (reconciliation) sheet. Facility Physician to follow. Call for further orders (hand written) Diet as tolerated..." The medication reconciliation sheet, dated 10/16/14, documented all medications were discontinued. There were no orders for wound care, splint care or care of the resident's fractured bones. A nursing admission screening/history assessment, effective date 10/16/14, documented the resident's right leg was fractured below the knee. She could bear weight on her right leg and had a wound on the front of her right knee measuring 2 cm x 2 cm x 1.7 cm at a stage III, which was caused by a screw rubbing her knee and a wound on her outer right ankle measuring 2 cm x 1 cm at a stage I caused by pressure. This was electronically signed on 10/18/14. A nurse's note, dated 10/16/14 at 12:30 p.m., documented, "Resident back from hospital...new order received and noted. (Hospice) for comfort care and pain control...Right knee has open area 2 x 1.5. Pink around outer area, yellow brownish slough to top part of area, rest of open area red. Tunneling 1.7 in depth by 1.3. Clear bloody drainage. Has scab to the right of wound. No undermining. Cleansed with NSS (normal saline solution) 4x4, applied with gauze 4x4 cover with abd (abdominal) pad and tape. Re wrapped with ace wrap. No open areas to rest of skin..." A physician's orders [REDACTED]. On 10/22/14 at 2:30 p.m., the MDS nurse was interviewed. She was asked if the ace wraps were taken off to assess the resident's leg between 09/09/14 and 09/24/14. She stated they did not take the wraps off. She stated they did not obtain an order to take the ace wraps off. At 3:55 p.m., the right knee wound was observed. The DON and the hospice nurse were performing the wound care. The resident was observed in bed with her right leg positioned on a hard splint from just slightly above the knee down to the foot. A pillow was positioned under the resident's lower right leg. The ace wrap had been removed and the indentation from the ace wrap could still be seen on the resident's skin from just above her knee to her toes. A foam pad was observed on the outside of the resident's right ankle. Both the DON and the hospice nurse positioned their hands under the resident's lower leg and slowly lifted the resident's leg, which caused the knee to assume a more flexed position. The resident yelled out in pain, "Ohh, that hurts!" As long as they held her leg the resident cried out in pain. A wound was observed on the top of her right knee. When the leg was lifted, a moderate amount of serosanguinous fluid ran out of the wound and down the inner side of the resident's knee. It measured 3cm wide by 3cm long. The DON inserted a cotton tipped swab into the wound and more serosanguinous fluid ran out. The wound had a tunneling depth which measured 3cm deep. The bed of the wound was dark beefy red with stings of yellow slough covering the lateral area of the wound. A white curved shaped object was protruding from the lower aspect of the wound approximately 1/2 inch. The DON tapped the white object several times with the cotton swab. The object made a tapping sound. The DON stated she thought the object was part of a bone. She was asked if the physician had been notified about the object. She just shrugged her shoulders. The DON was asked about the hard splint. She stated there was a top half to the splint that fit down over the bottom piece which made the splint more like a cast. She stated the top edge of the splint had been rubbing on the top of the knee and they had been concerned about the development of a pressure ulcer on the knee. She was asked if they had contacted the physician about this concern. She stated she had taken over the DON position after the fracture and had not been told there was a resident with a fracture and a splint in the facility for over a week. She stated she had attempted to contact the orthopedic surgeon but he never returned her call. She stated she had called the PCP but he didn't want to give orders related to the splint and she had called the medical director but he didn't want to give orders on another physician's resident. She was asked if there was any documentation of the phone calls. She stated, "No." The DON was asked about the removal of the ace wrap on 09/09/14, without physician's orders [REDACTED]. She stated there were no open areas but the right ankle was getting pink. She was asked about the nurse's note, dated 09/19/14, which documented they were unable to view the skin because they had no orders to remove the ace wrap and splint. The DON stated they still had not received orders to be able to remove the ace wrap and the splint at that time. She was asked about the knee wound, when it was found on 10/08/14. She stated the resident's knee wound was very small when she was admitted to the hospital and returned from the hospital stay with the large knee wound. She stated she thought the wound was possibly caused by a loose screw from the past knee replacement. The DON was asked if the physician had ordered a wound consult after the resident's return from the hospital. She stated, "No." She was asked if the facility had talked with the physician about a wound consult. She stated, "No." At 3:55 p.m., the regional DON was interviewed. She was asked if the resident was seen by the wound care nurse. She stated there was an order for [REDACTED]. She stated when the resident came back from the hospital she was on hospice. At 5:30 p.m., the medical director (MD) was interviewed. He was asked if he had been contacted by the facility in regard to the resident's leg. He stated he didn't remember being contacted by the facility. The MD stated he had never heard of the resident until that day. He was the physician for the hospice service who had assumed her care. He was asked if he would be managing her wound. He stated, "No, just pain." The MD was asked if he, as the medical director, would give orders if the facility told him they were unable to get orders from a resident's PCP. He stated, "Yes. That is my job. They just have to call me." On 10/23/14 at 9:30 a.m., the QA nurse was interviewed. She was asked if there were any treatment sheets for the order on 10/08/14, to cleanse the area on the right knee with normal saline, four by fours and cover with foam dressing. At 9:45 a.m., the QA nurse stated the 10/08/14, order to cleanse the knee didn't get transcribed to the treatment sheet, so the treatments didn't get done. At 12:55 p.m., LPN #2 was interviewed. She was asked about the resident's skin assessment that she had performed on 10/04/14. She was asked if there were any indications of the development of a pressure ulcer at that time. She stated there were no indications of a pressure ulcer. She stated she didn't think her wound was a pressure ulcer but thought the screw in her knee caused the wound. The LPN was asked if the resident's right leg should have been unwrapped and her skin assessed between the dates of 09/09/14 through 09/24/14. She stated she thought she told someone but couldn't remember. She stated the MDS nurse would have been the one to take the order and or call. At 1:35 p.m., the regional DON was interviewed. She was asked if there were any readmission orders [REDACTED]. She stated there were no readmission orders [REDACTED] At 2:00 p.m., the resident's PCP was interviewed. He was asked if he had been contacted by the facility to get clarification on the order "to maintain the split to the resident's right leg continuously." He stated he would have to look at the resident's chart because he couldn't recall. The PCP stated if they would have called him in the clinic, it would have been documented. The PCP was asked if he had seen the resident's wound. He stated he had not seen the wound. He stated he wanted the orthopedic surgeon to make the decisions in regard to the wound and be involved. The PCP was asked if the facility had contacted him in regard to changing the dressing. He stated he did not recall any other requests for a different dressing change. The PCP was asked if the facility called him for a wound care consult. He stated the facility called him in regard to an open wound. He stated he told the facility to get a culture of the knee wound, before he started her on antibiotics. The PCP stated by the time they got the results she had been sent to the emergency room . He stated he has not been involved in the care of her leg since the resident came back from the hospital. The PCP stated he has not seen the resident since she's been back from the hospital.

Based on observation, record review, and interview, it was determined the facility failed to prevent the development of recurring pressure sores for one (#5) of six sampled residents with pressure sores. This constituted actual harm to the resident. The resident census and condition report dated 09/28/11, documented six residents had pressure sores. Findings: A "Pressure Ulcer Treatment Policy and Procedure" documented, "Policy to promote the healing and prevent the deterioration of existing pressure ulcers and to prevent new ones..." A "Policy/Procedure for Skin Screening" documented, "Every resident will have a head to toe assessment on admission. If the resident is found to have skin breakdown at that time, the LPN will contact the doctor to obtain orders as needed. A Braden Scale will be done on admission and quarterly thereafter by the LPN or RN. Residents found to be anything other than low risk will be placed on weekly skin screenings done either by the 2-10 or 10-6 LPN. The 2-10 LPN will screen the residents that do require personal care throughout the night. A thorough head to toe skin screening includes checking behind ears, between fingers and toes, under skin folds, etc. Document findings on skin screening sheet. If LPN finds a new skin problem that requires intervention then the doctor is to be notified." Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making, minimal indicators of depression, required limited assistance with transfers, walking in the room, walking in the corridor, dressing, toileting, personal hygiene, and required extensive assistance with bathing. The assessment also documented the resident had no skin breakdown. A "Binger Nursing Home Narrative Report" dated 11/01/2010, documented, "...pressure ulcer: Due to decrease in mobility at times, is at risk for pressure ulcers, skin monitored weekly by LPN and Dr. notified if any problems." A care plan dated 11/03/10, documented, "Problem: Potential for skin breakdown D/T decrease in mobility. Goal: Resident will have no skin breakdown. Approach...apply lotion to skin at least X 2 daily...antipressure device on bed when resident in bed. On chair when up. (Avoid doughnut type devices)...Monitor skin weekly for S/SX of potential skin breakdown (E.G. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for TX orders...turn and reposition at least Q2 hours in good body alignment and support with pillows as needed remind him to turn...keep skin clean/dry and bed linens clean, dry and wrinkle free Q shift...minimize environmental factors leading to dry skin (E.G. low humidity (<70%), exposure to cold)... do not position directly onto trochanter when the side-lying position is used. Maintain HOB at lowest degree of elevation possible...avoid exposure to hot water and use mild cleansing agent and gentle touch to minimize irritation and dryness of skin." A quarterly assessment dated [DATE], documented the resident had moderately impaired cognitive skills for daily decision making, minimal indicators of depression, was totally dependent on staff for transfers, walking in the room, dressing, toileting, and bathing. The assessment also documented the resident had no skin breakdown and had a pressure reducing device for the chair and bed. A "Braden Scale- For Predicting Pressure Sore Risk" dated 02/04/11, documented the resident was a mild risk for developing pressure sores with a score of 16. A score of 15 to 18 placed the resident at a mild risk for developing pressure sores. A "Pressure Ulcer Risk Screening" dated 02/04/11 documented, "...does the resident have a [DIAGNOSES REDACTED].? yes....Yes to any...questions put the resident at risk of pressure ulcer. Problem; At risk for pressure ulcers. Goal: Skin to remain intact. Interventions: Turn and reposition q 2 hours...pressure relieving devices..." An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in April: 04/16/11 and 04/27/11. An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in May and June 2011: 05/03/11, 05/11/11, 05/18/11, 05/24/11, 06/2/11, 06/11/11, 06/20/11, and 06/27/11. A quarterly assessment dated [DATE], for resident #5 documented the resident was severely impaired in cognitive skills for daily decision making, had minimal indicators of depression, required limited assistance with transfers, dressing, toileting, personal hygiene, and was dependent on staff for bathing. The assessment also documented the resident was at risk for developing pressure ulcers, had no skin breakdown, and had a pressure reducing device for the chair and bed. An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in July and August 2011: 07/09/11 and 07/17/11. The entries for 07/26/11 and 08/02/11, documented the resident was in the hospital. The "LPN Weekly Skin Evaluation" documented, "08/10/11 skin CDI; 08-19-11 coccyx/bottom area red- S/P Q shift" The care plan last updated 08/11/11, documented only one additonal comment under the problem in regard to skin breakdown: "...comment: no breakdown noted @ present. Is @ risk d/t poor intake, decreased mobility..." A telephone order dated 08/19/11, documented, "Apply skin prep to open area on (L) buttock q shift until healed." A "Monthly Summary" dated 08/21/11, documented, "skin conditions: # of stage 1 pressure ulcers (L) buttocks skin prep q shift...skin treatments: turning/repositioning...ointments/medications (other than to feet) skin prep to (L) buttocks..." The "Weekly Pressure Ulcer QI Log" dated 08/23/11, documented the resident had a stage two pressure ulcer to his buttocks that measured .2 cm X .2 cm. It also documented the resident was receiving skin prep for the treatment. A "Nurse's Note" dated 08/23/11, documented, "... area on (R) buttocks is .2 X .2 surface looks more like sheer area than pressure." The "LPN Weekly Skin Evaluation" documented, "08/26/11 coccyx red- s/p applied & repositioned." The "Weekly Pressure Ulcer QI Log" dated 08/30/11, documented the resident's stage II pressure ulcer was healed. A "Nurse's Note" dated 08/30/11, documented, "Open area on buttocks closed..." There was no documentation to indicate the weekly skin evaluations had been completed in the month of September. A telephone order dated 09/18/11, documented, "Barrier cream to buttocks q shift & prn." A "Monthly Summary" dated 09/21/11, documented, "skin conditions: # of stage 1 pressure ulcers (L) buttocks...skin treatments: turning/repositioning...ointments/medications (other than to feet) skin prep..." On 09/27/11 at 11:25 a.m., the resident was observed in his room, in a recliner with his feet elevated. No pressure relieving device was visible in the recliner, wheelchair, or in the room. At 12:10 p.m., the same observation was made. At 1:50 p.m., the resident was observed in his wheel chair outside in the smoke area. No pressure relieving cushion or device was visible in the wheel chair. The resident's recliner, located in his room, was also observed without a pressure relieving device. At 3:35 p.m., the resident was once again in the recliner in his room. No pressure relieving device was visible in the room, recliner or wheelchair. At 3:50 p.m., a request was made to LPN #3 to let the surveyors know when the resident was receiving care so an observation of the resident's skin could be completed. She stated, "He had an open area, it was healed, but it's back open." She was asked how long it had been open. She stated, "I found out about it last night (09/26/11)." On 09/27/11 at 4:00 p.m., CNA #2 was observed providing care to the resident. The resident's skin was observed to have two stage two pressure ulcers measuring approximately 1 cm x 1 cm located on the left and right buttocks. On 09/28/11 at 9:05 a.m., the resident was observed in his room in bed. The recliner was observed without a pressure relieving device. The wheel chair was observed with a sheep skin cover in the seat of the wheelchair. No pressure relieving cushion was observed in the wheel chair. An interview was conducted on 09/28/11 at 11:55 a.m., with the MDS coordinator regarding the resident's skin breakdown. She was asked when the resident first had a pressure ulcer on the buttocks. She stated, "Opened on 08/23/11 and closed on 08/30/11." She was asked when the last weekly skin evaluation was completed for the resident. She stated, "08/26/11." She was asked if there was documentation to indicate weekly skin evaluations had been completed for the month of September. She stated, "No weekly skin evaluations for September 2011." A "Nurse's Note" dated 09/28/11, documented, "12 noon, reported has open area on (L) buttocks- area checked has a 1 x 1 cm sheer area noted. Dr. (Name withheld) notified new Tx orders recd." A telephone order dated 09/28/11, documented, "Clean area on (L) buttocks c NS pat dry apply collagen & spot dsg dly until healed. Vit C 500 mg po BID, Zinc 500 mg po dly, [MEDICATION NAME] pkg in 8 oz H2O bid w/ meals." The nurse's note and the telephone order had been signed by the MDS coordinator. There was no documentation of notification to the physician for a two day period. A care plan comment dated 09/28/11, for skin breakdown documented, "Open area on (L) buttocks 1 X 1 cm,...New TX orders & vit c, zinc & [MEDICATION NAME]" An interview was conducted on 09/28/11 at 3:20 p.m., with the DON regarding the resident's current skin condition. She was asked if a sheep skin cover was considered a pressure relieving device. She stated, "No, it's not a pressure relieving device. His wife brought them and he uses them." She then stated, "He would have a pressure relieving cushion not just the sheep skin." The DON was informed of the weekly skin evaluations not being completed, physician not being notified of a pressure ulcer, and the pressure relieving devices not being used. She was asked if the resident's care plan was being followed for skin breakdown. She stated, "No, it's not being followed." She was asked when a physician needed to be notified of a pressure ulcer. She stated, "When it's identified." The DON requested LPN #3 to come into her office as well as the MDS coordinator. The DON made a request to the MDS coordinator to check the resident's room to see if there was a pressure relieving cushion for the resident to use. The MDS coordinator left and returned. She stated the resident had not been using a cushion for a long time. She stated a pressure relieving cushion was found under blankets in his closet. At 3:53 p.m., the LPN entered the DON's office and was asked when the resident's current pressure ulcer was first identified. She stated, "I found it Monday night and told the oncoming charge nurse." She was asked if she notified the physician of the pressure ulcer. She stated, "I didn't notify the physician." An interview was conducted on 09/28/11 at 5:05 p.m., with the resident's physician regarding the resident's pressure ulcer. He was asked when he received notice about the current pressure ulcer. He stated, "I found out today about the open area."

Based on observation, record review, and interview, it was determined the facility failed to implement the care plan interventions: a. for skin breakdown to prevent reoccurring pressure ulcers for one (#5) of six sampled residents with pressure ulcers. This constituted actual harm to the resident. The resident census and condition report dated 09/28/11, identified six residents had pressure sores. b. required to maintain a residents independence with toileting for one (#10) of four sampled residents. The resident census and condition report dated 09/28/11, identified 12 residents who were occasionally incontinent of bladder. Findings: The facility policy for "Pressure" documented, "Using the Care Plan" documented, "The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident." A "Goals and Objectives" policy documented, "Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence." 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment dated [DATE], documented the resident was moderately impaired in cognitive skills for daily decision making, minimal indicators of depression, required limited assistance with transfers, walking in the room, walking in the corridor, dressing, toileting, personal hygiene, and required extensive assistance with bathing. The assessment also documented the resident had no skin breakdown. A "Binger Nursing Home Narrative Report" dated 11/01/2010, documented, "...pressure ulcer: Due to decrease in mobility at times, is at risk for pressure ulcers, skin monitored weekly by LPN and Dr. notified if any problems." A care plan dated 11/03/10, documented, "Problem: Potential for skin breakdown D/T decrease in mobility. Goal: Resident will have no skin breakdown. Approach...apply lotion to skin at least X 2 daily...antipressure device on bed when resident in bed. On chair when up. (Avoid doughnut type devices)...Monitor skin weekly for S/SX of potential skin breakdown (E.G. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for TX orders...turn and reposition at least Q2 hours in good body alignment and support with pillows as needed remind him to turn...keep skin clean/dry and bed linens clean, dry and wrinkle free Q shift...minimize environmental factors leading to dry skin (E.G. low humidity (<70%), exposure to cold)... do not position directly onto trochanter when the side-lying position is used. Maintain HOB at lowest degree of elevation possible...avoid exposure to hot water and use mild cleansing agent and gentle touch to minimize irritation and dryness of skin." A quarterly assessment dated [DATE], documented the resident had moderately impaired cognitive skills for daily decision making, minimal indicators of depression, was totally dependent on staff for transfers, walking in the room, dressing, toileting, and bathing. The assessment also documented the resident had no skin breakdown and had a pressure reducing device for the chair and bed. A "Braden Scale- For Predicting Pressure Sore Risk" dated 02/04/11, documented the resident was a mild risk for developing pressure sores with a score of 16. A score of 15 to 18 placed the resident at a mild risk for developing pressure sores. A "Pressure Ulcer Risk Screening" dated 02/04/11 documented, "...does the resident have a [DIAGNOSES REDACTED].? yes....Yes to any...questions put the resident at risk of pressure ulcer. Problem; At risk for pressure ulcers. Goal: Skin to remain intact. Interventions: Turn and reposition q 2 hours...pressure relieving devices..." An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in April: 04/16/11 and 04/27/11. An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in May and June 2011: 05/03/11, 05/11/11, 05/18/11, 05/24/11, 06/2/11, 06/11/11, 06/20/11, and 06/27/11. A quarterly assessment dated [DATE], for resident #5 documented the resident was severely impaired in cognitive skills for daily decision making, had minimal indicators of depression, required limited assistance with transfers, dressing, toileting, personal hygiene, and was dependent on staff for bathing. The assessment also documented the resident was at risk for developing pressure ulcers, had no skin breakdown, and had a pressure reducing device for the chair and bed. An "LPN Weekly skin Evaluation" for the resident documented no breakdowns on the following dates in July and August 2011: 07/09/11 and 07/17/11. The entries for 07/26/11 and 08/02/11, documented the resident was in the hospital. The "LPN Weekly Skin Evaluation" documented, "08/10/11 skin CDI; 08-19-11 coccyx/bottom area red- S/P Q shift" The care plan last updated 08/11/11, documented only one additonal comment under the problem in regard to skin breakdown: "...comment: no breakdown noted @ present. Is @ risk d/t poor intake, decreased mobility..." A telephone order dated 08/19/11, documented, "Apply skin prep to open area on (L) buttock q shift until healed." A "Monthly Summary" dated 08/21/11, documented, "skin conditions: # of stage 1 pressure ulcers (L) buttocks skin prep q shift...skin treatments: turning/repositioning...ointments/medications (other than to feet) skin prep to (L) buttocks..." The "Weekly Pressure Ulcer QI Log" dated 08/23/11, documented the resident had a stage two pressure ulcer to his buttocks that measured .2 cm X .2 cm. It also documented the resident was receiving skin prep for the treatment. A "Nurse's Note" dated 08/23/11, documented, "... area on (R) buttocks is .2 X .2 surface looks more like sheer area than pressure." The "LPN Weekly Skin Evaluation" documented, "08/26/11 coccyx red- s/p applied & repositioned." The "Weekly Pressure Ulcer QI Log" dated 08/30/11, documented the resident's stage II pressure ulcer was healed. A "Nurse's Note" dated 08/30/11, documented, "Open area on buttocks closed..." There was no documentation to indicate the weekly skin evaluations had been completed in the month of September. A telephone order dated 09/18/11, documented, "Barrier cream to buttocks q shift & prn." A "Monthly Summary" dated 09/21/11, documented, "skin conditions: # of stage 1 pressure ulcers (L) buttocks...skin treatments: turning/repositioning...ointments/medications (other than to feet) skin prep..." On 09/27/11 at 11:25 a.m., the resident was observed in his room, in a recliner with his feet elevated. No pressure relieving device was visible in the recliner, wheelchair, or in the room. At 12:10 p.m., the same observation was made. At 1:50 p.m., the resident was observed in his wheel chair outside in the smoke area. No pressure relieving cushion or device was visible in the wheel chair. The resident's recliner, located in his room, was also observed without a pressure relieving device. At 3:35 p.m., the resident was once again in the recliner in his room. No pressure relieving device was visible in the room, recliner or wheelchair. At 3:50 p.m., a request was made to LPN #3 to let the surveyors know when the resident was receiving care so an observation of the resident's skin could be completed. She stated, "He had an open area, it was healed, but it's back open." She was asked how long it had been open. She stated, "I found out about it last night (09/26/11)." On 09/27/11 at 4:00 p.m., CNA #2 was observed providing care to the resident. The resident's skin was observed to have two stage two pressure ulcers measuring approximately 1 cm x 1 cm located on the left and right buttocks. On 09/28/11 at 9:05 a.m., the resident was observed in his room in bed. The recliner was observed without a pressure relieving device. The wheel chair was observed with a sheep skin cover in the seat of the wheelchair. No pressure relieving cushion was observed in the wheel chair. An interview was conducted on 09/28/11 at 11:55 a.m., with the MDS coordinator regarding the resident's skin breakdown. She was asked when the resident first had a pressure ulcer on the buttocks. She stated, "Opened on 08/23/11 and closed on 08/30/11." She was asked when the last weekly skin evaluation was completed for the resident. She stated, "08/26/11." She was asked if there was documentation to indicate weekly skin evaluations had been completed for the month of September. She stated, "No weekly skin evaluations for September 2011." A "Nurse's Note" dated 09/28/11, documented, "12 noon, reported has open area on (L) buttocks- area checked has a 1 x 1 cm sheer area noted. Dr. (Name withheld) notified new Tx orders recd." A telephone order dated 09/28/11, documented, "Clean area on (L) buttocks c NS pat dry apply collagen & spot dsg dly until healed. Vit C 500 mg po BID, Zinc 500 mg po dly, [MEDICATION NAME] pkg in 8 oz H2O bid w/ meals." The nurse's note and the telephone order had been signed by the MDS coordinator. There was no documentation of notification to the physician for a two day period. A care plan comment dated 09/28/11, for skin breakdown documented, "Open area on (L) buttocks 1 X 1 cm,...New TX orders & vit c, zinc & [MEDICATION NAME]" An interview was conducted on 09/28/11 at 3:20 p.m., with the DON regarding the resident's current skin condition. She was asked if a sheep skin cover was considered a pressure relieving device. She stated, "No, it's not a pressure relieving device. His wife brought them and he uses them." She then stated, "He would have a pressure relieving cushion not just the sheep skin." The DON was informed of the weekly skin evaluations not being completed, physician not being notifeid of a pressure ulcer, and the pressure relieving devices not being used. She was asked if the resident's care plan was being followed for skin breakdown. She stated, "No, it's not being followed." She was asked when a physician needed to be notified of a pressure ulcer. She stated, "When it's identified." The DON requested LPN #3 to come into her office as well as the MDS coordinator. The DON made a request to the MDS coordinator to check the resident's room to see if there was a pressure relieving cushion for the resident to use. The MDS coordinator left and returned. She stated the resident had not been using a cushion for a long time. She stated a pressure relieving cushion was found under blankets in his closet. At 3:53 p.m., the LPN entered the DON's office and was asked when the resident's current pressure ulcer was first identified. She stated, "I found it Monday night and told the oncoming charge nurse." She was asked if she notified the physician of the pressure ulcer. She stated, "I didn't notify the physician." Toileting: 2. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan last updated 06/23/11, documented: "Problem - requires assistance in ADL's at least directives or verbal prompts from staff, incontinent of bladder on occasion. Goal: Will keep her on a bladder program as long as improvement continues: (Resident #10) requires extensive assist with verbal cues for toileting. ... staff has to encourage her to toilet and change." A quarterly comprehensive assessment dated [DATE], documented the resident had minimal difficulty with hearing, and was usually able to understand and make her needs known. The assessment further documented the resident was occasionally incontinent of bladder and required supervision with set up for self toileting. On 09/29/11 at 1:50 p.m., the resident was observed being assisted to the toilet by CNA #1. After toileting, the resident was observed to wipe herself, moving her hand from the back to the front of her vaginal area. The resident was asked if she had ever been instructed on how to properly cleanse herself. She stated she had, but by her mother years ago. CNA #1 was asked if she had ever instructed the resident on how to properly cleanse herself after she toileted. She stated, "She won't let us wipe her." The CNA was asked how often the resident was being toileted since she was on a toileting program. The CNA stated, "What's that." On 09/28/11 at 2:45 p.m., an interview was conducted with the MDS coordinator. The coordinator was asked to explain the bladder program that was listed as an "approach" on the current careplan for the resident. She stated, "That can't be right. We don't have a bladder program." The coordinator was asked to identify the approach's documented to teach the resident to clean herself properly. She stated, "Oh, she won't let you. She insists on doing it herself." The coordinator was asked if the direct care staff were encouraged to explain to the resident the possible harm caused by improper wiping. She stated, " They just let her do it." The MDS coordinator was asked what approach's had been implemented to encourage the resident to properly cleanse herself after every toileting episode d/t the persistent UTI's. She stated, " We help her as much as she will allow us to." On 09/30/11 at 9:00 a.m., an interview was conducted with the DON regarding the above observations. The DON was asked what approach's were being implemented for the resident to reduce the number of UTI's. She stated, "We remind her of how to wipe, but she forgets, but they are suppose to monitor and cue her every time." The DON was then asked about the bladder program that was documented on the resident's current care plan. She stated, "We will implement a bladder program and will retrain and inservice the staff on retraining residents on wiping technique."