Every finding on record at Excel Care Center

Based on observations, interviews and record review, the facility failed to ensure incontinent care was provided for four residents (#7, #8, #9, #10) out of five residents sampled. Findings Included: On 12/02/25 at 9:37 a.m., Resident #10 was observed and interviewed lying in bed waiting for incontinent care. Resident #10 stated they have been asking for help going to the bathroom all morning and most days they are left sitting in their wet incontinent product for long periods of time.Review of Resident #10's admission record revealed an admission date of 10/20/25, with diagnoses to include Parkinson's disease, diabetes mellitus, hypertension, dementia, anxiety, dizziness, and muscle weakness.A review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed: a brief interview for mental status (BIMS), a score of 6, meaning severe impairment. Functional Abilities, dependent for toileting hygiene and lower body dressing; partial/moderate assistance for toilet transfers. Bladder and Bowel revealed Resident #10 as incontinent for urinary and bowel continence.A review of Resident #10's bladder continence task log dated 11/04/25-12/02/25, revealed the resident was approached for incontinent product changes only once in an eight-hour shift on the following dates: 11/07/25, 11/12/25, 11/16/25, 11/17/25, 11/24/25, and 11/30/25. Resident #10 was approached for incontinent product changes one time in twelve hours on the following dates: 11/15/25 and 11/21/25. Resident #10 was approached for incontinent product changes once in 24 hours on the following date: 11/29/25.A review of Resident #10's bowel continence/movements task log, dated 11/04/25-12/02/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/07/25, 11/12/25, 11/16/25, 11/17/25, 11/24/25, and 11/30/25. Resident #10 was approached for incontinent product changes one time in twelve hours on the following dates: 11/15/25 and 11/21/25. Resident #10 was approached for incontinent product changes once in 24 hours on the following date: 11/29/25.A review of Resident #10's care plan, dated 10/20/25, revealed that the resident, has an alteration in elimination as evidenced by (AEB): is incontinent of bowel and bladder due to impaired cognition does not recognize toileting needs, is at risk for constipation due to decreased mobility. Requires staff assistance with incontinent/toileting needs. Resident #10's care plan's focus revealed the resident will be clean, dry, and odor free daily. Interventions included checking on the resident upon arising, before/after meals and at night for incontinence, and to observe and notify the physician for changes in bowel/bladder function. Resident #10 requires assistance by one person with toileting. Further review of Resident #10's care plan revealed the resident is dependent and requires assistance with toileting hygiene. No documentation of a care plan for behaviors and refusal of care was found. A review of Resident #10's progress notes dated 11/02/25-12/03/25 revealed no documentation of the resident refusing toileting/hygiene care.On 12/02/25 at 9:52 a.m., an observation and interview of Resident #8 lying in bed waiting for incontinent care was made. Resident #8 stated it takes staff a long time to complete incontinent care. The resident said the night shift is when wait times take the longest.Review of Resident #8's admission record revealed an admission date of 11/08/25. Resident #8 was admitted to the facility with a diagnosis to include: acute kidney failure, urinary tract infection, repeated falls, colostomy, weakness and severe sepsis with septic shock.A review of Resident #8's MDS dated [DATE], revealed a BIMS score of 9, meaning moderately impaired. Functional Abilities revealed substantial/maximal assistance toileting hygiene and lower body dressing; toilet transfer and R#8 is always incontinent of urine. A review of Resident #8's bladder continence task log, dated 11/08/25-12/03/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/12/25, 11/17/25, 11/24/25 and 11/25/25. Resident #8 was approached for incontinent product changes once in twelve hours on the following dates: 11/21/25 and 11/27/25 to 11/29/25. Resident #8 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #8's care plan, dated 11/08/25, revealed the following, the resident has an alteration in elimination AEB: has a colostomy in place and is incontinent of urine, requiring enhanced barrier precautions and assistance of one with toileting hygiene. Resident #8's care plan focus revealed the resident will be clean, dry, and odor free daily. Interventions included: check on resident upon arising, before/after meals and at HS for incontinence, and to observe and notify the physician for changes in bowel/bladder function. Resident #8 requires assistance x1 with toileting hygiene. Resident #8's care plan revealed no history of resident refusing care.A review of Resident #8's progress notes revealed no documentation of the resident having a history of refusing incontinent/hygienic care.On 12/02/25 at 9:59 a.m., an observation and interview of Resident #9 revealed they were lying in bed waiting for incontinent care to be completed. Resident #9 stated they have been waiting almost an hour to be changed, and they are often left in bed waiting to be changed for extended periods of time.Review of Resident #9's admission record revealed an admission date of 11/21/25. Resident #9 was admitted to the facility with a diagnosis to include chronic kidney disease, a history of falling, displaced fracture in right foot, and type 2 diabetes.A review of Resident #9's MDS dated [DATE], BIMS revealed a score of 14, meaning cognitively intact. R#9's functional Abilities revealed R#9 requiring substantial/maximal Assistance for toileting hygiene and lower body dressing. Bladder and Bowel revealed R#9 is frequently Incontinent for urinary and bowel continence.A review of Resident #9 's bladder continence task log, dated 11/22/25 to 12/02/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/23/25 to 11/25/25, 11/30/25, and 12/02/25. Resident #9 was approached for incontinent product changes one time in twelve hours on the following dates: 11/28/25 and 11/29/25. Resident #9 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #9's bowel continence/movements task log dated from 10/1/25 to 10/23/25 revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 11/23/25 to 11/25/25, 11/30/25, and 12/02/25. Resident #9 was approached for incontinent product changes one time in twelve hours on the following dates: 11/28/25 and 11/29/25. Resident #9 was approached for incontinent product changes once in 24 hours on the following date: 12/01/25.A review of Resident #9's care plan, dated 11/21/25, revealed the resident has an alteration in elimination AEB: is incontinent of bowel and bladder due to impaired mobility, use of diuretic, requires assist with toileting/incontinent, and is at risk for constipation due to decreased mobility. Resident #9's care plan focus revealed the resident will be clean, dry, and odor free daily. Interventions included, check on resident upon arising, before/after meals and at HS for incontinence. Resident #9 requires assistance x1 with toileting hygiene. Resident #9's care plan revealed no history of the resident refusing care.A review of Resident #9's progress notes revealed no documentation of resident #9 having a history of refusing care.Review of Resident #7's admission record revealed an admission date of 10/01/25. Resident #7 was admitted to the facility with a diagnosis to include a displaced trimalleolar fracture of right lower leg, wedge compression fracture of third lumbar vertebra, Type 2 diabetes, and heart failure.A review of Resident #7's MDS dated [DATE], revealed: BIMS score of 14, meaning cognitively intact; functional abilities as partial/moderate assistance for toileting transfer; bladder and bowel, revealed Resident #7 occasionally incontinent for urinary continence.A review of Resident #7's bladder continence task log, dated 10/1/25 to 10/23/25 revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 10/2/25 to 10/4/25, 10/6/25 to 10/9/25, 10/11/25 to 10/13/25, and 10/15/25 to 10/22/25.A review of Resident #7's bowel continence/movements task log, dated 10/1/25 to 10/23/25, revealed the resident was approached for incontinent product changes one time in an eight-hour shift on the following dates: 10/2/25 to 10/4/25, 10/6/25 to 10/9/25, 10/11/25 to 10/13/25, and 10/15/25 and 10/22/25.A review of Resident #7's care plan, dated 10/1/25, revealed the resident requires assistance x1 with toileting hygiene. Resident #7's care plan also revealed no history of the resident refusing care.A review of Resident #7's progress notes revealed no documentation of the resident having a history of refusing care.An interview was conducted with Staff G, Registered Nurse (RN) on 12/02/25 at 10:20 a.m. Staff G, RN stated if a certified nursing assistant (CNA) comes to her with a resident who is refusing incontinent care, the nurse is to talk to the resident, and each attempt should be documented whether the resident refuses incontinence care or not.An interview was conducted with Staff H, CNA on 2/02/25 at 10:27 a.m. Staff H, CNA stated residents should be checked for incontinence care every two hours, and each attempt should be documented in the resident's chart.An interview was conducted with Staff A, CNA, on 12/02/25 at 1:56 p.m. Staff A, CNA stated residents should be checked for incontinence care every two hours, and each attempt should be documented in the residents' chart.An interview was conducted with Staff F, RN, on 12/02/25 at 2:13 p.m. Staff F, RN stated staff know to document and attempt every two hours, all attempts for incontinence care.An interview was conducted with Staff B, CNA, on 12/02/25 at 2:20 p.m. Staff B, CNA stated she does not document attempts to change an incontinent product if the resident does not need to be changed when checked for incontinence care.An interview was conducted with Staff C, CNA, on 12/02/25 at 2:26 p.m. Staff C, CNA stated not documenting attempts to change an incontinent product if the resident does not need to be changed when checked for incontinent care.An interview was conducted with Staff E, CNA, on 12/02/25 at 2:31 p.m. Staff E, CNA stated incontinence care should be attempted every two hours, and document each attempt whether the incontinence care was completed or not.An interview was conducted with Staff D, RN/Unit Manager (UM), on 12/03/25 at 10:03 a.m. Staff D, RN/UM stated CNAs are to complete first rounds when they clock-in and then see what their residents' needs are, pertaining to their assignment. Residents are to be checked and changed every two hours, as needed, and as the residents' call light comes on. If a resident refuses incontinence care, CNAs are expected to try again after the initial refusal, then should go get the nurse if the resident refused a second time. The nurse and UM would go and check back with the resident to, convince, them to complete incontinence care. Each attempt on incontinence care that is being made by staff should be documented. Between the UM, Assistant Director of Nursing (ADON), and the Director of Nursing (DON), they all check the dashboard system, speak with staff, and check tasks to ensure that care is properly being provided. The UM is responsible for checking the dashboard system at least once an hour, and when the UM is out of office the ADON and DON monitored care checks.An interview was conducted with the ADON on 12/03/25 at 12:17 p.m. The ADON stated every two hours is the standard for providing incontinent care but is more frequent, whenever a resident needs to be changed. The ADON said CNAs needed to be walking the floor as frequently as possible to ensure needs are being met. The staff are to document each attempt, this way all responsible parties know that care is provided properly. The ADON said all resident interactions are to be documented timely. The ADON stated it is not acceptable to only have two or three incontinent care changes documented in a 24-hour day. The ADON said the expectation is for documentation to be completed and incontinent care provided. The ADON stated the documentation provided for Residents #7, #8, #9, and #10 is not the expectation or standard of documentation for incontinence care.Review of the facility's policy titled Charting and Documentation, dated July 2017, revealed the following: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Policy Interpretation and Interpretation and Implementation. The following information should be documented in the resident medical record: a. objective observations. c. Treatments or services performed . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individuals who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, not dated revealed: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: a. hygiene (bathing, dressing, grooming, and oral care); . e. elimination (toileting) .Review of the facility's policy titled Dignity, dated February 2021 revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: . b. promptly responding to a resident's request for toileting assistance.Review of the facility's policy titled Urinary Incontinence-Clinical Protocol dated April 2018 Policy revealed: . Assessment and Recognition . 4. For incontinent individuals, the nursing staff will identify, and document circumstances related to the incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing or sneezing. Treatment/Management . 4. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continent status. Monitoring, 1. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. a. This should include documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence.

Based on observation, interview and record review, the facility failed to store food under sanitary condition by not ensuring the walk-in refrigerator and the milk box cooler contained thermometers on the inside. This has the potential to affect 108 out of 116 residents who eat orally residing in the facility at the time of the survey. The findings included: Observation of the initial kitchen tour on 1/22/24 at 8:42 AM with the Certified Dietary Manager Dietitian (CDM) revealed the following: 1) Walk-in refrigerator temperature outside was 40 degrees F and for the inside temperature, there was no thermometer noted. The walk-in refrigerator contained dairy products, cheese, pasteurized eggs in the shell, liquid pasteurized eggs, milk, vegetables, fruits, and preparation lunch items and 2) Milk Box temperature inside, there was no thermometer noted. The milk box contained milk cartons. Record review of the facility's Food Storage Policy indicated: Cold Policy and Procedure (revision date October 2019); Policy Statement-It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the [ ] federal organization Food Code; Action Steps: 2) The Dining Services Director/Cook ensures that all perishable foods will be maintained at temperature of 41 degrees Fahrenheit (F) or below and 4) The Dining Services Director/Cook insures that an accurate thermometer will be kept in each refrigerator and freezer. Interview with the CDM on 1/22/24 at 8:43 AM. She acknowledged that the thermometers were missing in the walk-in refrigerator and the milk box. She stated: There should be a thermometer in here.

Based on record review and interview the facility failed to complete the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 103) out of one resident was discharged to the community who was investigated for Resident Assessment. This deficiency has the potential to affect 116 residents residing in the facility at the time of survey. The findings included: Record review of the clinical records for Resident #103 revealed the resident was admitted to the facility on [DATE] and was discharged home on 09/11/2023. Review of the Discharge-Return Non-Anticipated MDS assessment dated [DATE] was in progress. Section C and E-K were not completed. Interview with MDS Coordinator on 01/24/2024 at 12:17 PM. She stated that the assessment was not completed. She stated they did not realize the assessment was not completed until Tuesday January 23 when the system alerted them. She stated the assessment will be completed today. Further review after the above interview indicated the Discharge Non-Anticipated MDS dated [DATE] was completed on 01/24/2024. Review of policy and Procedures non dated for Minimum Data Set Completion and Submission Timeframes revealed Policy Statement: Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1-The assessment coordinator or designee is responsible for ensuring that resident assessment is submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2-Timeframes for completion and submission of assessment are based on the current requirements published in Resident Assessment Instrument Manual.

Based on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 103) out of one resident whose Resident Assessments was investigated that was discharged to the community. There were 116 residents residing in the facility at the time of the survey. The findings included: Record review of the clinical records for Resident #103 revealed the resident was admitted to the facility on [DATE] and was discharged home on 09/11/2023. Review of the Discharge-Return Non-Anticipated MDS assessment dated [DATE] was completed and transmitted on 01/24/2024. Interview with MDS Coordinator on 01/24/2024 at 12:17 PM. She stated that the assessment was not completed in a timely manner. She stated they did not realize the assessment was not completed until Tuesday January 23 when the system alerted them. She stated the assessment will be completed and transmitted today. Follow up review after the above interview of Discharge Non-Anticipated MDS dated [DATE] was transmitted on 01/24/2024. Review of policy and Procedures non dated for Minimum Data Set Completion and Submission Timeframes revealed Policy Statement: Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1-The assessment coordinator or designee is responsible for ensuring that resident assessment is submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2-Timeframes for completion and submission of assessment are based on the current requirements published in Resident Assessment Instrument Manual

Based on observations, interviews, and record review the facility failed to ensure the provision of a safe environment related to safety floor mats to prevent accidents in the event of a fall for one Resident (#83) out of 27 sampled residents. There were 116 residents residing at the facility at the time of the survey. The findings included: On 01/22/24 at 09:31 AM, during the initial observation Resident # 83 was in bed asleep, no distress noted, one fall mat was observed on the left side of bed and one safety floor mat was against the wall behind the head of the bed, (Photographic evidence available). On 01/23/24 at 09:15 AM Resident observed in bed awake watching television, call light on bed, one floor mat on left side of the bed on the floor, right side floor mat against the wall, behind the head of the bed, (Photographic evidence available). On 01/24/24 at 10:17 AM Resident #83 was observed seated in a wheelchair in the therapy room with therapist, no distress noted. During observation on 1/24/23 at 09:00 AM Resident #83 was not in bed, the bilateral safety floor mats were beside bed. On 01/25/24 at 08:24 AM Resident # 83 was observed in bed eating breakfast, the bilateral safety floor mats were beside the bed. Review of the medical records for Resident #83 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] and 12/29/23. Clinical diagnoses included but not limited to: History of falling, Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing, Unspecified fracture of right acetabulum, subsequent encounter for fracture with routine healing, and Fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing. Review of the Physician's Orders Sheet for January 2024 revealed Resident #83 had orders that included but not limited to: Tramadol HCL oral tablet 50 milligram (mg)-give 50 mg by mouth every 8 hours as needed for mild to severe pain level 4-10. Record review of Resident #83 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 4, on a 0-15 scale indicating the resident is cognitively impaired. Section E for behavior documented Physical behavioral symptoms directed towards others occurred 1-3 days. Section GG for Functional Abilities documented resident requires partial/moderate assistance for Activities of daily living. Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section J for Health Conditions documented resident had a fall with major injury since admission, received scheduled pain medications in the last five days, and experienced no shortness of breath. Section N for Medications documented resident is taking antidepressants and opioids and Section O for Special Treatments and Procedures documented no special treatments received. Review of Resident #83's Care Plans Reference Date 01/02/24 revealed: Resident is at risk for falls and/or fall related injury related to: impaired balance, cognitive deficits, requires staff assist with transfers, is non ambulatory, is impulsive; attempts transfer self independently, uses wheelchair as primary mode of locomotion, has a history of falls, has poor safety awareness, receives psychotropic medications, use of anticoagulants. Resident will minimize the risk of falls with staff intervention through the next review date. Target Date: 04/01/2024. Interventions included- Floor mats to both sides of the bed when in bed, Quarter side-rails up in bed as an enabler, assist to wheel to destinations, Low bed, keep call light within reach, Report falls to physician and responsible party as needed, invite to activities of interest and escort to activity as needed. Review of the physical medicine and rehabilitation follow up note dated 1/12/2024, timestamped 15:32 stated: On 11/6/23 patient had fall and was sent to Emergency Department for further evaluation. Suffered laceration to the right forehead. On 12/26/23 patient was sent to Emergency Department due to fall on 12/23/23 and x-ray confirmed left femur fracture. The patient underwent surgical intervention of left hip arthroplasty. Patient was medically stabilized but not strong enough to return home. Patient admitted to the facility on [DATE] for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. Interview on 01/24/24 at 08:40 AM, the Director of Nursing (DON) stated: the resident was admitted on ,d+[DATE] 23, he has had 2 falls in the facility on 11/06/23 and 12/23/23. On 11/06/23 the resident bumped his head and had to get stiches on his forehead, he was in the day room on the subacute side, the resident was in wheelchair watching television, the resident was observed 5 minutes prior by staff, two nurses that were counting their medication cart observed the resident on the floor, he had fallen forward, we placed an order through Therapy for wheelchair adequacy and positioning, completed labs on the resident. The resident was sent out to the hospital for stitches to the right forehead and came back later that night on the same day with four staples to his right forehead. On 12/23/23 the resident was sitting in the common room watching television, the Certified Nursing Assistant (CNAs) and the nurse witnessed the resident getting up out of the chair suddenly, took two steps and fell on his left side, the staff was unable to get to the resident on time to prevent the fall. A complete assessment was done, resident denied pain and was able to move all extremities. On 12/26/23 the resident was in therapy and was grimacing holding his left side, we did an in-house x-ray of the resident's left hip, results showed a hairline fracture of the femur on the left side, the resident was sent to the emergency room for evaluation and was admitted for surgical repair to the left hip. The resident was readmitted on [DATE], we completed pertinent labs on the resident, kept resident in common areas when out of bed, and completed follow up x-rays. The was shown the photos taken by the surveyor; after seeing photos of multiple days observations of the resident's right floor mat against the wall at the head of the bed while the resident was in bed sleeping. The DON stated that she will get the matter corrected as soon as possible and get training and education started immediately with the nursing staff. Interview on 01/24/24 at 10:45 AM Certified Nursing Assistant (CNA) (Staff B) stated: I have been working here since August 2023, I became a CNA in July 2023, I am fairly new to this profession, I do my rounds several times during my shifts checking on each of my residents, I am usually assigned about 10 residents, this week I am assigned on the unit this resident is on. If the resident has any special equipment that needs to be placed in a certain way the DON would let us know about the care, regarding the resident's floor mats I have been educated today by the DON that when the resident is in bed, both resident's floor mats must be placed on the sides of the bed for safety. ` Interview on 01/24/24 at 11:07 AM Licensed Practical Nurse (LPN), (Staff C) stated: I do my rounds several times during my shifts, we placed the floor mats behind the bed at breakfast time so we can get the overbed table close to the resident for him to eat his breakfast, we all should be following up to make sure the floor mats get replaced beside the bed after the resident is done eating. The DON did a teachable moment with me about making sure the mats are in place when the resident is in bed. Moving forward, when I do my rounds if the resident is in bed, I will make sure that the floor mats are in place beside the bed. Review of the facility's policy titled Safety and Supervision of Residents revision date March 2023 states: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Individualized, Resident- Centered Approach to Safety 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Assigning responsibility for carrying out interventions. c. Ensuring that interventions are implemented; and d. Documenting interventions

Based on observations, interviews, and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration. As evidenced by during medication administration the Registered Nurse signed off on Resident #2's medication as given before administering the medications for one out of four residents observed, and left the medication cart unlocked in the hallway during medication administration in Resident #2's room. There were 116 residents residing in the facility at the time of the survey. The findings included: On 1/23/24 at 9:35AM, during medication administration observation Registered Nurse (Staff A), prepared all the medications for administration to Resident #2, signed off all the medications as given on the Electronic Medication Administration Record, locked the computer and entered the room to give Resident # 2 the medications. Staff A entered the room, gave Resident #2 the medications and exited the room. On 1/23/24 at 9:43AM, the Surveyor apprised Registered Nurse, Staff A that she was observed signing off on Resident's #2's medications as given before she went into the room to administer the medications. Staff A stated she did check off and saved the medications as given to the resident on the system before she administered the medications to the resident. Staff A further stated that she does the check off based on how she knows the residents, the resident usually does not refuse the medications, that is why she checked off the medications before administering. The surveyor showed the Staff A a picture of her cart with the bingo cards (medication packets) turned face-side down on top of the medication cart and the cart unlocked. The picture was taken when the nurse was in the room administering medications to Resident # 2. Staff A stated: I was supposed to lock my cart when I went to give the resident the medications, and the bingo cards that were on top of the medication cart turned face-side down were empty. The surveyor checked the bingo cards that were face-side down on the top of the cart and confirmed they were empty. Review of the facility's policy titled Administering Medications revision date April 2019 states: Medications are administered in a safe and timely manner, as prescribed. Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones

Based on facility and hospital medical record review, interviews, and policy and procedure review, it was determined the facility failed to notify the attending physician in a timely manner of a change in condition and critically elevated Prothrombin Time and International Normalized Ratio (INR) for one (Resident #5) of three residents requiring laboratory monitoring for anticoagulants out of a total sample of 14 residents reviewed for lab results. The facility failed to notify Resident #5's attending physician of a need to alter treatment in response to the critical lab values resulting in an emergency transfer and an 11 day hospitalization . Resident #5 required a blood transfusion, suffered from acute [CONDITION(S)] due to ST-Elevation [CONDITION(S)] (STEMI), acute gastrointestinal (GI) bleed in the setting of supratherapeutic INR, and acute blood loss [CONDITION(S)]. The facility's failure to notify the physician in a timely manner resulted in the findings of Immediate Jeopardy. The Immediate Jeopardy began on [DATE] and was removed on [DATE], with a Scope and Severity reduced to a D. Findings included: A phone interview was conducted with the Health Care Surrogate (HCS) for Resident # 5 on [DATE] at 12:37 pm. He stated Resident #5 called him at about ten minutes to midnight on [DATE]. Resident #5 reported to the HCS, he was pretty sure he was having a [CONDITION(S)] or a stroke. The HCS stated Resident #5 has had a lot of pain in his life and in his body, but he's not a complainer. He doesn't complain unless he is really hurting. Something was happening. My hearing his voice, he was scared. During the phone interview and in a follow up communication from the HCS, received on [DATE] at 6:49 pm, the HCS stated Resident #5 told me that he had told an employee, he thought might have been a Certified Nursing Assistant (C.N.A.), what he thought was happening to him and had then waited over an hour prior to calling me after having asked for help. None was forthcoming. An employee, probably a CNA was supposed to get someone but told him they were having a shift change. That person never returned, nor did a nurse show up which was who was asked for. I told Resident #5 to keep the phone in his hand while I hung-up and called the facility seeking to speak with the person in-charge of the facility at that time. A man answered and I told him that I needed to speak with the person in-charge immediately as my friend, one of their patients, was having either a stroke or [CONDITION(S)] while we were speaking. He told me he would try to connect me with someone. He came back and said he was having a problem, I told him to immediately find me a nurse. I hung up and called Resident #5 back and said that someone should be coming as soon as possible (ASAP). We talked and waited. I kept assuring him that someone would be there soon. I told Resident #5 to start yelling for help. Still nothing. I told him again to keep the phone in hand. I was going to hang up again, and I would call right back. I called the facility again. I believe it was the same man who answered. At this point, I am very worried and extremely upset. Next thing I know I am talking to a nurse. She told me that she was an agency nurse just reporting in to work and that she couldn't give me any information, she did not give me her name. It was unbelievable. She said she would get another nurse. I called Resident #5 back and waited with him. Finally, a nurse called me, and she said she would check on him. She told me that we are calling his doctor and they were waiting to get his permission. I told them that they should immediately call 911, or that I would call both 911 and the police. I spoke with Resident #5 again, and no one was at his room yet. I told him that I had asked them to call 911 but that I was hanging up again and calling myself. At 1:13 am the nurse called me back and told me that 911 had arrived and that they were taking him to (name of local Hospital). When I got to the hospital, he had two heart attacks. He might have died if he hadn't called me, and I was going ballistic trying to get someone to talk to me and do something. I was upset when she told me she had to wait for the doctor to call back, so I called 911. He told me his call light was on for an hour or more. I'm not sure. It can seem like longer when in pain. A phone interview was conducted with Resident # 5, on [DATE] at 9:31 am. He stated, I was desperate. I pushed the call light, no one came, no one came - it was a long time, probably about 45 minutes. I called on my cell phone to my friend and he got help for me. He stated I had no idea what was going on with me. I was scared. I was having chest pain and things felt unusual. After my friend called and got the nurse to come in, it still took a while to get me to the hospital. He stated his friend saved his life by getting him help. The resident reported that he remained in an acute long term care hospital. He stated he was feeling better but was still very weak. An interview was conducted on [DATE] at 3:33 pm with Staff C, C.N.A., who provided care to Resident # 5 on the 3 pm to 11 pm shift on [DATE]. She stated she remembered Resident # 5, and he was a sweetheart. She stated he would say sometimes his stomach hurt, and she would report this to the nurse. She stated the only pain he complained of was his stomach hurting but she had no recall of when he reported this to her. She stated his stool was always, putty like and real dark stool. She reported that his stool, as far as she knew, was like that since he was admitted . She stated she would document stool on his ADL tasks but there was no place to record the color of it. She stated it should be reported to the nurse, but she did not report it to the nurse. She did not recall anything unusual occurring with Resident #5 on [DATE]. Staff C stated Resident # 5 did not report chest pain or shortness of breath and she did not recall whether he put his call light on during the shift. On [DATE] at 9:32 am, a telephone interview was conducted with Staff B , Licensed Practical Nurse (LPN). Staff B stated she was an agency nurse who did not receive the assignment to this facility until after 11 pm on [DATE]. She stated she did not arrive at the facility until 12 am that day. She stated she was sitting at the nurse's station when the nurse from the other unit came over and told her that Resident # 5 needed assistance. She stated the CNA who was supposed to have him had not arrived yet and the other CNA on duty was assigned to two hallways. She stated she saw on her assignment sheet she was assigned to Resident # 5. She reported that she looked down his hall and believes she saw that his call light was on, but she can't be 100% sure. She stated she could not hear him shouting but when she got to the room, the TV was very loud, and she had to turn it down. Staff B stated when she went in the room, he told her he was having chest pain and needed to go to the hospital. She stated she left the room to see if Resident # 5 had any [MEDICATION(S)] in the medication cart but there was none. Another nurse logged into the computer to see if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she checked his vital signs, and they were fine. She stated the friend wanted to talk to her and the only face sheet she could find for Resident # 5 had no diagnoses and no emergency contact information on it. She told him she would have to verify who he was before she could give him any information. She stated she got onto the other nurse's computer and saw that the caller was the Health Care Surrogate (HCS). She stated she saw that Resident # 5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B reported that the HCS wanted the resident sent out immediately to the hospital, and she told him she had to call the physician first. She explained to the HCS, if the physician did not call back within 5 minutes, she would call 911. She stated the physician did not call back and with the resident's history of [CONDITION(S)], she called 911 . She stated Resident # 5 was not any worse when he left for the hospital, he was not cool or clammy and his vitals were stable. Staff B further explained when she got to the facility at 12 am on [DATE], she went down to the other unit to obtain a login for access to the facility's electronic record system from the nurse down there. She stated the login the nurse gave her did not work and she had no access to Resident # 5's clinical records. She had to ask the other nurse on the unit to let her use her computer to see Resident # 5's clinical record. She stated she only had access to a dummy login that did not include clinical information on residents. She stated she did not get access to resident's clinical records until 2:00 am on [DATE]. A review of Resident #5's medical record revealed a narrative nurse's note, dated [DATE] at 4:35 am by Staff B, Licensed Practical Nurse (LPN). The note indicated that at approximately 12:45 am, the nurse from LEU (Long Term Extended Unit) came to writer and was informed that resident's family was on the phone and stated resident in room . needed assistance. Writer then went to room, observed resident in bed lying in supine position with head of bed elevated talking on cell phone. Writer asked resident what was going on, what did he need assistance with. Resident stated, I'm having chest pain and it's a [CONDITION(S)]. I'm having a [CONDITION(S)] and I need to go to the hospital now. Resident screamed, I'm having a [CONDITION(S)]! Writer exited room and went to cart to check if resident had any nitro, on hand. Another nurse had computer up and allowed writer to check resident's orders. No orders for nitro and no history of [CONDITION(S)]. Resident then told writer and Certified Nursing Assistant (CNA) that his left arm was tingling, he has a crushing feeling on his chest, and jaw pain. Vital Signs : ,d+[DATE] (blood pressure), 117 (heart rate), 21 (respirations), oxygen saturation 97 % on RA (Room Air). Resident was non diaphoretic and afebrile. Call placed to on call for primary care physician. Resident's friend was asking to speak to writer. Writer informed him that she had to make sure he was on the face sheet and authorized to speak to him about resident's condition. Resident's friend identity confirmed as (name) Health Care Surrogate (HCS). HCS informed writer he wanted resident to go out to hospital. Informed HCS she was trying to give the on-call physician time to return her call but after 5-minute mark would just call 911. No return call from provider. Call placed to 911 regarding COC (Change of Condition). Approximately 1:08 am, resident was transported to (local hospital) via EMS (Emergency Medical Services) transport. Call placed to HCS to inform resident has left facility and what hospital he was in-route to. Review of the Change in Condition Evaluation dated [DATE] at 4:01 am, revealed Resident stated he needed to go to hospital, his chest is hurting and he's having pain in his left arm. Resident was on phone with the Health Care Surrogate and proxy demanded he go to hospital. Review of vital signs evaluation for [DATE] at 00:45 revealed Most Recent Pulse: 117, Pulse Type Irregular- UTD (unable to determine). The SNF/NF Hospital Transfer Form revealed: Date Transferred to hospital as [DATE] at 01:08 am. A review of Resident #5's Admission Record revealed he was originally admitted to the facility from the hospital on [DATE] with diagnoses which included metabolic [CONDITION(S)], unspecified [CONDITION(S)], acute [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A review of the admission Minimum Data Set (MDS) assessment, dated [DATE] revealed a Brief Interview for Mental Status ( BIMS) score of 15, indicating intact cognition. The MDS indicated Resident # 5 needed extensive assistance for activities of daily living (ADL's) and utilized a wheelchair. A review of the hospital discharge summary, dated [DATE], revealed discharge diagnoses to include Ischemic Stroke, High grade Right Cavernous ICA ( Internal Carotid Artery) Stenosis vs Non-occlusive Thrombus. Hospital discharge orders for [DATE] included [MEDICATION(S)] 6 mg one tablet by mouth daily. A review of the facility's comprehensive care plan, initiated [DATE], revealed: Focus: ( Resident # 5) is at risk for abnormal bleeding and increased bruising reference to use of anticoagulants for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Goal: resident will remain free of complications from anticoagulant therapy through next review date. Interventions included but not limited to Obtain labs/diagnostics as ordered; report results to physician and follow up as needed. Focus: (Resident #5) has potential for complications related to diagnoses of A-Fib, [CONDITION(S)]. Goal: resident will remain free from cardiovascular complications through the next review date. Interventions included: Labs & diagnostic tests as ordered; update physician of results; Observe for complaints and signs and symptoms of cardiac complications; notify physician if noted. A review of the facility's physician order summary for [DATE], revealed an order, dated [DATE], for [MEDICATION(S)] Sodium 6 mg, give 1 tablet by mouth in the evening for treating/preventing blood clots. A physician's order, dated [DATE], stated INR every night shift every Sunday. A review of the Treatment Administration Record (TAR) for [DATE] revealed that the order for INR blood draw was noted as having been completed on Sunday, [DATE]. On [DATE] at 2:30 p.m., the Interim Director of Nursing stated there was no INR lab drawn on [DATE] for Resident #5. Continued review of the [DATE] TAR revealed the order for INR was completed during the night shift the following Sunday, [DATE]. Review of the Lab Results Report, revealed an INR was collected on [DATE] at 5:14 am and the results were reported to the facility on [DATE] at 8:35 pm. The Lab Results Report revealed a high PT (Prothrombin Time) of 58.7 seconds with a reference range of 11.4- 14.6 seconds and a critically high (CH) INR result of 6.4 (verified by repeat) with a reference range of 0.8 -1.2. The report indicated an INR Range for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. A PT/INR test helps find out if your blood is clotting normally. It also checks to see if a medicine that prevents blood clots, such as [MEDICATION(S)], is working the way it should. If you are taking [MEDICATION(S)]: INR levels that are too low may mean you are at risk for dangerous blood clots. INR levels that are too high may mean you are at risk for dangerous bleeding. Your health care provider will probably change your dose of [MEDICATION(S)] to reduce these risks. https://medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr Continued review of the medical record revealed a physician's progress note dated [DATE], which was electronically signed by the physician on [DATE] at 1:52 pm. The note revealed Reason for Appointment: Initial H&P [History and Physical] History of Present Illness; He was hospitalized in [local hospital] for [CONDITION(S)] [[CONDITION(S)]], has CTA [commuted tomography [MEDICATION(S)]] showing high grade stenosis, 1st nonocclusive thrombus in cavernous R ICA [right internal carotid artery], Neuro IR [[MEDICATION(S)] Radiologist] did not recommend intervention. No TPA [Tissue [MEDICATION(S)] activator] is on [MEDICATION(S)] now. He has Secondary hypercoagulable state on [MEDICATION(S)] which INR not done on [DATE] as he refused blood draw. Will reorder for Thursday. Assessments: Secondary hypercoagulable state- Continue [MEDICATION(S)] until next INR check on Thursday, no bleeding at this time evident. INR [DATE] was 1 then 2.8 on [DATE]. The physician's progress note of [DATE] showed no indication that he was notified of the critical PT/INR results reported at 8:35 pm on [DATE]. The Lab Results Report indicated this lab result was reviewed by Staff A, the SRU (Short Term Rehabilitation Unit) Unit Manager on [DATE] at 3:50 p.m. (15:50), three days after the critically high PT/INR lab report was received. A review of the nursing progress notes, for [DATE], revealed no documentation related to the critical laboratory results of [DATE], and no documentation the physician was notified of the results on [DATE]. A review of Resident # 5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A narrative nursing note dated [DATE] at 4:41 am, indicated Resident PT/INR from [DATE] reviewed with on call MD (medical doctor). New orders received to discontinue [MEDICATION(S)] and repeat PT/INR on Friday ([DATE]). Resident stable at this time, no signs and symptoms (S/S) of bleeding noted. A subsequent narrative nurses note, dated [DATE] at 11:48 am and written by Staff A, the SRU Unit manager indicated: This writer spoke with NP ( Nurse Practitioner) covering for MD and changed order to daily PT/INR x 7 days to monitor and when therapeutic she would up (sic) resident back on [MEDICATION(S)]. No further concerns at this time. Review of the [DATE] TAR revealed the following orders: [DATE] at 4:40 AM PT/INR on Friday one time only for 1 day. The order was noted as d/c (discontinued) on [DATE] at 12:15 PM. [DATE] at 11:47 AM PT/INR every night shift for 7 days. There was no documentation that a PT/INR was drawn on [DATE], and on [DATE] the TAR was marked to indicate the resident was hospitalized . A Review of the hospital medical record for Resident #5, for a hospitalization from [DATE] to [DATE], revealed: On arrival to the emergency department (ED) an Electrocardiogram ( EKG) showed a ST-Elevation [CONDITION(S)] ( STEMI), and an alert was called. Cardiologist at bedside who determined that the patient was not stable enough for catheterization. Patient had a variety of complaints including chest pain, back pain ,and generally not feeling well, that started suddenly prior to him calling EMS. Patient has several episodes of [NAME] ( black tarry stool) while in the ED. Patient was intubated prior to exam. In the ED, Hemoglobin was 9.3, hematocrit 25.1. Patient given 2 units of PRBCs (Packed Red Blood Cells). First initial INR noted to be at 10.37, repeat was 6.28. Patient was given a dose of Vitamin K in addition to 4 units of FFP (Fresh Frozen Plasma) . Final Impression: High density material noted within the stomach which can represent blood products in the appropriate clinical scenario. Bilateral non obstructing calculus. Resident # 5 was admitted to the ICU (Intensive Care Unit) A review of the hospitalization summary revealed, date of admission [DATE], Reason for hospitalization was Chest Pain, Discharge Diagnoses (included but not limited to) Acute hypoxic respiratory failure requiring mechanical ventilation greater than 72 hours, Acute [CONDITION(S)] due to STEMI, Acute GI bleed in the setting of Supratherapeutic INR, Acute blood loss [CONDITION(S)] requiring blood transfusion, Supratherapeutic INR. A phone interview was conducted with Resident #5's Nurse Practitioner, on [DATE] at 10:33 am. She reviewed her notes, contained in the resident's medical record. She stated she had a note from [DATE], which indicated she was informed by the nurse that Resident # 5 refused the [DATE] PT/INR. The NP stated she did not recall being notified of any PT/INR results on [DATE]. She stated, maybe they called me for it, but I don't have anything here. She stated her expectation is, If it's a critical level, lab is supposed to call unit and speak with the nurse, and the nurse will let me know. Whether that happens is dependent on the lab. The NP was informed that facility documentation indicated that the on-call MD was notified of the [DATE] abnormal lab value on [DATE]. The NP stated, Oh wow, that's a long time. She stated the [MEDICATION(S)] Sodium 6 mg would have needed to be discontinued with those results. She confirmed that continued use of the medication could cause a GI bleed. A phone interview was conducted with Resident # 5's primary care physician on [DATE] at 10:52 am. He remembered Resident # 5 was a resident who had a stroke. He had paralysis or weakness from baseline MS ( [CONDITION(S)]) and was weak and debilitated. He could not recall the exact reason the resident was receiving [MEDICATION(S)] and thought it might have been related to a risk of DVT ([CONDITION(S)]). He recalled the resident having had some stenosis in one of the carotid or cerebral arteries. The physician stated he did remember that he was made aware that Resident # 5 did not want to get one of his INR labs done. He did not recall when he was notified of the refusal of the INR but stated, I am sure they must have notified me that day or I found out that day, but I don't see any note that I wrote that day. I don't remember. I could have found out before, or I could have found out on the 24th. The physician confirmed the INR results from [DATE] and [DATE] were documented in his progress notes and were the labs he reviewed on [DATE]. The physician indicated he did not think he was notified of the PT result of 58.7 and INR of 6.4 from [DATE]. He stated that he had taken two days off at that time. The physician stated that it sounded problematic that there was no notification to a medical provider until [DATE]. He stated his expectation was for the medical provider to be notified the same day. He indicated there was an answering service and we are available ,d+[DATE]. The physician stated he found out of Resident #'5's condition when he was finishing his progress note. Review of the physicians' progress note revealed that he electronically signed the note on [DATE]. The physician stated he would not have continued the [MEDICATION(S)] (also referred to as [MEDICATION(S)]) if he had been aware of the PT/INR results on [DATE]. He stated, I can't verify that the person on call wasn't notified but if it's not documented in [the electronic medical record system] notes then it did not occur. On [DATE] at 3:06 pm, Staff A, the SRU (Short Term Rehabilitation Unit) Unit Manager stated she was off for the week and just returned to work on [DATE] (Thursday). She stated she returned to work and reviewed the lab dashboard, in the electronic record system, and saw the critical lab result for Resident #5. She stated she called the Nurse Practitioner (NP) and notified her of the results. She stated she told the NP the results were from [DATE]. She stated she could not recall if the NP asked her why she wasn't notified until the 27th of [DATE]. Staff A stated when she was off, it's all hands-on deck. She stated day shift should be checking what labs were drawn, and if results were not back, they should pass it on to the next shift to check for the results. Staff A stated she was concerned that the critical lab results from [DATE] were not reported until [DATE]. She confirmed she saw no evidence that anyone saw the lab before [DATE]. She stated she did not investigate what happened and did not report this to the Interim Director of Nursing (DON). She indicated no one brought the critical lab result to her attention when she came in the morning of [DATE]. She stated, the only way I saw it was on the list of labs and the red thing [a red stop sign shaped indicator]. Staff A indicated she did see where the 11:00 pm to 7:00 am nurse reported it to the on-call physician at 4:41 am on [DATE]. She stated her expectation was that this should have been passed on during nurse-to-nurse report in the morning, and she would have contacted the doctor immediately and asked if he wanted the resident sent to the hospital. She stated she was not notified Resident # 5 went out to the hospital and did not get a report from the nurses. She stated it wasn't until she walked to Resident # 5's room and his bed was empty and stripped that she then looked at his record and found out he was sent to the hospital for chest pain. An interview was conducted with the Nursing Home Administrator (NHA), on [DATE] at 3:50 pm. She stated she was not aware of the PT/INR results not being reported timely prior to today. She stated no one had reported this to her and there was no investigation done. She stated there was no investigation done after he was sent out to the hospital on [DATE]. She stated, I am aware of it today and we are trying to provide the information. We have reached out to the lab regarding why they didn't speak to a nurse at the facility. An interview was conducted with the Interim DON, on [DATE] at 4:07 pm. She stated she was not aware of the PT/ INR results prior to the survey on [DATE]. On [DATE] at 2:39 pm, an interview was conducted with the Administrator and the Interim DON. The Interim DON stated that immediate education was started on [DATE] related to the process for review of labs. Lab results were to be addressed on each shift with immediate notification of critical lab values to the physician. Documentation of the contact with the physician and any follow up action to be taken must be completed. In addition, the nurse on each shift was to notify the supervisor if something was not followed through on. She stated that lab results will also be addressed in morning clinical team meetings. The lab results will be moved up on the electronic dashboard, and it will be the responsibility of the nurse on the cart to review and act upon the lab results. The Administrator and Interim DON stated that PRN ( as needed) staff will be given the education by phone and that agency nursing staff who were in the building were educated. They stated that the education was added to the Agency sign in book and the agency staff has to read and sign that they reviewed the education before coming on each shift. The agency sign in book was reviewed daily and copies were retained of the sign in. On [DATE] at 2:48 pm, the Interim DON stated that there was supplementary documentation added to the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated staff are in process of being educated on change of condition and monitoring for bleeding, especially for residents on anticoagulants. The Interim DON stated that nursing staff were being educated regarding what to do if a resident was experiencing chest pain/shortness of breath. She stated they were to immediately take care of the resident, call the physician and if the physician does not call back in 15 minutes and the resident was deteriorating call 911. Continued interview with the Administrator revealed the lab that was utilized in [DATE] was no longer providing lab services to the facility. She stated the new lab started on [DATE]. She stated the new lab has conducted education with the nursing staff to make sure there was a seamless transition with the lab companies. She stated there is a process in place with the new lab that if lab is unable to reach anyone within the facility, they escalate the call to the DON and Administrator. The facility's removal plan was reviewed and verified by surveyors with the determination that the Immediate Jeopardy was found to be removed on [DATE]. The Removal Plan to the Immediate Jeopardy included: · As of [DATE], our current lab provider is integrated into the facility's electronic medical records system and labs are directly uploaded. The primary responsibility to review lab results is the assigned nurse every shift. Nurse management to follow up to ensure labs have been reviewed. · Educated 100% of staff nurses that lab review is the nurse on shift responsibility and should be reviewed every shift, all labs to be called into physician and progress note stating such. Clinical management team to follow up on any outstanding labs. Educated 100% of staff nurses on PRN (as needed) medication. Educated 100% of nurses on calling 911 and physician immediately for resident in distress. This education added to agency education book. · Put on Kardex for the CNAs for all residents on anti-coagulants: Report to nurse any of the following signs and symptoms of bleedings gums, nose bleeds, unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine. · An audit was completed to ensure all residents on anti-coagulants have monitoring in place for nurses to document any signs and symptoms of bleedings gums, nose bleeds, unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine and 100% complete. · Electronic medical record system supplemental documentation added to the one resident with [MEDICATION(S)]. This triggers the nurses to look up date of last PT/INR and results prior to administration of [MEDICATION(S)]. Verification by the survey team confirmed only one resident in the facility was receiving [MEDICATION(S)] at time of survey. · Audited the one current resident on [MEDICATION(S)] and all PT/INR results are current with no issues noted. · Current lab company confirmed that if critical labs are called in without the ability to reach nurse at the facility despite multiple attempts, then DON notified and if no response, then NHA notified. · Agency nurse, Staff B, DNR (Do Not Recall) from facility and contact initiated and awaiting response to agency regarding same. · Facility provided documentation on [DATE] of education to 100 % of their staff nurses on lab review, PRN medication and calling 911. Records were verified with no discrepancies identified. · The facility agency sign in book was reviewed on [DATE] and confirmed education to agency staff working on [DATE]. A policy and procedure for lab results, PRN medications and calling 911 was placed in the front of the agency sign in book for agency staff review prior to each shift. · Two of two current residents receiving anticoagulant therapy ([MEDICATION(S)] and [MEDICATION(S)]) were reviewed with no concerns identified. · Current lab results were reviewed for fourteen current residents, related to timeliness of reporting lab results to the physician, to ensure prompt recognition and reporting of results to providers with no concerns identified. · Verification interviews were conducted on [DATE] with licensed nurses Staff E, F, G, H, I, and J regarding current education and training in accordance with the facility's removal plan. The nurse's worked across all shifts. Education sign in sheets and interviews validated the education was received and understood.

Based on facility and hospital medical record review, policy and procedure review, and staff, medical providers, resident, and responsible party interviews, it was determined the facility failed to take appropriate action in response to a critically elevated Prothrombin Time (PT) and International Normalized Ratio (INR) for one (Resident #5) of three residents requiring laboratory monitoring for anticoagulants out of a total sample of 14 residents reviewed for lab results. Serious harm occurred to Resident #5 when a critically elevated INR level was not recognized, reported, and treated in a timely manner. Resident #5 was hospitalized for 11 days, required transfusion, and suffered from acute [CONDITION(S)], acute gastrointestinal (GI) bleed in the setting of supratherapeutic INR, and acute blood loss [CONDITION(S)]. The facility ' s failure to respond in a timely manner to a critical INR level resulted in the findings of Immediate Jeopardy. The Immediate Jeopardy began on [DATE] and was removed on [DATE], with a Scope and Severity reduced to a D. Findings Included: A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. A PT/INR test helps find out if your blood is clotting normally. It also checks to see if a medicine that prevents blood clots, such as [MEDICATION(S)], is working the way it should. If you are taking [MEDICATION(S)]: · INR levels that are too low may mean you are at risk for dangerous blood clots. · INR levels that are too high may mean you are at risk for dangerous bleeding. Your health care provider will probably change your dose of [MEDICATION(S)] to reduce these risks. https://medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr A review of Resident #5 ' s medical record revealed a narrative nurse ' s note, dated [DATE] at 4:35 am by Staff B, Licensed Practical Nurse (LPN). The note indicated that at approximately 12:45 am, the nurse from LEU (Long Term Extended Unit) came to writer and was informed that resident ' s family was on the phone and stated resident in room . needed assistance. Writer then went to room, observed resident in bed lying in supine position with head of bed elevated talking on cell phone. Writer asked resident what was going on, what did he need assistance with. Resident stated, I ' m having chest pain and it ' s a [CONDITION(S)]. I ' m having a [CONDITION(S)] and I need to go to the hospital now. Resident screamed, I ' m having a [CONDITION(S)]! Writer exited room and went to cart to check if resident had any nitro, on hand. Another nurse had computer up and allowed writer to check resident ' s orders. No orders for nitro and no history of [CONDITION(S)]. Resident then told writer and Certified Nursing Assistant (CNA) that his left arm was tingling, he has a crushing feeling on his chest, and jaw pain. Vital Signs : ,d+[DATE] (blood pressure), 117 (heart rate), 21 (respirations), oxygen saturation 97 % on RA (Room Air). Resident was non diaphoretic and afebrile. Call placed to on call for primary care physician. Resident ' s friend was asking to speak to writer. Writer informed him that she had to make sure he was on the face sheet and authorized to speak to him about resident ' s condition. Resident ' s friend identity confirmed as (name) Health Care Surrogate (HCS). HCS informed writer he wanted resident to go out to hospital. Informed HCS she was trying to give the on-call physician time to return her call but after 5-minute mark would just call 911. No return call from provider. Call placed to 911 regarding COC (Change of Condition). Approximately 1:08 am, resident was transported to (local hospital) via EMS (Emergency Medical Services) transport. Call placed to HCS to inform resident has left facility and what hospital he was in-route to. Review of the Change in Condition Evaluation dated [DATE] at 4:01 am, revealed Resident stated he needed to go to hospital, his chest is hurting and he ' s having pain in his left arm. Resident was on phone with the Health Care Surrogate and proxy demanded he go to hospital. Review of vital signs evaluation for [DATE] at 00:45 revealed Most Recent Pulse: 117, Pulse Type Irregular- UTD (unable to determine). The SNF/NF Hospital Transfer Form revealed: Date Transferred to hospital as [DATE] at 01:08 am. A Review of the hospital medical record for Resident #5, for a hospitalization from [DATE] to [DATE], revealed: On arrival to the emergency department (ED) an Electrocardiogram ( EKG) showed a ST-Elevation [CONDITION(S)] ( STEMI), and an alert was called. Cardiologist at bedside who determined that the patient was not stable enough for catherization. Patient had a variety of complaints including chest pain, back pain ,and generally not feeling well, that started suddenly prior to him calling EMS. Patient has several episodes of [NAME] ( black tarry stool) while in the ED. Patient was intubated prior to exam. In the ED, Hemoglobin was 9.3, hematocrit 25.1. Patient given 2 units of PRBCs (Packed Red Blood Cells). First initial INR noted to be at 10.37, repeat was 6.28. Patient was given a dose of Vitamin K in addition to 4 units of FFP (Fresh Frozen Plasma) . Final Impression: High density material noted within the stomach which can represent blood products in the appropriate clinical scenario. Bilateral non obstructing calculus. Resident # 5 was admitted to the ICU ( Intensive Care Unit) A review of the hospitalization summary revealed, date of admission [DATE], Reason for hospitalization was Chest Pain, Discharge Diagnoses (included but not limited to) Acute hypoxic respiratory failure requiring mechanical ventilation greater than 72 hours, Acute [CONDITION(S)] due to STEMI, Acute GI bleed in the setting of Supratherapeutic INR, Acute blood loss [CONDITION(S)] requiring blood transfusion, Supratherapeutic INR. A review of the facility medical record for Resident # 5 revealed he was originally admitted to the facility from the hospital on [DATE] with diagnoses which included Metabolic [CONDITION(S)], Unspecified [CONDITION(S)], Acute [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A review of the admission Minimum Data Set (MDS) assessment, dated [DATE] revealed a Brief Interview for Mental Status ( BIMS) score of 15, indicating intact cognition. The MDS indicated Resident # 5 needed extensive assistance for activities of daily living (ADL ' s) and utilized a wheelchair. A review of the hospital discharge summary, dated [DATE], revealed discharge diagnoses to include Ischemic Stroke, High grade Right Cavernous ICA ( Internal Carotid Artery) Stenosis vs Non-occlusive Thrombus. Hospital discharge orders for [DATE] included [MEDICATION(S)] 6 mg one tablet by mouth daily. A review of the comprehensive care plan, initiated [DATE], revealed: Focus: ( Resident # 5) is at risk for abnormal bleeding and increased bruising reference to use of anticoagulants for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Goal: resident will remain free of complications from anticoagulant therapy through next review date. Interventions included but not limited to Obtain labs/diagnostics as ordered; report results to physician and follow up as needed. A review of the facility ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) for [DATE] revealed that the order for INR blood draw was noted as having been completed on Sunday, [DATE]. On [DATE] at 2:30 p.m., the Interim Director of Nursing stated there was no INR lab drawn on [DATE] for Resident #5. Continued review of the [DATE] TAR revealed the order for INR was completed during the night shift the following Sunday, [DATE]. Review of the Lab Results Report, revealed an INR was collected on [DATE] at 5:14 am and the results were reported to the facility on [DATE] at 8:35 pm. The Lab Results Report revealed a high PT (Prothrombin Time) of 58.7 seconds with a reference range of 11.4- 14.6 seconds and a critically high (CH) INR result of 6.4 (verified by repeat) with a reference range of 0.8 -1.2. The report indicated an INR Range for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician ' s progress note dated [DATE] and electronically signed by the physician on [DATE] at 1:52 pm revealed Reason for Appointment: Initial H&P [History and Physical] History of Present Illness; He was hospitalized in [local hospital] for [CONDITION(S)] [[CONDITION(S)]], has CTA [commuted tomography [MEDICATION(S)]] showing high grade stenosis, 1st nonocclusive thrombus in cavernous R ICA [right internal carotid artery], Neuro IR [[MEDICATION(S)] Radiologist] did not recommend intervention. No TPA [Tissue [MEDICATION(S)] activator] is on [MEDICATION(S)] now. He has Secondary hypercoagulable state on [MEDICATION(S)] which INR not done on [DATE] as he refused blood draw. Will reorder for Thursday. Assessments: Secondary hypercoagulable state- Continue [MEDICATION(S)] until next INR check on Thursday, no bleeding at this time evident. INR [DATE] was 1 then 2.8 on [DATE]. The physician ' s progress note of [DATE] showed no indication that he was notified of the critical PT/INR results reported at 8:35 pm on [DATE]. The Lab Results Report indicated this lab result was reviewed by Staff A, the SRU (Short Term Rehabilitation Unit) Unit Manager on [DATE] at 3:50 p.m. (15:50), three days after the critically high PT/INR lab report was received. A review of the nursing progress notes, for [DATE], revealed no documentation related to the critical laboratory results of [DATE], and no documentation the physician was notified of the results on [DATE]. A review of Resident # 5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A narrative nursing note dated [DATE] at 4:41 am, indicated Resident PT/INR from [DATE] reviewed with on call MD (medical doctor). New orders received to discontinue [MEDICATION(S)] and repeat PT/INR on Friday ([DATE]). Resident stable at this time, no signs and symptoms (S/S) of bleeding noted. A subsequent narrative nurses note, dated [DATE] at 11:48 am and written by Staff A, the SRU Unit manager indicated: This writer spoke with NP ( Nurse Practitioner) covering for MD and changed order to daily PT/INR x 7 days to monitor and when therapeutic she would up (sic) resident back on [MEDICATION(S)]. No further concerns at this time. Review of the [DATE] TAR revealed the following orders: [DATE] at 4:40 AM PT/INR on Friday one time only for 1 day. The order was noted as d/c (discontinued) on [DATE] at 12:15 PM. [DATE] at 11:47 AM PT/INR every night shift for 7 days. There was no documentation that a PT/INR was drawn on [DATE], and on [DATE] the TAR was marked to indicate the resident was hospitalized . On [DATE] at 3:06 pm, Staff A, the SRU Unit Manager stated she was off for the week and just returned to work on [DATE] (Thursday). She stated she returned to work and reviewed the lab dashboard, in the electronic record system, and saw the critical lab result for Resident #5. She stated she called the Nurse Practitioner (NP) and notified her of the results. She stated she told the NP the results were from [DATE]. She stated she could not recall if the NP asked her why she wasn ' t notified until the 27th of [DATE]. Staff A stated when she was off, it ' s all hands-on deck. She indicated the ADON (Assistant Director of Nursing), the other Unit Manager, and other nurse staff on the unit come together to ensure the unit was running. She stated day shift should be checking what labs were drawn, and if results were not back, they should pass it on to the next shift to check for the results. Staff A stated she was concerned that the critical lab results from [DATE] were not reported until [DATE]. She indicated the lab was supposed to call the facility, speak to the nurse, and obtain the nurse ' s name. She indicated when a critical lab value was reported the lab was supposed to document on the lab form who they spoke to so if something happens it can be tracked. She confirmed she saw no evidence that anyone saw the lab before [DATE]. She stated she did not investigate what happened and did not report this to the Interim DON. She indicated no one brought the critical lab result to her attention when she came in the morning of [DATE]. She stated, the only way I saw it was on the list of labs and the red thing [a red stop sign shaped indicator]. Staff A indicated she did see where the 11:00 pm to 7:00 am nurse reported it to the on-call physician at 4:41 am on [DATE]. She stated her expectation was that this should have been passed on during nurse-to-nurse report in the morning, and she would have contacted the doctor immediately and asked if he wanted the resident sent to the hospital. She stated she was not notified Resident # 5 went out to the hospital and did not get a report from the nurses. She stated it wasn ' t until she walked to Resident # 5 ' s room and his bed was empty and stripped that she then looked at his record and found out he was sent to the hospital for chest pain. A phone interview was conducted with Resident #5 ' s Nurse Practitioner, on [DATE] at 10:33 am .She reviewed her notes, contained in the resident ' s medical record. She stated she had a note from [DATE], which indicated she was informed by the nurse that Resident # 5 refused the [DATE] PT/INR. The NP stated she did not recall being notified of any PT/INR results on [DATE]. She stated, maybe they called me for it, but I don ' t have anything here. She stated her expectation is, If it ' s a critical level, lab is supposed to call unit and speak with the nurse, and the nurse will let me know. Whether that happens is dependent on the lab. The NP was informed that facility documentation indicated that the on-call MD was notified of the [DATE] abnormal lab value on [DATE]. The NP stated, Oh wow, that ' s a long time. She stated the [MEDICATION(S)] Sodium 6 mg would have needed to be discontinued with those results. She confirmed that continued use of the medication could cause a GI bleed. A phone interview was conducted with Resident # 5 ' s primary care physician on [DATE] at 10:52 am. He remembered Resident # 5 was a resident who had a stroke. He had paralysis or weakness from baseline MS ( [CONDITION(S)]) and was weak and debilitated. He could not recall the exact reason the resident was receiving [MEDICATION(S)] and thought it might have been related to a risk of DVT ([CONDITION(S)]). He recalled the resident having had some stenosis in one of the carotid or cerebral arteries. The physician stated he did remember that he was made aware that Resident # 5 did not want to get one of his INR labs done. He did not recall when he was notified of the refusal of the INR but stated, I am sure they must have notified me that day or I found out that day, but I don ' t see any note that I wrote that day. I don ' t remember. I could have found out before, or I could have found out on the 24th. The physician confirmed the INR results from [DATE] and [DATE] were documented in his progress notes and were the labs he reviewed on [DATE]. The physician indicated he did not think he was notified of the PT result of 58.7 and INR of 6.4 from [DATE]. He stated that he had taken two days off at that time. The physician stated that it sounded problematic that there was no notification to a medical provider until [DATE]. He stated his expectation was for the medical provider to be notified the same day. He indicated there was an answering service and we are available ,d+[DATE]. The physician stated he found out of Resident # ' 5 ' s condition when he was finishing his progress note. Review of the physicians ' progress note revealed that he electronically signed the note on [DATE]. The physician stated he would not have continued the [MEDICATION(S)] (also referred to as [MEDICATION(S)]) if he had been aware of the PT/INR results on [DATE]. He stated, I can ' t verify that the person on call wasn ' t notified but if it ' s not documented in [the electronic medical record system] notes then it did not occur. A review of a facility policy, entitled Medication and Treatment Orders, Revised [DATE] revealed: Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 14. Orders for anti- coagulants will be prescribed only with appropriate clinical and laboratory monitoring. a. The attending physician must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. On [DATE] at 9: 32 am, Staff B , LPN, contacted the surveyor via telephone in response to an attempt to conduct an interview on [DATE] at 11:11 am. Staff B wrote the narrative nurse ' s note in Resident # 5 ' s record on [DATE] at 4:35 am where he complained of chest pain and was sent out to the hospital via EMS. Staff B stated she was an agency nurse who did not receive the assignment to this facility until after 11 pm on [DATE]. She stated she did not arrive at the facility until 12 am that day. She stated she was sitting at the nurse ' s station when the nurse from the other unit came over and told her that Resident # 5 needed assistance. She stated the CNA who was supposed to have him had not arrived yet and the other CNA on duty was assigned to two hallways. She stated she saw on her assignment sheet she was assigned to Resident # 5. She reported that she looked down his hall and believes she saw that his call light was on, but she can ' t be 100% sure. She stated she could not hear him shouting but when she got to the room, the TV was very loud, and she had to turn it down. Staff B stated when she went in the room, he told her he was having chest pain and needed to go to the hospital. She stated she left the room to see if Resident # 5 had any [MEDICATION(S)] in the medication cart but there was none. Another nurse logged into the computer to see if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she checked his vital signs, and they were fine. She stated the friend wanted to talk to her and the only face sheet she could find for Resident # 5 had no diagnoses and no emergency contact information on it. She told him she would have to verify who he was before she could give him any information. She stated she got onto the other nurse ' s computer and saw that the caller was the Health Care Surrogate (HCS). She stated she saw that Resident # 5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B reported that the HCS wanted the resident sent out immediately to the hospital, and she told him she had to call the physician first. She explained to the HCS, if the physician did not call back within 5 minutes, she would call 911. She stated the physician did not call back and with the resident ' s history of [CONDITION(S)], she called 911 . She stated Resident # 5 was not any worse when he left for the hospital, he was not cool or clammy and his vitals were stable. Staff B further explained when she got to the facility at 12 am on [DATE], she went down to the other unit to obtain a login for access to the facility ' s electronic record system from the nurse down there. She stated the login the nurse gave her did not work and she had no access to Resident # 5 ' s clinical records. She had to ask the other nurse on the unit to let her use her computer to see Resident # 5 ' s clinical record. She stated she only had access to a dummy login that did not include clinical information on residents. She stated she did not get access to resident ' s clinical records until 2:00 am on [DATE]. An interview was conducted on [DATE] at 3:33 pm with Staff C, C.N.A., who provided care to Resident # 5 on the 3 pm to 11 pm shift on [DATE]. She stated she remembered Resident # 5, and he was a sweetheart. She stated he would say sometimes his stomach hurt, and she would report this to the nurse. She stated the only pain he complained of was his stomach hurting but she had no recall of when he reported this to her. She stated his stool was always, putty like and real dark stool. She reported that his stool, as far as she knew, was like that since he was admitted . She stated she would document stool on his ADL tasks but there was no place to record the color of it. She stated it should be reported to the nurse, but she did not report it to the nurse. She did not recall anything unusual occurring with Resident #5 on [DATE]. Staff C stated Resident # 5 did not report chest pain or shortness of breath and she did not recall whether he put his call light on during the shift. A phone interview was conducted with the Health Care Surrogate (HCS) for Resident # 5 on [DATE] at 12:37 pm. He stated Resident #5 called him at about ten minutes to midnight on [DATE]. Resident #5 reported to the HCS, he was pretty sure he was having a [CONDITION(S)] or a stroke. The HCS stated Resident #5 has had a lot of pain in his life and in his body, but he ' s not a complainer. He doesn ' t complain unless he is really hurting. Something was happening. My hearing his voice, he was scared. During the phone interview and in a follow up communication from the HCS, received on [DATE] at 6:49 pm, the HCS stated Resident #5 told me that he had told an employee, he thought might have been a CNA, what he thought was happening to him and had then waited over an hour prior to calling me after having asked for help. None was forthcoming. An employee, probably a CNA was supposed to get someone but told him they were having a shift change. That person never returned, nor did a nurse show up which was who was asked for. I told Resident #5 to keep the phone in his hand while I hung-up and called the facility seeking to speak with the person in-charge of the facility at that time. A man answered and I told him that I needed to speak with the person in-charge immediately as my friend, one of their patients, was having either a stroke or [CONDITION(S)] while we were speaking. He told me he would try to connect me with someone. He came back and said he was having a problem, I told him to immediately find me a nurse. I hung up and called Resident #5 back and said that someone should be coming as soon as possible (ASAP). We talked and waited. I kept assuring him that someone would be there soon. I told Resident #5 to start yelling for help. Still nothing. I told him again to keep the phone in hand. I was going to hang up again, and I would call right back. I called the facility again. I believe it was the same man who answered. At this point, I am very worried and extremely upset. Next thing I know I am talking to a nurse. She told me that she was an agency nurse just reporting in to work and that she couldn't give me any information, she did not give me her name. It was unbelievable. She said she would get another nurse. I called Resident #5 back and waited with him. Finally, a nurse called me, and she said she would check on him. She told me that we are calling his doctor and they were waiting to get his permission. I told them that they should immediately call 911, or that I would call both 911 and the police. I spoke with Resident #5 again, and no one was at his room yet. I told him that I had asked them to call 911 but that I was hanging up again and calling myself. At 1:13 am the nurse called me back and told me that 911 had arrived and that they were taking him to (name of local Hospital). When I got to the hospital, he had two heart attacks. He might have died if he hadn ' t called me, and I was going ballistic trying to get someone to talk to me and do something. I was upset when she told me she had to wait for the doctor to call back, so I called 911. He told me his call light was on for an hour or more. I ' m not sure. It can seem like longer when in pain. A phone interview was conducted with Resident # 5, on [DATE] at 9:31 am. He stated, I was desperate. I pushed the call light, no one came, no one came - it was a long time, probably about 45 minutes. I called on my cell phone to my friend and he got help for me. He stated I had no idea what was going on with me. I was scared. I was having chest pain and things felt unusual. After my friend called and got the nurse to come in, it still took a while to get me to the hospital. He stated his friend saved his life by getting him help. The resident reported that he remained in an acute long term care hospital. He stated he was feeling better but was still very weak. An interview was conducted with the Nursing Home Administrator (NHA), on [DATE] at 3:50 pm. She stated she was not aware of the PT/INR results not being reported timely prior to today. She stated no one had reported this to her and there was no investigation done. She stated there was no investigation done after he was sent out to the hospital on [DATE]. She stated, I am aware of it today and we are trying to provide the information. We have reached out to the lab regarding why they didn ' t speak to a nurse at the facility. An interview was conducted with the Interim DON, on [DATE] at 4:07 pm. She stated she was not aware of the PT/ INR results prior to the survey on [DATE]. On [DATE] at 2:39 pm, an interview was conducted with the Administrator and the Interim DON. The Interim DON stated that immediate education was started on [DATE] related to the process for review of labs. Lab results were to be addressed on each shift with immediate notification of critical lab values to the physician. Documentation of the contact with the physician and any follow up action to be taken must be completed. In addition, the nurse on each shift was to notify the supervisor if something was not followed through on. She stated that lab results will also be addressed in morning clinical team meetings. The lab results will be moved up on the electronic dashboard, and it will be the responsibility of the nurse on the cart to review and act upon the lab results. The Administrator and Interim DON stated that PRN ( as needed) staff will be given the education by phone and that agency nursing staff who were in the building were educated. They stated that the education was added to the Agency sign in book and the agency staff has to read and sign that they reviewed the education before coming on each shift. The agency sign in book was reviewed daily and copies were retained of the sign in. On [DATE] at 2:48 pm, the Interim DON stated that there was supplementary documentation added to the electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated staff are in process of being educated on change of condition and monitoring for bleeding, especially for residents on anticoagulants. The Interim DON stated that nursing staff were being educated regarding what to do if a resident was experiencing chest pain/shortness of breath. She stated they were to immediately take care of the resident, call the physician and if the physician does not call back in 15 minutes and the resident was deteriorating call 911. Continued interview with the Administrator revealed the lab that was utilized in [DATE] was no longer providing lab services to the facility. She stated the new lab started on [DATE]. She stated the new lab has conducted education with the nursing staff to make sure there was a seamless transition with the lab companies. She stated there is a process in place with the new lab that if lab is unable to reach anyone within the facility, they escalate the call to the DON and Administrator. The facility ' s removal plan was reviewed and verified by surveyors with the determination that the Immediate Jeopardy was found to be removed on [DATE]. The Removal Plan to the Immediate Jeopardy included: · As of [DATE], our current lab provider is integrated into the facility ' s electronic medical records system and labs are directly uploaded. The primary responsibility to review lab results is the assigned nurse every shift. Nurse management to follow up to ensure labs have been reviewed. · Educated 100% of staff nurses that lab review is the nurse on shift responsibility and should be reviewed every shift, all labs to be called into physician and progress note stating such. Clinical management team to follow up on any outstanding labs. Educated 100% of staff nurses on PRN (as needed) medication. Educated 100% of nurses on calling 911 and physician immediately for resident in distress. This education added to agency education book. · Put on Kardex for the CNAs for all residents on anti-coagulants: Report to nurse any of the following signs and symptoms of bleedings gums, nose bleeds, unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine. · An audit was completed to ensure all residents on anti-coagulants have monitoring in place for nurses to document any signs and symptoms of bleedings gums, nose bleeds, unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine and 100% complete. · Electronic medical record system supplemental documentation added to the one resident with [MEDICATION(S)]. This triggers the nurses to look up date of last PT/INR and results prior to administration of [MEDICATION(S)]. Verification by the survey team confirmed only one resident in the facility was receiving [MEDICATION(S)] at time of survey. · Audited the one current resident on [MEDICATION(S)] and all PT/INR results are current with no issues noted. · Current lab company confirmed that if critical labs are called in without the ability to reach nurse at the facility despite multiple attempts, then DON notified and if no response, then NHA notified. · Agency nurse, Staff B, DNR (Do Not Recall) from facility and contact initiated and awaiting response to agency regarding same. · Facility provided documentation on [DATE] of education to 100 % of their staff nurses on lab review, PRN medication and calling 911. Records were verified with no discrepancies identified. · The facility agency sign in book was reviewed on [DATE] and confirmed education to agency staff working on [DATE]. A policy and procedure for lab results, PRN medications and calling 911 was placed in the front of the agency sign in book for agency staff review prior to each shift. · Two of two current residents receiving anticoagulant therapy ([MEDICATION(S)] and [MEDICATION(S)]) were reviewed with no concerns identified. · Current lab results were reviewed for fourteen current residents, related to timeliness of reporting lab results to the physician, to ensure prompt recognition and reporting of results to providers with no concerns identified. · Verification interviews were conducted on [DATE] with licensed nurses Staff E, F, G, H, I, and J regarding current education and training in accordance with the facility ' s removal plan. The nurse ' s worked across all shifts. Education sign in sheets and interviews validated the education was received and understood.

Based on medical record review, review of facility policies and procedures, and staff interviews, the facility failed to identify and correct its own quality deficiencies for one (#5) of four residents reviewed for rehospitalization out of a total sample of 17 residents. The facility failed to identify a delay in communicating a critical lab result to Resident #5 ' s physician resulting in continued use of a high risk medication and transfer to an acute care hospital. Findings included: A review of the facility medical record for Resident # 5 revealed he was originally admitted to the facility from the hospital on 1/14/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the January 2022 TAR revealed the order for INR was completed during the night shift the following Sunday, 1/23/22. Review of the Lab Results Report, revealed an INR was collected on 1/24/22 at 5:14 am and the results were reported to the facility on [DATE] at 8:35 pm. The Lab Results Report revealed a high PT (Prothrombin Time) of 58.7 seconds with a reference range of 11.4- 14.6 seconds and a critically high (CH) INR result of 6.4 (verified by repeat) with a reference range of 0.8 -1.2. The report indicated an INR Range for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ' s progress note of 1/24/22 showed no indication that he was notified of the critical PT/INR results reported at 8:35 pm on 1/24/22. A review of Resident # 5 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A narrative nursing note dated 1/27/22 at 4:41 am, indicated Resident PT/INR from 1/24/22 reviewed with on call MD (medical doctor). New orders received to discontinue [MEDICATION(S)] and repeat PT/INR on Friday (1/28/22). Resident stable at this time, no signs and symptoms (S/S) of bleeding noted. A subsequent narrative nurses note, dated 1/27/22 at 11:48 am and written by Staff A, the SRU Unit Manager indicated: This writer spoke with NP ( Nurse Practitioner) covering for MD and changed order to daily PT/INR x 7 days to monitor and when therapeutic she would up (sic) resident back on [MEDICATION(S)]. No further concerns at this time. Review of the Change in Condition Evaluation dated 1/28/22 at 4:01 am, revealed Resident stated he needed to go to hospital, his chest is hurting and he ' s having pain in his left arm. Resident was on phone with the Health Care Surrogate and proxy demanded he go to hospital. Review of vital signs evaluation for 1/28/22 at 00:45 revealed Most Recent Pulse: 117, Pulse Type Irregular- UTD (unable to determine). The SNF/NF Hospital Transfer Form revealed: Date Transferred to hospital as 1/28/22 at 01:08 am. A Review of the hospital medical record for Resident #5, for a hospitalization from [DATE] to 2/8/22, revealed: On arrival to the emergency department (ED) an Electrocardiogram ( EKG) showed a ST-Elevation [CONDITION(S)] ( STEMI), and an alert was called. Cardiologist at bedside who determined that the patient was not stable enough for catheterization. Patient had a variety of complaints including chest pain, back pain ,and generally not feeling well, that started suddenly prior to him calling EMS. Patient has several episodes of [NAME] ( black tarry stool) while in the ED. Patient was intubated prior to exam. In the ED, Hemoglobin was 9.3, hematocrit 25.1. Patient given 2 units of PRBCs (Packed Red Blood Cells). First initial INR noted to be at 10.37, repeat was 6.28. Patient was given a dose of Vitamin K in addition to 4 units of FFP (Fresh Frozen Plasma) . Final Impression: High density material noted within the stomach which can represent blood products in the appropriate clinical scenario. Bilateral non obstructing calculus. Resident # 5 was admitted to the ICU ( Intensive Care Unit) A review of the hospitalization summary revealed, date of admission 1/28/22, Reason for hospitalization was Chest Pain, Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a policy and procedure entitled Transfers, Reducing Acute Care revealed Policy Statement Transfers to acute care hospitals will be minimized in situations where early interventions would make such transfers avoidable and where the resident ' s directives specifically request that he or she remain in the facility. Policy Interpretation and Implementation 1. Standardized tools for early recognition and management of acute changes of condition will be used to achieve the facility ' s ' overall goal of reducing avoidable hospital transfers. 3. Symptoms or problems that may require physician or practitioner intervention will be documented in a format that will facilitate adequate information when communication occurs. For example: a. Situation – information about the condition, situation or sign b. Background- information about the resident, medications, vital signs, recent lab results and changes related to the problem ( i.e., Mental, functional , respiratory changes, etc.), including advance directive information c. C. Assessment or Appearance – what appears to be going on with the resident, and d. Request- suggestions or requests for the provider ( i.e., labs, x ray, acute care transfer, etc.) 4. Detailed information regarding acute care transfers will be reviewed at regular intervals and data will be reported to the QAPI committee as part of the overall facility quality assurance and performance improvement plan. A review of a facility policy and procedure, entitled Quality Assurance and Performance Improvement (QAPI) Program ( 2001 MED- PASS, Inc.( Revised February 2020) revealed: Policy Statement :This facility shall develop, implement, and maintain an ongoing, facility -wide, data drive (QAPI) Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation The objectives of the QAPI Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions. Implementation: 1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI Committee. 2. The QAPI plan descries the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance improvement; c. Identifying and prioritizing quality deficiencies; d. Systemically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing correction action of performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/ performance improvement activities and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI – related activities and make adjustments to the plan. On 2/16/22 at 3:06 pm, Staff A, the SRU Unit Manager stated she was off for the week and just returned to work on 1/27/22 (Thursday). She stated she returned to work and reviewed the lab dashboard, in the electronic record system, and saw the critical lab result for Resident #5. She stated she called the Nurse Practitioner (NP) and notified her of the results. She stated she told the NP the results were from 1/24/22. She stated she could not recall if the NP asked her why she wasn ' t notified until the 27th of January 2022. Staff A stated when she was off, it ' s all hands-on deck. She indicated the ADON (Assistant Director of Nursing), the other Unit Manager, and other nurse staff on the unit come together to ensure the unit was running. She stated day shift should be checking what labs were drawn, and if results were not back, they should pass it on to the next shift to check for the results. Staff A stated she was concerned that the critical lab results from 1/24/22 were not reported until 1/27/22. She indicated the lab was supposed to call the facility, speak to the nurse, and obtain the nurse ' s name. She indicated when a critical lab value was reported the lab was supposed to document on the lab form who they spoke to so if something happens it can be tracked. She confirmed she saw no evidence that anyone saw the lab before 1/27/22. She stated she did not investigate what happened and did not report this to the Interim DON. She indicated no one brought the critical lab result to her attention when she came in the morning of 1/27/22. She stated, the only way I saw it was on the list of labs and the red thing [a red stop sign shaped indicator]. Staff A indicated she did see were the 11:00 pm to 7:00 am nurse reported it to the on-call physician at 4:41 am on 1/27/22. She stated her expectation was that this should have been passed on during nurse-to-nurse report in the morning, and she would have contacted the doctor immediately and asked if he wanted the resident sent to the hospital. She stated she was not notified Resident # 5 went out to the hospital and did not get a report from the nurses. She stated it wasn ' t until she walked to Resident # 5 ' s room and his bed was empty and stripped that she then looked at his record and found out he was sent to the hospital for chest pain. An interview was conducted with the Nursing Home Administrator (NHA), on 2/16/22 at 3:50 pm. She stated she was not aware of the PT/INR results not being reported timely prior to today. The Administrator stated no root cause investigation was conducted after Resident # 5 went to the hospital on 1/28/22. She stated, We track and trend, and we get updates from the hospital. She stated, I am aware of it today and we are trying to provide the information. We have reached out to the lab regarding why they didn ' t speak to a nurse at the facility. An interview was conducted with the Interim DON, on 2/16/22 at 4:07 pm. She stated she was not aware of the PT/ INR results prior to the survey on 2/16/22. On 2/24/22 at 12:48 pm an interview was conducted with the Interim DON regarding the facility ' s process for resident review following a rehospitalization . She stated the process was to review the residents who were rehospitalized the following morning at the stand-up meeting. Then review their medical records at the clinical meeting, which follows the morning stand up meeting. She stated the review for Resident #5 at the clinical meeting did not occur because the managers were on the carts. She stated, We did not do it for [Resident # 5]. The Interim DON stated we are in the process of reviewing rehospitalization s again to see if we missed anything. She stated the process has changed, We now follow the patient throughout their entire hospital stay and get updates regularly. An interview was conducted with the Administrator, on 2/24/22 at 3:25 pm regarding the process for reviewing clinical records for residents who have been rehospitalized . She stated that the facility obtains updates from the hospital with details of what the resident went out to the hospital for. She stated we follow the residents on a daily basis while they are in the hospital, we try to get as many daily hospital updates as we can. The Administrator reported that Resident #5 was reviewed at the clinical meeting the very next day, but she does not attend the clinical meetings nor was there any documentation kept for this meeting. She stated, I am not clinical, I wasn ' t at the clinical meeting, but they reviewed his record. She stated we knew what he was admitted for and his conditions. We were told STEMI [CONDITION(S)]. The medical record was reviewed; he had chest pains; he was sent out; he had a [CONDITION(S)]. The Administrator stated she used an internal document to track and trend for QAPI. We look for tracks and trends, that ' s what I look for. A follow-up interview with the Administrator and Interim DON on 2/24/22 at 3:51 pm was conducted related to the rehospitalization clinical review for Resident #5. The Administrator stated, They did review him [referring to Resident # 5] in the clinical meeting. I was told he had a STEMI, looked at clinical record, looked at diagnoses, change in condition, he was complaining of chest pain, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .something. We did look at the reason for rehospitalization and then at the record. Based on the information we received from the hospital, we determined the rehospitalization was related to his condition and diagnosis. I was at that clinical meeting, that part of it. The [Interim DON] was not at the meeting as she was on the med cart. His primary hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . We talked about it as a collective group. The Interim DON stated, Yes, they did discuss at the clinical meeting. You only asked me if I was there, and I was not as I was on the med cart. The Administrator and Interim DON were asked if Resident # 5 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator responded, I am not clinical, and the Interim DON stated there was a review only as to whether Resident # 5 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to provide wound care in accordance with professional standards for two (#54, #21) of three residents sampled for pressure ulcers out of 11 total residents with pressure ulcers related to failure to change Resident #54's dressings daily as ordered for two of four days, failure to provide positioning and offloading for wound healing for Resident #54, and failure to ensure weekly wound measurements were taken for Resident's #54, and #21. Findings Included: 1. Review of Resident #54's Admission Record revealed an admitted [DATE] and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Unstageable wounds included: right heel, right lateral foot, left sole and left trochanter. Deep tissue injuries included left heel and right treat toe. Stage 3 wounds included right medial malleolus. Stage 4 wounds included: left medial foot, right buttock. Plan of care: pressure reduction and turning precautions, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Factors affecting healing: frequent incontinence which can decrease wound healing. Recommend providing incontinence care as needed, increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound care consult dated 9/3/21 Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam every day shift for wound care, dated 10/6/21. Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam as needed for wound care dated 10/6/21. Left sole of foot: apply [MEDICATION(S)] and leave open to air every shift for wound care dated 9/22/21. Left heel: apply [MEDICATION(S)] and leave open to air every shift dated 9/22/21. Right great toe: apply [MEDICATION(S)] and leave open to air every shift for wound care dated 9/22/21. Right heel: Apply [MEDICATION(S)] and leave open to air every shift for wound care dated 9/22/21. Right lateral foot: Apply [MEDICATION(S)] and leave open to air every shift for wound care dated 9/22/21. Right medial malleolus Cleanse with normal saline, pat dry, Santyl, and foam dressing every day shift for wound care, dated 10/6/21. Apply house barrier cream to buttocks, peri area for protection dated 9/3/21. Cleanse left trochanter with normal saline, pat dry, apply Santyl and cover with foam dressing as needed for wound care dated 10/6/21. Cleanse Right buttock with normal saline, pat dry, apply Santyl, calcium alginate and cover with foam dressing every day shift for wound care dated 10/6/21. [MEDICATION(S)] tablet 500 mg one time a day every 12 hours for infection dated 9/24/21, ended 10/1/21. [MEDICATION(S)]-[MEDICATION(S)] 800-160 mg one tab every 12 hours for 10 days for wound infection started on 9/30/21. [MEDICATION(S)] solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection dated 9/30/21. On 10/13/21 at 11:00 a.m., Resident #54 stated he had not had his brief changed since around 6 a.m. that morning and he had not had wound care for his feet completed in at least two days. During the interview, a pungent odor was noticed. The resident was lying on his left side. Additional observations of Resident #54 on 10/12/21 at 11:08 a.m., 10/12/21 at 4:00 p.m., 10/13/21 at 11:00 a.m., and 10/14/21 at 3:24 p.m. revealed the resident was lying on his left side. The resident confirmed on 10/14/21 at 3:24 p.m. that he stays primarily on the left side, and no one turns him every 2 hours or offers to turn him. The resident confirmed his feet were always touching and no one had offered to place anything between his feet, so they did not touch; however, they did place a pillow between his knees. An interview and observation of Resident #54's dressings with Staff B, Unit Manager, on 10/13/21 at 11:15 a.m., confirmed the resident was lying on his left side on an air mattress with his legs contracted. The visible wound dressings were not dated. The dressing on the left foot was observed with copious amounts of thick brown drainage, saturated through to the sheet folded beneath the resident's feet. The right medial side of the foot was without a dressing and observed resting on top of the left medial side of the foot placing pressure on the left foot. Resident #54 said, in the presence of Staff B, the dressings were not changed for at least 2 days. Staff B confirmed the pillow was only separating his knees. Staff B confirmed the wound care nurse practitioner was due to come in on this day but did not. On 10/13/21 at 3:24 p.m., wound care observation was conducted with Staff B and the Assistant Director of Nursing (ADON). They gathered supplies and placed disposable trays on a cleaned bedside table. The ADON held the right leg up to allow Staff B to remove the dressing on the left foot. Staff B completed the dressing removal for the left foot. The sole and lateral side of the left foot were observed with red granulation tissue, heavy drainage, and heavy slough with a strong odor. An unknown aide came in to assist Staff B and the ADON. Staff B cleansed the left foot using normal saline soaked gauze by tapping the wound and drying in the same fashion while the aide held the right foot. The aide let the right foot down which touched the area of the left foot that was cleaned. Staff B cleaned the left foot by tapping one time again and drying in the same fashion while the aide held the right foot up. Staff B applied Santyl in a thin layer to most of the wound and calcium alginate sheets, that were observed to not cover the wound completely, and then wrapped the left foot with one roll of gauze, leaving the heel and toe exposed to air. The aide lowered the right leg down on the left foot. Staff B measured the left sole wound as 8 cm x 5 cm, left medial foot wound as 8 cm x 4.5 cm. No dressing was observed on the right foot except one small white square on the top of the right foot. Staff B stated she was unsure why this white square was there since the right foot did not get a dressing. Staff B did not clean, assess, or apply a dressing to the medial malleolus of the right foot. The aide then prepared the resident for the coccyx dressing and left trochanter by removing the stool and urine saturated brief. The coccyx and left trochanter were observed uncovered without dressings. Staff B, set up for the dressing change of the coccyx and left trochanter and hand sanitized prior to donning gloves. Staff B soaked gauze and tapped the center of the coccyx wound that was observed with tunneling around 12 o'clock. Staff B measured the wound as 5 cm x 5 cm. Staff B removed gloves, hand sanitized and donned new gloves. Staff B confirmed the Coccyx wound had tunneling and stated, I should measure that. The ADON advised on how to measure the tunneling. Staff B, measured a wound depth of 4.5 cm, tunneling 3.5 cm at 12 o'clock. Staff B applied Santyl to the center of the wound only. Applied calcium alginate at the point of tunneling and the center of the wound then covered the area with a dated foam dressing. The resident was turned toward his right side complaining of pain and tenderness on his left trochanter. Staff B confirmed the coccyx and left trochanter did not have dressings present at the start of the wound care and should always have dressings on. Staff B, donned gloves and cleaned the left trochanter with saline soaked gauze by tapping the center of the wound one time. Staff B dried the wound by tapping after changing gloves. Measurements of the left trochanter were taken, Santyl was applied to the center of the wound, and a large piece of calcium alginate was laid over the left trochanter wound and covered with a dated dressing. A new brief was secured in place. The resident was turned back to the left side on the left trochanter and his legs were separated at the knees, but the feet remained touching. Staff B confirmed the resident needed a pillow between his feet for offloading and removed the pillow at his knees and placed it between his feet. A blanket was then used between his knees. The resident's bilateral heels, right great toe, and right lateral foot had [MEDICATION(S)] applied and were left open to air. During an interview with Staff B and the ADON, on 10/13/21 at 4:24 p.m. Staff B confirmed she normally just dabs the wound and does not clean from the inside to the outside. Staff B confirmed she did the best she could cleaning the left foot after the right one touched it multiple times. She confirmed the right medial foot wound was unchanged and she had not applied a dressing as ordered. Staff B confirmed the resident should be offloading his feet and turning every few hours. Staff B stated she would check to see why the resident was always on his left side when he needs staff to turn him. Review of the treatment administration record (TAR) for October 2021 revealed the dressings changes were signed by Staff F, Licensed Practical Nurse (LPN) as completed for the last 2 days (10/11 and 10/12). During an interview on 10/14/21 at 1:26 p.m. with Staff F, LPN she confirmed she did not change the dressings on 10/11/21 or 10/12/21. Staff F confirmed she checked the wound care as being completed and stated she usually checked them off as done since she does the dressings last and will let the oncoming nurse know that she did not finish. Staff F, LPN then said she forgot to change the dressings as the resident required several people for the dressing change and she was busy. Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 resulted in gram positive cocci, staphylococcus aureus (isolate1) [MEDICATION(S)] resistant staphylococcus aureus ([CONDITION(S)]) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of progress notes dated 10/13/21 at 4:56 p.m. revealed: wound care performed on resident, cleaned and dressed as ordered. Resident pre-medicated prior to procedures. Resident calm and cooperative during care, verbalized comfort levels throughout procedure. Resident complaint of pain and tender to touch on left trochanter, redness, serosanguineous drainage, Doctor notified. Wound care areas include heavy slough, drainage of left foot and sacrum. Previous dressings saturated. Measurements of wounds as follows: Left middle foot (sole) 8 cm x 5 cm. Left lateral foot (medial) 8 cm x 4.5 cm, left heel 1 cm x 1 cm dry, necrotic tissue, Sacrum 5 cm x 5 cm, depth 4.5 cm, tunneling 3.5 cm @ 12 o'clock, right heel 2.3 cm x 2 cm dry, necrotic tissue, right great toe 2 cm x 2.5 cm. On 10/13/21 at 4:37 p.m., a phone interview with the wound care nurse revealed the nurse practitioner assesses the resident's wounds and this should be completed as ordered by the physician. Typically, the order says what to clean the wound with and the expectation would be to clean it from the inside to the outside, throwing the gauze away with each rotation. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan of care: turning precautions, heel protection, incontinence care as needed. Increased moisture at wound site can promote poor prognosis of wound healing. Keep wound site covered and avoid contamination with feces at all times. Review of wound evaluation documentation revealed the following for the Medial Left Foot: 10/6/21 stage IV, measurements: Area - 9.8 cm2 (centimeters squared), Length - 3.9 cm (centimeters), Width - 3.4 cm, depth 0.2 cm. No odor. Progress documented as improving. 9/29/21 stage IV, no wound measurements. Continuous pain. Pain management provided prior to wound care. Moderate odor. Wound improving. 9/15/21 stage IV, measurements: Area - 12.8 cm2, Length - 4.5 cm, Width - 4.2 cm. Moderate pain. No odor. Mattress with pump. Wound stable. Review of wound evaluation documentation revealed the following for the sole to the left foot: 10/6/21 unstageable, measurements: Area - 11.66 cm2, Length - 6.61 cm, Width - 2.29 cm, Depth 0.1 cm. 9/29/21 unstageable, measurements: Area - 12.6 cm2, Length - 6.3 cm, Width - 2.9 cm. Pain at site. Patient received pain management prior to wound care. Healing stalled. 9/23/21 unstageable, measurements: 2.5 cm x 7 cm x 0.3 cm. The wound was debrided by the Certified Registered Nurse Practitioner (CRNP) for wound care post measurements. 9/15/21 unstageable, measurements: Area - 9.4 cm2, Length - 5.0 cm, Width - 2.7 cm. Applying [MEDICATION(S)] only. Review of wound evaluation documentation revealed the following for the left heel: 10/6/21 DTI, measurements: Area - 0.66 cm2, Length - 1.09 cm, Width - 0.8 cm. 9/29/21 DTI, no measurements documented. Resident continues to be in pain. Pain management provided prior to wound care. 9/15/21 DTI, measurements: Area - 0.6 cm2, Length - 1.1 cm, Width - 0.7 cm. Resident refuses pain management, [MEDICATION(S)] to left heel. Review of wound evaluation documentation revealed the following for the Right Medial Malleolus: 10/6/21 cluster stage 3, improving. No wound measurements were recorded. 9/29/21 stage 3, measurements: 2.2 cm x 2.1 cm x 1.3 cm x 0.2 cm in depth. 9/23/21 stage 3, measurements: 4 cm x 3.2 cm x 0.2 cm. 9/15/21 stage 3, no wound measurements recorded. Review of wound evaluation documentation revealed the following for the right heel: 10/6/21 unstageable, measurements: Area - 2.69 cm2, Length - 2.37 cm, width - 1.51 cm. 9/29/21 unstageable, measurements: 3.5 cm x 2.7 cm x 1.7 cm. 9/23/21 unstageable, measurements: 3 cm x 2 cm x 0. 9/15/21 unstageable, measurements: 6.6 cm x 3.3 cm x 2.8 cm. Review of wound evaluation documentation revealed the following for the lateral right foot: 10/6/21 unstageable, measurements: Area - 2.78 cm2, Length - 2.11 cm, width - 1.94 cm. 9/29/21 unstageable, measurements: 3.2 cm x 2.2 cm x 2. 0 cm. 9/23/21 unstageable, measurements: 3.5 cm x 2.5 cm x 0. 9/15/21 unstageable, measurements: 4.3 x 3.0 x 2.0 cm. Review of wound evaluation documentation revealed the following for the right buttock: 10/6/21 stage 4, no wound measurements recorded, and moderate drainage. 9/29/21 stage 4, measurements: Area - 7.5 cm2, Length - 4.9 cm, Width - 2.9 cm, Depth 1.2 cm, undermining- 3.0 cm. Moderate odor. Wound infection noted - currently on IV antibiotics. 9/23/21 stage 4, measurements: 5.5 cm x 4.5 cm x 4 cm, 6 to 3 o'clock. 9/15/21 stage 4, measurements: Area- 3.6 cm2, length- 2.8 cm, width- 2.1 cm. Review of wound evaluation documentation revealed the following for the left trochanter: 10/6/21 unstageable, no measurements documented. 9/29/21 unstageable, measurements: Area - 3.7 cm2, length- 2.6 cm, width- 1.9 cm. 9/23/21 unstageable, measurements: 2 cm x 2 cm x 0. 9/15/21 unstageable, measurements: Area - 2.6 cm2, Length- 2.2 cm, Width- 1.6 cm. During an interview with the Director of Nursing (DON) on 10/14/21 at 12:32 p.m. she confirmed the resident should have seen a physician related to wounds after admission and the wounds should be measured weekly. The DON confirmed the nurses document after the treatment is completed and should make sure that their documentation is accurate. The DON confirmed Staff F, did not change the dressings on 10/12/21 and only asked about 10/12/21. Review of the treatment administration record (TAR) for 10/11/21 and 10/12/21 showed the treatments were documented as completed by Staff F for wounds on Left medial foot, left trochanter, right buttock, right medial alveolus, [MEDICATION(S)] to left heel, [MEDICATION(S)] to left sole of foot, [MEDICATION(S)] to right great toe, [MEDICATION(S)] to right heel, [MEDICATION(S)] to right lateral foot. During an interview with Staff B on 10/14/21 at 12:55 p.m. she confirmed Resident #54 did not see a wound care physician or nurse practitioner from 9/3/21 to 9/15/21 and the wounds were not measured until the wound care nurse practitioner came in to see him. Staff B confirmed the aides should be offloading the resident and turning the resident every 2 hours and did not realize they placed the resident back on his left side where he was positioned prior to wound care. Staff B confirmed the resident was on an air mattress but was not sure who sets them up or what the correct setting should be. During a phone interview on 10/14/21 at 9:44 a.m. with the wound care Nurse Practitioner she stated she completes wound rounds weekly on Wednesday around 7:30 a.m. and Mondays were typically the days she sees new patients. She stated she conducts rounds with Staff B and the DON, completes the wound measurements with Staff B, gives verbal recommendations, and verifies later the orders were correct from the physician. The Nurse Practitioner stated she was a consultant and makes recommendations. The Nurse Practitioner stated she will make referrals to infectious disease and dermatology. She stated the wound measurements were captured with the camera which does not keep the picture but measures the wound. She confirmed the staff complete the dressing changes and should complete them as ordered. The Nurse Practitioner confirmed that staff should not be seeing thick brown odorous dressings on Resident #54 and if they did, she should be contacted and had not been as of this time. She stated she would expect the staff to call her. The Nurse Practitioner confirmed the resident's feet should be offloaded and not touching together. She confirmed the resident should be moved every couple hours to assist with healing and offloading of the left trochanter and should not be left on the side of the wound. They should be offloading every day. The Nurse Practitioner stated she would expect the nurse to clean the wound using a little pressure to get it clean and would expect it to be cleaned from the inside out in a clockwise motion, not tapped or dabbed. The Nurse Practitioner confirmed the wounds should be covered at all times as ordered. 2) During an interview with Resident #21 on 10/11/21 at 11:44 a.m. the resident stated he had no issues with his wound care. Review of Resident #21's skin and wound evaluation dated 10/6/21 revealed the stage 4 coccyx wound measured 2.0 cm x 2.9 cm x 0.5 cm. with moderate drainage and no odor. Wound improving. Review of Resident #21's skin and wound evaluation dated 9/29/21 revealed no measurements were taken for the stage 4 coccyx wound with moderate drainage and faint odor. Wound improving. Review of Resident #21's skin and wound evaluation dated 9/22/21 revealed the stage 4 coccyx wound measured 2.5 cm x 2.0 cm x 2.0 cm, moderate drainage. Wound stable. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Nurse Practitioner on 10/14/21 at 9:58 a.m. she stated she debrided the wound last week due to increased slough in the wound. Review of facility policy wound care, revised October 2010, 2 pages revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of facility policy charting and documentation, revised July 2017, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. c. treatments or services performed.

Based on observation, interview, and record review the facility failed to provide care and treatment in accordance with professional standards of practice, the plan of care, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #79, and lack of modification to the medication schedule to accommodate for scheduled [CONDITION(S)] for Resident #43. Findings included: 1. Review of the Admission Record for Resident #91 revealed an initial admitted in 2016, a most recent hospital stay of 9/28/21 to 10/5/21, a most recent re-admitted [DATE], and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's record indicated that the Primary Care Physician had written an order on 10/8/21 at 10:13 a.m., that instructed staff to discontinue left hip staples every day shift for 1 day. The October 2021 Treatment Administration Record (TAR) indicated that Resident #91's left hip staples were discontinued on Sunday, 10/10/21 during the day shift. A review of progress notes written by nurses identified the following: - 10/9/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/10/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/11/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . Review of Resident #91's care plan identified that on 10/11/21 a focus was initiated indicating that the resident was noted to have skin impairment as follows: surgical wound: left hip. The interventions related to this focus included, perform wound treatments as ordered. The October TAR identified that nursing staff had applied [MEDICATION(S)] cream topically to Resident #91's body twice daily for dry skin as scheduled at 9:00 a.m. on 10/7 - 10/13/21 and at 9:00 p.m. on 10/6 - 10/13/21 and had Monitor 4 staples to the left hip for signs of infection/redness every shift beginning on the evening shift of 10/6 and continued three times daily through the day shift on 10/14/21. During an interview with Resident #91 on 10/14/21 at 11:15 a.m., the resident identified that he had injured himself back in September when he tried to transfer himself from the bed and fell . The resident stated, I knew I had done something to my hip. The resident stated he currently had four surgical staples that the staff assessed. On 10/14/21 at 11:17 a.m., Staff Member H, Licensed Practical Nurse (LPN), was asked about Resident #91's surgical staples. Staff H stated, staples, let me check. She reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted with Staff H of Resident #91's left hip. The observation identified four intact surgical staples to the resident's left hip. The staff member confirmed the presence of 4 surgical staples to the resident's left hip. On 10/14/21 at 11:32 a.m., Staff H stated that she spoke with the Director of Nursing (DON) and that the scheduler was trying to schedule Resident #91 to return to the orthopedist (Ortho) but had been notified that the resident did not have to go back to their office, and the facility could remove the staples. The staff member reported that the DON was going to schedule Resident #91's staple removal for Sunday (10/17/21). On 10/14/21 at 12:53 p.m., the DON reported that Resident #91 had two (2) falls related to transferring independently and had to have a left hip replacement. She stated the facility did not have any order to remove the staples and that the facility concierge had informed her yesterday that she had attempted to get an appointment with the Ortho and that the staples could come out on Sunday. She stated she would expect staff to monitor the incision site, document the status of the staples, and describe how the wound looked. She reviewed the October TAR indicating staples had been discontinued. The DON stated she wanted to check to see if the resident's stapled were still in. At 1:05 p.m. on 10/14/21 the DON observed and confirmed that the resident did have 4 surgical staples in the left hip. She stated her expectation was if the staples had been documented as removed that they would have been removed. Continued review of Resident #91's October TAR identified that the facility had received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A review of the Admission Record revealed Resident #28 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #28's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was obtained on 6/29/21 and did not have an end date. The review of the order details indicated that the order type was Standard Other. A review of Resident #28's care plan, initiated on 9/25/19 indicated that the resident had the potential for complications related to an alteration in cardiac function due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions related to this issue included .Provide diet as ordered. Observed for compliance with diet. Weights as scheduled Vital signs as ordered and as needed . Continued review of the care plan identified that the resident required a therapeutic diet due to CHF, Diabetes Mellitus, and [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions instructed staff to obtain weights as ordered and as needed and to notify the physician of significant weight changes if noted. Review of the electronic Weight Summary, reviewed on 10/12/21 at 2:36 p.m., indicated that the following weights were obtained: - 4/9/21: 281.0 pounds (lbs) - 6/7/21: 278.5 lbs. - 8/9/21: 286.0 lbs. - 8/11/21: 286.0 lbs. - 9/6/21: 283.0 lbs. - 10/6/21: 284.0 lbs. The review of the weights that were obtained for Resident #28 did not indicate any weights were obtained from 6/29 (the day the order was written) until 8/9/21, five weeks after the order was written. The review identified that weekly weights had not been obtained per the Primary Care Physicians' order. A review of the October Treatment Administration Record (TAR), printed on 10/14/21 at 3:52 p.m., indicated the following: - weekly weight one time only for CHF for 1 day, order date 10/14/21. Documentation indicated that a weight was obtained on 10/14 at 10:29 a.m. - Weekly weights every day shift every Thursday (Thu) for CHF monitoring, order date 10/14/21 at 10:11 a.m. The TAR indicated that staff were to obtain a weekly weight on 10/21 and 10/28/21. - Weekly weights every day shift for CHF monitoring, order date 10/13/21 at 6:20 p.m. and discontinued on 10/14/21 at 10:11 a.m. The October 2021 Medication Administration Record (MAR) identified that Resident #28 received the diuretic medications [MEDICATION(S)] 40 milligrams twice daily and [MEDICATION(S)] 25 milligrams twice daily for CHF. The review of the October 2021 MAR and TAR did not include the order, dated 6/29/21, for the resident's Weekly weights. The Kardex for the resident's care did not include the order for weekly weights. A progress note, dated 6/26/21, indicated that the Advanced Registered Nurse Practitioner (ARNP) was notified of [CONDITION(S)] in legs. The note identified that the resident refused to elevate legs. Resident #28 was observed and interviewed, on 10/11/21 at 12:22 p.m., while he was sitting in a wheelchair in his room. Multiple observations from 10/11 to 10/14/21 identified that the resident was observed sitting in the wheelchair. During an interview with the Director of Nursing, on 10/13/21 at 3:45 p.m., she stated that a lot of residents had triggered for weight loss. The DON reported that she and the Dietary Manager were reviewing the monthly weights, and she was also reviewing the weekly weights. She reviewed Resident #28's order for weekly weights and did not know if the resident was on the weekly weight list. The facility policy, Charting and Documentation, revised July 2017, identified that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. and that Documentation of procedures and treatments will include care-specific details, including: Whether the resident refused the procedure/treatment. 3. Review of the Admission Record revealed Resident#79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #79 on 10/11/21 at 1:59 P.M. revealed numerous crustaceous [CONDITION(S)] on his arms and forehead along with what appeared to be dried blood on his bed sheets and underneath his fingernail bed. On 10/12/21 at 10:44 A.M., Resident #79 was observed in bed. His arms and face appeared to have a rash along with crustaceous [CONDITION(S)]. Resident #79 reported that he has been scratching due to itching of his bilateral arms and face. The resident reported that facility staff should be aware because his physician ordered an ointment for itching, and they have not applied it on his arms or face. Resident #79 reported that he was admitted to the facility with the itching and rash. The resident was observed picking at his scabs and had blood on his right arm during the interview. A review of the Medication Administration Record (MAR) from the date of admission 9/14/2021 through the current date of 10/12/2021 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read: [MEDICATION(S)] cream 1% every 24 hours as needed for itching. Review of the MAR/TAR (Treatment Administration Record) revealed no indications that Resident #79 had received his physician ordered treatment. A review of the resident's Kardex indicated that the Certified Nursing Assistants were to notify the nurse of any noted skin issues. Review of the medical record for any skin issues on his bilateral arms and face revealed no documentation. Only one weekly skin assessment was present in the resident's medical record. The assessment was dated 9/15/2021 and indicated no issues with his skin. There was no other information present related to skin assessments. A review of weekly skin notes revealed that on 10/10/21, 10/2/21, and 9/25/21 Resident #79 had no new skin impairments. An additional observation and interview was conducted on 10/13/21 at 11:44 AM in which Resident #79 stated that his arms have been itching and no cream has been put on his arms. On 10/13/21 at 1:16 P.M., an interview was conducted with the DON regarding Resident #79's itching and the medication ordered ([MEDICATION(S)] cream 1% every 24 hours as need for itching). The DON checked the treatment cart and was able to confirm that the medication was not present for the resident. The DON was asked to observe the residents' arms and face which was noted with scabs and a rash throughout his bilateral arms and face. The DON stated that she had not made this observation before. The DON stated that nursing was responsible for following through on physicians' orders and should have applied the medication on the resident for itching. 4. A review of the Admission Record for Resident #43 revealed that the resident was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #43 had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview. A review of the Order Summary Report revealed the following active active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] Monday, Wednesday, and Friday at 5:00 a.m. Nepro 1 can- one time a day for nutritional support Prostat Sugar Free- one time a day for nutritional support 30 ml Aspirin Tablet 325 MG- Give 1 tablet by mouth (po) one time a day for generalized pain [MEDICATION(S)] Tablet 80 MG- Give 1 tablet po at bedtime for [CONDITION(S)] Calcium [MEDICATION(S)] Tablet- Give 750 mg po three times a day for gastroesophageal reflux disease (GERD) [MEDICATION(S)] Tablet 6.25 MG- Give 1 tablet po two times a day for hypertension [MEDICATION(S)] Tablet 5000 unit- Give 1 tablet po one time a day for supplement FerrouSul Tablet- Give 325 mg po two times a day for [CONDITION(S)] [MEDICATION(S)] Tablet 50 MG- Give 1 tablet po three times a day for hypertension [MEDICATION(S)] Tablet 50 MG- Give 1 tablet po two times a day for hypertension [MEDICATION(S)] Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD Sevelamer [MEDICATION(S)] Packet 0.8 GM- Give 2 packets po with meals for [CONDITION(S)] mix with 8oz thickened fluid of choice There was no order related to holding the medications or giving the medications at an alternative time on scheduled [CONDITION(S)] days. Review of the Medication Administration Record (MAR) for August, September, and October 2021 reflected the following physician ordered medications and supplements were not administered on scheduled [CONDITION(S)] days: Aspirin Adult Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, and 10/11. [MEDICATION(S)] Tablet Delayed Release (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Tablet (0900 and 1700) - 08/20, 08/25, 08/27, and 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Sulfate Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Calcium [MEDICATION(S)] Tablet (0900, 1400, 2100) - 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Tablet (0900, 1400, and 2100) - 08/18, 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. [MEDICATION(S)] Packet (Sevelamer [MEDICATION(S)]) (0800, 1200, and 1700) - 08/30, 09/01, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/06, 10/08, 10/11, and 10/13. Sevelamer HCL Tablet for [MEDICATION(S)] control 800 MG - (0800, 1200, and 1700) - 08/18, 08/20, 08/25, and 08/27. [MEDICATION(S)] HCL Tablet 50 MG for depression (2100) - 09/08, 09/10, 09/13, 09/15, 09/24, and 09/27. [MEDICATION(S)] Sprinkles Capsule Delayed Release Sprinkle 125 MG related to [CONDITION(S)] with behavioral disturbances - 09/17, 09/20, 09/22, 09/24, and 09/27. [MEDICATION(S)] Tablet 5000 unit for supplement (0900) - 10/08, 10/11, and 10/13. Nepro 1 can was not administered on 10/11 and 10/13. The boxes for each medication was blank, had an X, the number three, the number five, the number nine, or the number ten. Per the Chart Codes, there was no code for X, the number three indicated away from facility without meds, the number five indicated to hold/see nurse notes, the number nine indicated other, and the number ten indicated out for [CONDITION(S)]. A review of the nurses' notes indicated the notes only indicated that the resident was out for [CONDITION(S)]. A review of the care plan for [CONDITION(S)] included the following intervention: adjust medication schedule as required to accommodate for [CONDITION(S)] treatments. On 10/14/21 at 8:40 a.m., Staff A/Licensed Practical Nurse (LPN) stated she had suggested to management that the medications be given on the night shift. She stated that she believed that the [CONDITION(S)] center was able to give blood pressure medications. Staff A stated that when Resident #43 goes out for [CONDITION(S)], they must make a note for the medication that she was in [CONDITION(S)]. By the time she comes in for her shift, Resident #43 was already gone to [CONDITION(S)] because she leaves at 5:00 a.m. Staff A stated that she can't hold the medicine until she comes back. On 10/14/21 at 9:00 a.m., Staff B/LPN Unit Manager stated that to her knowledge, the [CONDITION(S)] center does not give medications. She stated that the medication should be given prior to her leaving or the nurses should ask if the medications can be given later. Staff B confirmed that there was no order from the doctor to hold medications. On 10/14/21 at 1:08 p.m., the Director of Nursing (DON) stated the nurses should be communicating with the [CONDITION(S)] center if the physician did not give orders to hold medications. She stated a lot of times the doctor would say confer with the [CONDITION(S)] center. The DON confirmed that there was no documentation related to holding or rescheduling of the medications.

Based on observation, interview, and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of Resident #54's Admission Record revealed an admitted [DATE] and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 revealed gram positive cocci, staphylococcus aureus (isolate1) [MEDICATION(S)] resistant staphylococcus aureus ([CONDITION(S)]) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Ok to insert midline for IV antibiotic therapy x 10 days may use [MEDICATION(S)] 1% for insertion and [MEDICATION(S)] solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection. No additional orders were present related to the IV. On 10/12/21 at 4:00 p.m., Resident #54 was observed with an IV on the left upper arm dated 10/12/21. On 10/13/21 at 11:00 am., Resident #54 was observed with an IV to the left upper arm intact. On 10/13/21 at 3:24 p.m., Resident #54's wound care for pressure areas was observed with Staff B, Unit Manager and the Assistant Director of Nursing (ADON). After completion of the wound care on 10/13/21 at 4:24 p.m., Staff B confirmed the resident had a wound infection, finished antibiotics recently, and had orders for his IV in the left upper arm. On 10/13/21 at 4:26 p.m., the ADON checked Resident #54's orders and confirmed the resident did not have orders associated with the care and monitoring of the IV. The ADON stated that these orders should have been put in when the physician originally ordered the IV for the wound infection. Following the interview with the ADON, the following orders were added for Resident #54 on 10/13/21: Change midline IV dressing 24 hours post insertion, then weekly and as needed every 24 hours as needed for IV site care. Use securement device with each dressing change. Flush IV port with 10 ml normal saline (NS) one time a day every 7 days for IV maintenance. Number of lumens: single Observe site for signs and symptoms of infiltration, infection and extravasation every shift and as needed. Review of facility policy for administration set/tubing changes, Revised April 2016 revealed: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV equipment. Assessment: inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. Documentation: 6. The condition of the IV site.

Based on resident record and policy review and staff interview, the facility failed to allow one of one (#1) residents reviewed for transfer and discharge to remain in the facility until the outcome of the initial fair hearing. Findings Included: Review of the record for Resident # 1 revealed that he was admitted to the facility on [DATE], per the Admission Record with pertinent physical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 4/23/20 with a target date of 7/30/21 revealed: Focus: _____ has an alteration in mood and behavior as evidenced by displaying the following: being short tempered or easily annoyed and feeling bad about self. Observed on multiple occasions not wearing his mask. When asked to place mask on his face, he refuses. Resident makes false accusations towards staff and other resident. Resident makes threats toward staff and other residents that he will [NAME] this facility and it will be shut down. Resident is retaliatory towards staff and other residents when presented with information he disagrees with or has a deferring opinion. These behaviors have escalated in severity upon Resident receiving a 30-day notice to D/C. On 5/18/21, a Nursing Home Transfer and Discharge Notice was issued. Review of the form revealed the effective date of the transfer was 5/18/21 and the location the resident was transferred to was a local hospital. The reason for transfer was documented as The health of other individuals in this facility is endangered. Under the section for Brief explanation to support this action (attach additional documentation if necessary), the only documentation was Baker Act. The notice was signed by the Social Service Director, and it was noted that Resident # 1 refused to sign. Review of progress notes in Resident # 1's record revealed: 5/18/21 0854 Administrative note :( written by Administrator) Late entry Resident inciting a mob mentality by telling other residents not to follow the rules and telling them they don't have to wear a mask. Resident is telling cognitively impaired people that they don't need to wear a mask while not knowing anything about their health, vaccination status or cognitive impairments and resident's actions have a direct impact on his and others health around him. 5/18/21 13: 42 Administrative notes (written by Administrator.) Despite being provided education, resident has again refused numerous requests to wear his mask today. Resident was informed he would be transferred to quarantine unit if he refused to wear his mask. Resident refused to be moved. Resident is increasingly defiant in his refusal to follow the facility rules regarding wearing a mask. 5/18/21 14: 05 Administrator: This morning resident refused to put on his mask after request by management to follow facility rules and wear a mask. Resident stated that he called the . this morning and told him he didn't have to wear a mask. NHA, DON, and ADON called . and they denied providing that advice and denied that they had anyone with that name that worked there. The . followed up with an email to facility Administrator stating that new CDC guidelines do not apply to long term care and that masks for residents and staff in long term care setting is still required. Resident blatantly lied about his communication with . This is part of his ongoing refusal to wear a mask and his defiance of facility rules, which endangers this facility. 5/18/21 15: 07 Resident continues to be not compliant with facility rules related to wearing face mask in spite of education, resident refusing to comply, stated I don't have to wear it, order received from the Psychiatrist to transfer to the hospital via Baker Act. 5/18/21 15: 26 Resident fired (physician). (Another physician) to assume care ARNP has been made aware of resident refusal to wear face mask and order to Baker Act 5/18/21 15: 38 Social Service note: Resident observed by SW and NHA to again not be wearing a mask even though he was educated by Infection Prevention Nurse and SW that same morning on his requirement to do so. SW and NHA approached resident and provided further education regarding his requirement to wear a mask, offered him a mask and he again adamantly refused to comply with wearing a mask. Resident continued to use loud profane language during all attempts of education and redirection. He was informed that if he refused to wear a mask, he would have to be moved to the quarantine hall, but he refused to be moved as well. Due to resident continued refusal to comply with facility policies to ensure the health and wellbeing of all people within the facility, he is a danger to himself and others. IDT met while also consulting with resident's attending physician and psych to assess next steps. IDT was given the Baker Act order by Psych. Resident Baker Act to hospital for further evaluation. Review of a form entitled, Certificate of Professional Initiating Involuntary Examination revealed that at 2:06 p.m. on 5/18/21 a psychiatric nurse documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Supporting evidence stated, He has had several episodes of severe agitation, threatening staff, other residents, he will yell racial slurs and typically target African American or Hispanic residents. He has difficulty following facility rules and will become violent when staff attempts to educate or redirect him. He is at risk of injuring self, staff, or another resident during these episodes of agitation. He has displayed 3 or more of the diagnostic criteria of antisocial personality disorder including impulsivity, irritability, aggressiveness, reckless disregard for the safety of self or others, lack of remorse and deceitfulness. The occurrence of this behavior is not occurring during an episode of [CONDITION(S)] or [CONDITION(S)]. He has refused going into the quarantine unit and has refused to comply with facility policies and procedures related to continued mask requirements and puts himself and others at risk. At this time, he requires a high level of care. The Administrator and Social Service Director, on 7/8/21 at 4: 20 p.m., stated that Resident # 1 appealed this notice. The Administrator stated that she was contacted by the hospital to discharge Resident # 1 back to the facility. She stated she believed it was on the third day after the Baker Act. She stated, We did not want to take him back based on the fact that he was a danger to others at the facility. She stated she was following Statute 483.15 exception to statute for danger to others. She stated that We packed up his room the same day we transferred him to hospital and stated they were not going to take him back. The Administrator stated that a discharge notice was not issued She stated the only discharge notice Resident # 1 was given was Just the notice, the original one from March, and confirmed that no other notice was issued. The facility provided a policy, Transfer or Discharge, Emergency, which included the following: Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). 2. If resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. We have a hearing next week on 7/8/21 at 4: 17 p.m. The Administrator stated, however, she had no documentation from the physician which reflected that Resident # 1 was not safe to return to the facility after he was discharged from the hospital.

Based on observation, staff interviews and record review, the facility failed to ensure adherence to infection control practices as evidenced by: staff failure to disinfect medical equipment between use by different residents; staff failure to sanitize the ice water cooler after contact with the floor; failure to promptly dispose of a wound care tray; and failure to cover the tube feeding equipment to prevent possible contamination for one (1) resident (Resident #1). The failures to clean the lid to the ice water cooler and to disinfect shared equipment had the potential to affect all residents residing in the Long Term Care Unit (LRU) at the time of the survey. The findings include: 1. On 4/1/20 at 2:49 p.m., Certified Nursing Assistant (CNA) #1 was observed taking out the hoyer lift from Resident #2's room. CNA #1 transferred Resident #2 to his motorized wheelchair with the help of the Director of Nursing (DON) and another CNA. CNA #1 returned the hoyer lift to the equipment room. When CNA #1 was asked if she needed to do anything, CNA #1 stated, I'm done. CNA #1 did not clean or disinfect the equipment. This was confirmed by the DON. 2. On 4/1/20 at 2:55 p.m., the DON was observed picking up the big ice water cooler lid that had fallen on the floor. The ice water cooler which was used to provide cold water to residents in the LRU unit was filled half-full with ice and water. The ice water cooler was by the hallway of the LRU unit. The DON placed the lid back on. The DON did not sanitize the lid after it had been on the floor. 3. On 4/1/20 at 3:03 p.m., a styrofoam dressing tray was observed on top of the treatment cart exposed, with no barrier or covering. This was confirmed by the DON. The DON stated, Optimally it should not be there. During an interview with the DON on 4/1/20 at 1:28 p.m., when asked if staff should be cleaning and disinfecting the hoyer lift or any other shared equipment after use on a resident, the DON stated, Yes. When asked about the ice water cooler lid, the DON stated, That can be replaced. The DON further stated that he ordered a new one. Review of undated facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revealed, Resident-care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of the facility's undated policy titled Standard Precaution revealed, .Resident-Care Equipment .Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. Review of a CDC article titled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes with review date of 3/21/20 revealed under Environmental cleaning and disinfection, A new respiratory disease - coronavirus disease 2019 (COVID-19) - is spreading globally and there have been instances of COVID-19 community spread in the United States. The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies these facilities use every day to detect and prevent the spread of other respiratory viruses like influenza .Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term- care-facilities.html 4. On 4/1/20 at 2:40 p.m., Resident #1 was observed lying in bed. Resident #1's [DEVICE] (a feeding tube inserted into the stomach through the abdomen used to supply nutrition) feeding spike set was exposed, not covered. The feeding tube was filled with the [DEVICE] formula. This was confirmed by the Director of Nursing (DON). Resident #1 was receiving [MEDICATION NAME] 1.5 (a fiber -fortified therapeutic nutrition that provides complete, balanced nutrition for long or short-term tube feeding) at 55 cc/hr (cubic centimeter per hour) for 20 hours. R1's feeding was turned off at that time. During interview with the DON on 4/1/20 at 1:28 p.m., when asked about his expectation from staff with [DEVICE] care, the DON stated, If it's disconnected, it should be capped. If it's exposed, then we have to throw it away. The DON further stated, Definitely they (nurses) should check the [DEVICE] connection when they pass meds. Review of undated facility policy titled Enteral Feedings-Safety Precautions revealed under General Guidelines, Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas .Regularly inspect tubing for proper connections. In an article titled Tube Feeding and Diarrhea dated 8/14/17 revealed, Diarrhea is the most commonly reported gastrointestinal complication of tube feeding, reports the American Dietetic Association 1. There are many possible causes of diarrhea when you are on tube feeding, and a slew of potential solutions .Formula contamination caused by improper handling and storage of formula and equipment can also induce diarrhea, cautions the Oley Foundation. Likewise, gastrointestinal infections, or over-colonization of bacteria, can irritate the intestine and lead to watery stools. https://healthfully.com/ 1-tube-feeding-and-diarrhea.html

Based on observation, interview and record & policy review, the facility failed to provide care and services related to [MEDICAL TREATMENT] for 3 of 3 sampled residents (#1, #3, and #4). Residents #1, #3 and #4 lacked documentation of an assessment of the resident before and after [MEDICAL TREATMENT] treatments as well as ongoing communication and collaboration with the [MEDICAL TREATMENT] facility. Resident #1 lacked consistent transportation to the [MEDICAL TREATMENT] center. Findings included: 1. Resident #1 was admitted on [DATE] and discharged on [DATE], per the Transfer/Discharge form. The record reflected a [DIAGNOSES REDACTED]. Record review of the 5-day Minimum Data Set ((MDS) dated [DATE] found a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). The resident required extensive assistance of one for bed mobility, eating and toileting and extensive assistance of two for transfers. The resident was on [MEDICAL TREATMENT]. Record review of physician orders [REDACTED]. Review of the progress notes showed on 12/29/19 at 17:18 (5:18 p.m.) a call was placed to the daughter to inform her that Resident #1 did not attend [MEDICAL TREATMENT] today due to transportation issues. Documentation on 12/29/20 at 18:46 (6:46 p.m.) indicated the ARNP was notified the resident did not attend [MEDICAL TREATMENT]. New orders included to check her vital signs every 4 hours for 24 hours. On 01/06/20 at 17:04 (5:04 p.m.) showed the resident was already checked and changed while waiting for [MEDICAL TREATMENT] transport. The resident and daughter were notified of [MEDICAL TREATMENT] transportation in route. The daughter requested the resident be put back to bed to recheck the resident's buttock dressing. The [MEDICAL TREATMENT] transportation arrived at the facility while the dressing was being changed. The writer asked the transportation to wait while she finished the dressing change. After 10 minutes, it was discovered that the transportation had left without notification. On 01/07/20 at 6:45 a.m. the nurse had been informed by the Unit Manager that the resident was attending [MEDICAL TREATMENT] this a.m. with her daughter who was going to transport the resident. On 01/15/20 at 23:16 (11:16 p.m.) the record reflected showed the resident had not been transported to [MEDICAL TREATMENT] as a result of a scheduling mix-up. A call was placed to the physician. Record review of the care plans (Date initiated 12/29/2019) showed the resident had potential complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. The resident received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday at 3:00 p.m. Interventions included but were not limited to establish and manage transportation arrangements for [MEDICAL TREATMENT] and have the resident ready on [MEDICAL TREATMENT] days. Complete [MEDICAL TREATMENT] communicate tool on [MEDICAL TREATMENT] days and review upon return from [MEDICAL TREATMENT]. Review of the Treatment Sheet for Facility from the [MEDICAL TREATMENT] Center showed Resident #1 was absent from [MEDICAL TREATMENT] on 01/29/19, 01/06/20 and 01/15/20. On 03/04/20 the facility staff stated the [MEDICAL TREATMENT] Communication Forms were scanned onto the e-chart. The following were present on 03/04/20: January 03, 07, 08, 10, 27 and February 05, 07, 10, 12, 14, 7, 19. On 03/05/20 the facility presented a copy of the following dated [MEDICAL TREATMENT] Communication Forms: January 03, 06, 08, 10, 13, 15, 17, 20, 22, 24, 27, 29, 31 and February 03, 05, 07, 10, 12, 14, 17, 19, 21 (they did not give a copy of the 01/07 form that was in the e-chart). Record review of the 01/06/20 [MEDICAL TREATMENT] Communication Form showed the following documentation: transported by daughter, left at 2 p.m., respirations 18, blood pressure 132/76, pulse 80, temperature 98.2, and was signed by a LPN. The section for the [MEDICAL TREATMENT] Center to document in was blank. The section the facility was to complete on return showed: arrived at 7 p.m., with a blood pressure of 122/70, pulse 82, no pain, access shunt intact, bruit yes, no bleeding, signed and dated on 01/06/20. The [MEDICAL TREATMENT] Communication Form showed the resident left at 2 p.m., transported, respiration 18, blood pressure 132/70, pulse 68, temperature 98.4 and was signed by an LPN and dated 01/15/20. The section for the [MEDICAL TREATMENT] Center to document in was blank. The section the facility was to complete on return showed: arrived at 8 p.m., with a blood pressure of 136/80, pulse 76, respirations 20, no pain, access shunt intact, bruit yes, no bleeding and was signed by Staff C, RN, ADON and dated 01/15/20. During an interview on 03/05/20 at 9:25 a.m. the Nursing Home Administrator (NHA) stated that the daughter was very involved in Resident #1's care. He stated that they allowed the daughter set-up the resident's transportation. On 01/06/20 they told transportation it would be 10-15-minute wait because the daughter wanted the resident put back to bed so she could see the resident's wound. The transport did not stay, and the resident missed the transportation. Staff D, Licensed Practical Nurse (LPN) had called for another transport. They came to the front door and the resident and daughter were at the side door. The daughter would not let us take the resident to the front door and the resident missed the transport again. The transport was arranged for the next day, 01/07/20. The resident went to [MEDICAL TREATMENT] on 01/07. During an interview on 03/04/20 at 12:45 p.m. the NHA stated that they did have a transport van for wheelchair access. He stated that they have had issues with some residents not being realistic about pick-up times from [MEDICAL TREATMENT]. He stated that he had hired a second driver. The NHA stated that he put a QAPI in place for transportation on 01/07 because of Resident #1. Resident #1's transport was set-up for 01/07 as per the resident's wishes. The NHA stated that they checked with other residents that are transported and had no other issues at that time. He stated that the Assistant Director of Nursing (ADON) educated the staff on resident rights regarding to the [MEDICAL TREATMENT] transport. A full-time facility transport driver was hired and started on 02/14. The NHA stated that he will monitor grievances for accuracy and efficiency of transports weekly. The audits will continue for 90 days or until substantiated compliance was achieved. During an interview on 03/04/20 at 4:35 p.m. the facility's corporate nurse stated that they could only find one more [MEDICAL TREATMENT] Communication Form for Resident #1. She stated that they were going to call the [MEDICAL TREATMENT] center for the actual dates the resident visited the center. During an interview on 03/05/20 at 11:00 a.m. Staff B Licensed Practical Nurse (LPN) stated that she used to work the 3-11 p.m. shift and had just recently moved to the 7 a.m. -3 p.m. shift. She stated that Resident #1 went to [MEDICAL TREATMENT] 3 times a week. She stated that the resident would leave about 2 p.m. to go to [MEDICAL TREATMENT]. The resident took the [MEDICAL TREATMENT] Communication Forms with her. She stated that due to her working the 3-11 shift at the time, she never sent the resident to [MEDICAL TREATMENT]. She took care of her when she returned. Staff B, LPN stated that she would check the resident post [MEDICAL TREATMENT]; take her vital signs and check her port. She stated that the family set up her transportation. She stated that the resident would get back about 7:30 p.m. Staff B, LPN said the resident would, sometimes, not come back with her [MEDICAL TREATMENT] Communication Forms, the daughter would keep them. They would ask her if we could have a copy of them and she would not let us. Both the physician and [MEDICAL TREATMENT] center were aware. During an interview on 03/05/20 at 11:55 a.m. Staff A, Registered Nurse (RN), Unit Manager (UM) stated that Resident #1 was a very sweet lady. She stated that there was an issue with transportation. Staff A stated that she did not know how many [MEDICAL TREATMENT] visits Resident #1 missed. The Resident did go to the [MEDICAL TREATMENT] center with the Daily Communication Forms. She stated that she was not sure if the forms came back or not. On 03/05/20 at 12:55 p.m., the Director of Nursing (DON) was interviewed related to receiving of the [MEDICAL TREATMENT] Communication Forms for Resident #1. He stated that Staff A, RN, UM had given the forms to him that a.m. The Administrator was informed that yesterday, on 03/04, the surveyor was told that all of the [MEDICAL TREATMENT] Communication Forms had been scanned into the e-chart. The DON was told that the medical records clerk had stated that all of the Forms had been scanned. Also, the DON was told that, yesterday, the following was requested from the Corporate Nurse: a list of the dates that the resident attended [MEDICAL TREATMENT] and if there were any more [MEDICAL TREATMENT] Communication Forms. The DON was told that there were 12 Communication Forms available 03/04 in the e-chart and now 23 [MEDICAL TREATMENT] Communication Forms had been provided. The resident was admitted on ,[DATE] and did not go to [MEDICAL TREATMENT] on 12/29. The DON was told that, based on the Treatment Sheet for Facility forms sent from the [MEDICAL TREATMENT] center, Resident #1 was absent from [MEDICAL TREATMENT] on 12/29/19, 01/06/20, and 01/15/20. When asked how there were [MEDICAL TREATMENT] Communication Forms filled out by the nursing staff for 01/06 and 01/15 when the resident did not go? The DON stated that the signature was the same nurse and he did not know the signature. He stated, either they are asleep at the wheel or they falsified the documentation. When asked how the number of [MEDICAL TREATMENT] Communication Forms doubled since yesterday? The DON did not answer. The DON was informed that Staff B, LPN had stated that the [MEDICAL TREATMENT] Communication Forms did not always come back because the daughter kept them. On 03/05/20 at 1:00 p.m. the NHA stated they did a QAPI on the transportation due to Resident #1. The QAPI Transportation 01/07/20 reflected Resident #1's transport was set-up. Resident #1 was taken to [MEDICAL TREATMENT] on 01/07/20 per resident wishes. Other residents with transports were checked and no other issues at this time. The ADON educated staff on resident rights regarding [MEDICAL TREATMENT] transport. A full-time facility transport driver was hired and started on 02/14/20. The NHA will monitor grievances for accuracy and efficiency of transports weekly. Audits will continue for 90 days or until substantial compliance was achieved. During an interview on 03/05/20 at 1:14 p.m. Staff A, RN, UM stated that she did not know anything about the [MEDICAL TREATMENT] Communication Forms for 01/06 and 01/15. She stated that she came to the 400 floor as the UM on 01/07. She stated that she does not know who the nurse was that signed the forms but Staff C RN, ADON was the ADON that signed on 01/15. During an interview on 03/05/20 at 1:25 p.m., Staff C, RN, ADON stated that she usually filled in the vital signs on the [MEDICAL TREATMENT] Communication Forms. She stated that the nurses were too busy to do it. She stated that she only plugged in the vital signs but not the other parts of the assessment. Staff C, RN, ADON stated that yes, there was no division showing that she only filled in the vital signs and another nurse had performed the post [MEDICAL TREATMENT] assessment. Staff C stated, again, that she was just filling in the vital signs for the nurses. During an interview on 03/05/20 at 1:30 p.m. the NHA stated that if the ADON was going to sign the [MEDICAL TREATMENT] Communication Form as receiving the resident then she needed to sign the form as such. He stated what nurse signs a form without checking for another nurse signature. The NHA stated that his expectation was to do correct documentation. The NHA stated that there was an issue if the resident did not go to [MEDICAL TREATMENT] and had documentation as if they did go. During an interview on 03/05/20 at 4:54 p.m. the DON entered the conference room and stated that Staff C, RN, ADON had been suspended. She told me she was only signing the [MEDICAL TREATMENT] sheets for the vital signs. I told her if that were the case, I would have made sure it was noted on the [MEDICAL TREATMENT] form. The NHA came in and stated that the Staff C, RN, ADON had been suspended due to the [MEDICAL TREATMENT] Communication Forms for Resident #1. He stated that she should not have filled the sheets out for the nursing staff. If she was just filling out the vital signs, as she said, she should have documented it that way. 2. Resident #3 was admitted on [DATE] and readmitted on [DATE], per the Admission Record. Record review of the [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). The resident was totally dependent for bed mobility, transfers, and extensive assistance for toileting. The resident was receiving [MEDICAL TREATMENT]. Record review of the care plans (Date initiated 9/7/2018) showed the resident was at risk for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. The e-chart lacked any [MEDICAL TREATMENT] Communication Forms. The Corporate Nurse verified the lack of documentation. Record review of the [MEDICAL TREATMENT] Communication Forms from 01/10/20 and 03/02/20 showed the following forms missing: 01/15, 24, 27; 02/10, 12, 14, 17, 21, 24, and 28; as well as 03/02. Review of the [MEDICAL TREATMENT] Communication Forms showed the following forms did not have the Facility section filled out by the nursing staff: 01/29, 31, 02/03, 05, 07, 14, 19, and 26. During an interview on 03/05/20 at 3:30 p.m. Resident #3 was sitting in a wheelchair at his bedside. He was dressed and groomed. He stated that he went to [MEDICAL TREATMENT] on Monday, Wednesday, and Fridays. He stated that he did not take any paperwork to [MEDICAL TREATMENT]. During an interview on 03/05/20 at 4:40 p.m. Staff A, RN, UM, located Resident #3's [MEDICAL TREATMENT] notebook. She verified that there were missing [MEDICAL TREATMENT] Communication Forms and some of the forms lacked documentation related to the facility post [MEDICAL TREATMENT] assessment section on return of the resident. 3. Resident #4 was admitted on [DATE] and readmitted on [DATE], per the Admission Record. Record review of the [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], showed a BIMS score of 14 (cognitively intact). The resident required extensive assistance for bed mobility, transfers, and limited assistance for toileting. The resident was receiving [MEDICAL TREATMENT] Record review of the care plans (Initiated 12/12/19) reflected the resident was at risk for complications related to [MEDICAL TREATMENT] for treatment of [REDACTED]. Review of the e-chart only showed [MEDICAL TREATMENT] Communication Forms for 01/03, 01/13 and 02/07. The Corporate Nurse verified this lack of documentation. During an interview on 03/05/20 at 4:40 p.m. Resident #4 was sitting in a wheelchair in the smoking area. He was dressed and groomed for the day. He stated that he went to [MEDICAL TREATMENT] on Mondays, Wednesday, and Fridays. He stated that he takes paperwork with him. During an interview on 03/05/20 at 4:40 p.m. Staff A, RN, UM, located Resident #4's [MEDICAL TREATMENT] notebook. She verified that the notebook was empty. 4. Record review of the facility's [MEDICAL TREATMENT] Contract showed B. Obligations of Long Term Care Facility and / or Owner: 2. Interchange of Information: the Long Term Care Facility shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] Residents, including a contact person at the Long Term Care Facility whose responsibilities include assisting with the coordination of [MEDICAL TREATMENT] Services for [MEDICAL CONDITION] residents; 4. Preparation of [MEDICAL CONDITION] Residents. The Long Term Care Facility shall ensure that [MEDICAL CONDITION] Residents are prepared to spend an extended length of time at the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and have received proper nourishment and any medications prescribed for reasons other than the treatment of [REDACTED]. 5. Transport and Referral of [MEDICAL CONDITION] Residents. The Long Term Care Facility shall be responsible for arranging for suitable and timely transportation of the [MEDICAL CONDITION] Residents to and from the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit, including the selection of eh mode of transportation qualified personnel to accompany the [MEDICAL CONDITION] Residents, transportation equipment usually associated with this type of transfer or referral in accordance with the applicable federal and state laws and regulations and all costs or transportation expenses associated with such transfer. The Long Term Facility shall be responsible for ensuring that the [MEDICAL CONDITION] Residents are medically stable to undergo such transportation and medically suitable to receive treatment at the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. E. Mutual Obligations: 1. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long Term Care Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. Documentation shall include but not limited to, participation, as members of an interdisciplinary team, in care conferences, continual quality improvements program, annual review of infection of policies and procedures, and the signature of team members from both parties on a Short Term Care Plan (STCP) and Long Term Care Plan (LTCP). Team members shall include the physician, nurse, social worker, an dietician from the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and a representative from the Long Term Care Facility. The [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit shall keep the original STCP and LTCP in the medical record of the [MEDICAL CONDITION] Resident and the Long Term Care Facility shall maintain a copy. Record review of the facility's policy, [MEDICAL CONDITION], Care of a Resident with, revised September 2010, showed agreements between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: a. include measurable objectives and time frames; b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview policy, and record review, the facility failed to promote dignity and respect during the dining experience in the main dining room for ten (#s 20, 22, 23, 27, 39, 40, 43, 49, 101, and 211) of 52 sampled residents, during two (1/28 and 1/30/20) of four survey days, and in two (400 and 500) hallways and did not ensure that resident council members felt respected by staff during dining. Findings Included 1. An observation was conducted in the main hallway outside of the main dining room, on 1/28/20 at 12:04 p.m. A CNA was observed wheeling Resident #49 toward the area outside of the dining room. Four residents were observed to already be seated in wheelchairs in that area. The Director of Nursing (DON) was observed to stop Resident #49, and in front of four residents and the surveyor, ask the resident if he could come shave this stuff off your chin after lunch while pointing to the chin area of her face. Resident # 49 was observed to have visible hair growth on her chin. The resident was observed to nod yes. The DON moved away and the aide then placed Resident #49 outside of the main dining room. An interview was conducted with the DON, on 1/30/20 at 5:20 p.m. He confirmed that he did say that to the resident in the hall but stated he did not realize that he was that loud that he was overheard. He stated he did not know the name of the resident but he sees her all time time. An interview was attempted with Resident #49 on 1/30/20 at 11:30 a.m. She was asked about the conversation in the hallway with the DON however she did not recall the event. Review of the record for Resident #49 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 11/18/19, revealed a score of 7 on the Brief Interview for Mental Status (BIMS) assessment which is indicative of moderate cognitive impairment and indicated that Resident #49 required extensive assistance of one person for personal hygiene tasks. 2. Review of the meal times list provided by the facility revealed that there were two scheduled meal times for the lunch meal in the main dining room- 11:30 a.m. and 12:30 p.m. Review of a seating chart for the dining room revealed that the 11:30 a.m. lunch is for independent diners and the 12:30 p.m. Helping Hand Lunch is for residents who need to be fed or need assistance to eat. An observation of the 11:30 a.m. lunch meal commenced at 11:44 a.m. on 1/28/2020 with nine residents observed to be eating independently. At 12:04 p.m. on 1/28/20, four residents were seated in wheelchairs in the hallway outside of the dining room while the nine residents in the dining room were still eating their meals. At 12:10 p.m. six residents were observed in the hallway out side of the dining room while the nine residents in the dining room were still eating their meals. The six residents included Resident's #49 and #40 who were both seated in wheelchairs right outside of the dining room and Resident's #23 and #27. Resident #40 was observed to be attempting to move himself into the dining room by propelling with his feet. His wheelchair was observed to be locked so he was unsuccessful in his attempt. An unidentified CNA came out of the dining room and was heard to tell Resident #40 that he needed to stay out here for now as it was not time for him to eat. Resident #49 was observed to be shaking her head. A brief interview was conducted with Resident #49 and she stated, they are telling us to come down here and to come in and then we sit here. She expressed that she was frustrated at having to sit outside the dining room and wait while others were eating. Resident #49 had been observed at 12:04 p.m. being wheeled to the dining room in her wheelchair by a staff member and being placed where she was observed when interviewed. Resident #49 was observed to be moved out of the area she was seated in to an area across the hall in order for staff to assist wheelchair residents out of the dining room. An observation was made of Resident #27 seated in the hallway in her chair outside of the dining room. She was observed speaking to the Director of Social Services. She was heard saying to the Director of Social Services that they are upset, they want to come in the dining room and keep being told it is not time yet. The Social Service Director was heard to say, well they can go in there if they want to but made no attempt to inform other staff to bring these two residents into the dining room or assist them, herself, into the dining room. Observation of the second seating for lunch commenced at 12:27 p.m. when the six residents and other residents were observed to be assisted into the dining room for their lunch meal. Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and in a loud voice, heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22, after much conversation was heard in the dining room between the dietary aide and the CNAs. An interview was conducted with Resident #22 at 12:39 p.m., she stated she wants to eat in the dining room. Eighteen residents were observed in the dining room for the second meal time with the dietary person and three aides present. A female resident was wheeled into the dining room by a staff person and two aides, across the dining room assisting residents to eat, yelled out she already ate and the staff person wheeled the female resident back out of the room. Random observation at 12:37 p.m. on 1/28/20., revealed: Three residents seated at table 5. One resident was observed being served her soup by an aide while the other two residents had no food or soup in front of them. Three residents were observed to be seated at table one with one resident being fed soup by an aide and the other two residents with no food or soup. Three residents were observed to be seated at table 9 with one resident being fed soup and the other two residents with no food or soup. At 1:08 p.m. on 1/28/20, Staff I and Staff M were observed to be seated at a table assisting Resident's #101 and #43 to eat lunch. Staff I and Staff M were observed to be talking to each other about where staff, who used to work at the facility, were now working, while assisting the two residents to eat. During the Resident Council meeting, conducted on 1/30/20 at 2:00 p.m., three confidential residents, who have lunch during the 1st lunch serving (11:30 a.m.) in the main dining room, stated that they felt rushed eating lunch while the second seating residents are gathered outside the door of the dining room. They stated this happens every day during lunch. A second dining observation was conducted in the main dining room on 1/30/20, commencing at 11:47 a.m., with the first lunch seating and ending at 12:50 p.m. during the second seating. The following was observed: Nine Residents were observed to be eating their soup and or salad in the main dining room. At 11:50 a.m., a CNA, was observed to wheel Resident #211 into the dining room and left him in the middle of the dining room while she went to the seating chart to determine where he sat for lunch. He was placed at table 2 in front of a place setting. This aide and another staff person stated loudly that he was not the resident whose place setting he was seated at and that he was scheduled to eat during the second dining at 12:30 p.m. The aide then removed him from in front of the place setting and wheeled him out of the dining room. Review of the seating chart for the 12:30 dining revealed that Resident #211 was assigned to sit at table 9. Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her on 1/30/20 at 11:47 a.m. A dietary aide and a CNA were heard saying loudly that, she is second seating and another aide wheeled her away from the table and took her out of the dining room. An unidentified aide was observed in the middle of the dining room while residents were eating lunch, speaking with Staff O, a CN[NAME] Both were speaking in an audible tone that could be easily heard from the entrance to the dining room. They were discussing whether the unidentified aide should be helping during the meal. Staff O informed her no and explained to her how the schedule worked. As the aide was leaving the dining room, she was observed to yell out from the door to Staff O, who was still in the middle of the dining room, oh its breakfast tomorrow and Staff O was observed to yell back Yes. Resident #39 was observed seated at table 4 finishing his salad at 12:19 p.m. on 1/30/20. He then propelled himself out of the dining room and down the hall. An aide came out of the kitchen with his lunch and two staff who were in the middle of the dining room between table 5 and 6 were heard to yell out, he went to [MEDICAL TREATMENT] while other residents were seated in the dining room eating lunch. The Administrator in Training was observed to be assisting Resident #101 with a beverage. She was observed to call out to other staff in the dining room who were assisting residents Is she a sippy cup? to which the other staff who were assisting other residents verbally called out yes. Staff O was observed during the second dining in the main dining room, on 1/30/20 at approximately 12:50 p.m., wheeling a male resident, #20, into the room. She asked the dietary aide where the resident sat and the dietary aide responded that she would have to get the table set up first. Staff O left Resident #20 in the middle of the dining room and walked away. The dietary aide set up the table and moved him to the table, after he had sat in his wheelchair in the middle of dining room for five minutes. 3. Four of eight confidential residents in the Resident Council Meeting, on 1/30/20 at 2: 00 p.m. stated the did not feel that staff treated them with dignity and respect and felt that when they expressed concerns to the nurses and aides that nobody was listening. 4. An interview was conducted with the DON and the Administrator regarding the dignity concerns identified during dining. on Both the Administrator and the DON stated that 1st and 2nd dining was not set up to be for independent diners at one and assisted diners at the other. The Administrator stated that the intent of the two dining times was to get more residents out of their rooms and into the dining rooms by allowing the residents to choose which lunch time to go to. The Administrator stated its not supposed to be that way. Regarding the dignity, concerns they both stated that they will fix it. 5. An observation was conducted on 1/28/20 at 11:47 a.m. on the 400 hallway during the lunch meal. Staff I, CNA was observed entering room [ROOM NUMBER] without knocking. Then Staff I, CNA returned to the meal cart, removed a tray, and brought it into room [ROOM NUMBER] again, without knocking or announcing herself. Another observation was conducted on 1/28/20 at 12:05 p.m. during the lunch meal on the 500 hallway. Staff H, CNA removed a tray from the meal cart. Staff H, CNA entered room [ROOM NUMBER]. Staff H, CNA did not knock on the door or announce herself before entering the room. Then Staff H, CNA removed another tray from the cart and entered room [ROOM NUMBER] without knocking or announcing herself. Staff H, CNA exited the room. Staff H, returned to the meal cart. Staff H, CNA, removed a tray from the meal cart. Staff H, CNA took the tray into room [ROOM NUMBER]. Then Staff H, CNA, removed another tray from the meal cart, and returned to room [ROOM NUMBER]. Staff H, CNA did not knock or announce herself before entering the room. 6. Review of the policy, Resident Rights, revised (MONTH) (YEAR), reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and State laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity

Based on observation, interviews, record review, and policy review the facility did not ensure residents were free from significant medication errors, for 3 residents (#5, #33 and #100) of 11 residents observed during medication administration or reviewed for unnecessary medications. Findings Included: 1) Review of the record for Resident # 5 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Resident # 5 also had a physician's orders [REDACTED]. Hold for blood sugar less than 200. Review of Resident # 5's Medication Administration Record [REDACTED]. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for (MONTH) 2020 revealed the [MEDICATION NAME] Solution 100 Unit/ML (Insulin [MEDICATION NAME]): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. An interview was conducted with the Director of Nursing, on 1/31/2020 at 11:20 a.m. He reviewed the Medication Administration Records and confirmed that the [MEDICATION NAME]was being administered when it was supposed to be held for blood sugars under 200 . He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 pm. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he does not like this type of order as it puts more on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5. 2) Resident #100 was admitted to the facility with a [DIAGNOSES REDACTED]. On 1/30/20 at 8:47 a.m. with Staff A, LPN. Staff A, poured Resident #100's medications. Then Staff A, LPN knocked on the door and entered the room. Next, Staff A, LPN washed her hands in the bathroom sink. Then Staff A, LPN put on a pair of gloves. Staff A, LPN placed the supplies and medications on paper towels on bed side table. She gave Resident #100 his medications whole with water. Then Staff A, LPN opened the needle for the insulin pen. Staff A, LPN attached the needle to the pen. Then Staff A, LPN dialed the [MEDICATION NAME]pen to 10 units. Staff A, LPN did not prime the needle with 2 units of insulin prior to dialing it to 10 units. Next, Staff A, LPN used an alcohol prep to clean Resident #100's left lower abdomen. She placed the insulin pen against the area she had cleaned, and pressed the top to inject the medication. Then Staff A, LPN removed her gloves and placed them in the trash can near the bed side, along with the other supplies she had used. She went into the bathroom and disposed of the insulin needle in the Sharp's container. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN returned to the medication cart where she cleaned the insulin pen with a germicidal wipe. A review of Resident #100's physician's orders [REDACTED]. 1/29/20 [MEDICATION NAME] 10 units subcutaneously with meals 3) Resident #33 was admitted to the facility with a [DIAGNOSES REDACTED]. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN removed a glucometer, test strips, lancet, alcohol prep pad, [MEDICATION NAME], and a needle from the medication cart and placed the supplies on a foam plate. Then Staff A, LPN knocked on Resident #33's door. Staff A, LPN went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the [MEDICATION NAME]. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Staff A, LPN did not prime the insulin pen. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff [NAME] LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. The Staff A, LPN removed the gloves and placed the in the trash can as well. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the [MEDICATION NAME]. Then Staff A, LPN placed the [MEDICATION NAME] in a plastic bag and returned it to the drawer. On 1/30/20 at 11:54 a.m. in an interview with Staff A, LPN she said she did not know she had to prime the insulin pen. She said she did not know what priming was. A review of the physician's orders [REDACTED]. A review of the manufacturer's instructions for [MEDICATION NAME] reflected the following information: Getting started on [MEDICATION NAME] A Guide to Using Your [MEDICATION NAME] Prepare you pen Remove the cap Pull off the pen cap and wipe the rubber [MEDICATION NAME] with an alcohol swab. Attach a needle Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose Turn the dose selector to select the number of units you need to inject. Give your injection Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. On 1/31/20 at 4:04 p.m. an telephone interview was conducted with the Consultant Pharmacist. The surveyor asked if the insulin pen wasn't primed, if that would be a significant medication error. He said I think it would be a med error. I don't think it would qualify as a significant med error since it's only 2 units. The surveyor asked about use of the [MEDICATION NAME] inhaler. The Consultant Pharmacist said, You want to wait a minute between puffs, absolutely. When the surveyor asked about the [MEDICATION NAME] error, he said I don't like pseudophed for that population, but the only possible outcome would be a runny nose. If the order called for [MEDICATION NAME] D they should give [MEDICATION NAME] D. Then the surveyor asked what the outcome would be if the [MEDICATION NAME] wasn't mixed in 6-8 ounces (oz) of water. The Consultant Pharmacist said, A small amount of water won't dissolve the [MEDICATION NAME], so then you're not getting the full dose. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. The DON said, what do you mean prime it? What's an air shot? He was not aware the insulin pens needed to be primed. The surveyor shared the [MEDICATION NAME] error with him, and the DON said they called the physician and got the one time order for the [MEDICATION NAME]. He said It should be available, yes, of course. When the surveyor shared the concern with the inhaler, the DON said The resident shouldn't be doing his own inhaler. There should be some wait time between. The nurse should have administered the medication. Review of the policy, Administering Medications, revised (MONTH) 2012, revealed the following information: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation and interview, it was determined that the facility did not ensure that one (#22) of fifty two residents reviewed was provided the right to make choices regarding her dining experience. Findings include: On 1/28/20 between 12:23 p.m. and 12:27 p.m., Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and, in a loud voice heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22. Resident #22 was observed to independently eat her lunch meal. An interview was conducted with Resident #22 at 12:39 p.m. She stated she wants to eat in the dining room. On 1/30/20, at 11:47 a.m., Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her. A dietary aide and a CNA where heard saying that she is second seating and another aide wheeled her away from the table and took her out of the dining room. On 1/30/20 at 12:25 p.m. Resident #22 was located in her room in her wheelchair, with her lunch tray on the overbed table in front of her. She was observed to be eating her lunch meal independently. She stated, I eat where I want to. An interview with the Administrator and the DON was conducted on 1/31/20 at approximately 4:30 p.m. The Administrator and DON stated that Resident #22 should be able to eat in the dining room if she wants to.

Based on resident record review and staff interview, it was determined that the facility did not ensure that the plan of care was followed related to Diabetes Mellitus, Type II, for one of five residents reviewed for unnecessary medications (#5). Findings Include: Review of the Admission Record for Resident # 5 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Resident # 5 also had a physician's orders [REDACTED]. Hold for blood sugar less than 200. Review of a care plan with a focus of Is at risk for complication related to [DIAGNOSES REDACTED]. Goal : Will remain free of s/sx (signs and symptoms) of hypo or hyperglycemic episode thru the next review date. Interventions: Administer oral medications and/or insulin per physician orders. Obtain blood sugar levels/ lab as ordered; report results to physician as needed. Review of Resident # 5's Medication Administration Record [REDACTED]. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for (MONTH) 2020 revealed the [MEDICATION NAME] Solution 100 Unit/ML (Insulin [MEDICATION NAME]): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. An interview was conducted with the Director of Nursing, on 1/31/2020 at 11: 20 a.m. He reviewed the Medication Administration Records and confirmed that the [MEDICATION NAME]was being administered when it was supposed to be held for blood sugars under 200. He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 p.m. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he did not like this type of order as it put more stuff on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5.

Based on observations, record review, interviews, and policy review the facility failed to provide care and treatment in accordance with professional standards of practice for two(#34, #108) of 53 residents reviewed in regards to 1) not ensuring physician's orders [REDACTED]. Findings included: Resident #34 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment dated [DATE], Section H, bladder and bowel, indicated Resident #34 had an indwelling catheter. Upon review of the current physician's orders [REDACTED]. Review of the treatment administration record (TAR) for the month of (MONTH) showed catheter care orders were not obtained. On 1/29/20 at 9:53 a.m.an observation and interview were conducted with Resident #34. Resident #34 said she has a UTI (urinary tract infection) that started in December. She also said she is getting IV antibiotics for the UTI. The surveyor observed that Resident #34 had a left upper arm midline IV line, and a leg bag of which the contents were unable to be observed. A review of nurse's notes in the medical record revealed that upon admission on 1/9/20, a [MEDICATION NAME] and Foley catheter were noted. The nurse's note dated 1/27/20 reflected a new order to initiate contact isolation, insert midline, start Amakacin 10mg/kg daily x 7 days, pharmacy to dose, ID (Infectious Disease Physician) to consult and CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) on 1/30/20. IV team called for midline insertion. Further review of the nurse's notes showed a note entered on 1/29/20, which indicated Foley in place draining clear, amber urine, Precautions continue. IV site is CDI (clean, dry, intact) and flushes well. The 1/30/20 nurse's note showed Resident continues on IV antibiotic for ESBL ( extended spectrum beta-lactamase) in urine. Foley is in place and patent. Contact precautions continue. IV site is clean and dry. Flushes without difficulty. No other notes discuss catheter care, nephrostomy tube, or midline care. On 1/31/20 at 12:05 p.m. an observation was conducted with Staff L, CNA (Certified Nurses Assistant) during catheter care. Staff L, CNA entered Resident #34's room after knocking. Staff L, CNA explained the procedure to Resident #34. Staff L, CNA put on PPE (personal protective equipment) to include a gown and gloves. Staff L, CNA prepared a wash basin with water, which Staff L, CNA placed on the bedside table where there was a towel with supplies. Staff L, CNA used a soapy wash cloth to clean from the catheter insertion site downward. Staff L, CNA changed washcloths after each downward motion, wiping the catheter tubing from top to bottom. Staff L, CNA dried the areas with a dry wash cloth. The surveyor asked if she could look at the nephrostomy tube site. Resident #34 said it was okay. Staff L, CNA turned Resident #34 to her right side. The nephrostomy tube site was free from signs or symptoms of infection; no inflammation, redness, or drainage was observed. However, the dressing was wrapped around the tube beneath the site. There was also no odor present. Further review of physician's orders [REDACTED]. An interview was conducted with Staff K, LPN on 1/30/20 at 6:03 p.m. Staff K, LPN (Licensed Practical Nurse) confirmed Resident #34 had a midline in her left arm. Staff K, LPN also confirmed Resident #34 does have a catheter. The surveyor asked who provided care to the catheters and midline. Staff K, LPN said IV care would be herself. Staff K, LPN said it's documented on the resident's MAR (Medication Administration Record), and she documents it on the skilled notes. She said both herself and the CNAs document catheter care. It's documented on the TAR and ADL (Activity of Daily Living) sheets. Normally I assist her at night when we turn and reposition her. We do the Foley care. Staff K, LPN said there should be orders for the midline and catheters. Staff K, LPN reviewed the orders in the electronic record and confirmed there weren't any orders for the catheters or midline. Staff K, LPN also said they're not on the TAR either. Staff K, LPN said the midline gets flushes, and it requires dressing changes once a week. 2.On 01/28/20 at 10:01 a.m. Resident #108 was lying in bed and smiled with verbal stimuli. Her right hand was on top of the blanket that presented with a hematoma (localized bleeding outside of blood vessels, due to either disease or trauma including injury). Just lateral to the hematoma a crescent shape skin tear was noted with dried blood residual. The resident was asked if she knew what happened to the hand. She was unable to verbalize what had occurred. On 1/29/2020 at 11:10 a.m. Resident #108 was sitting in her wheelchair as a staff member was transporting her in the hallway. Resident #108 right hand was resting on her lap as it appeared the same as it had the day prior. On 01/29/2019 at 5:54 p.m. Resident #108 resident was observed in her bedroom with Certified Nursing Assistant N (CNAN) who was sitting next to her. Resident #108 was turned to her right in her wheelchair as the CNA was sitting to her right. CNAN at that time picked up the spoon off the plate that contained food. As the CNA attempted to assist the resident, the resident raised her left hand and swung her hand out blocking the spoon from going to her mouth. CNA N was asked if she knew what had happened to the resident's right hand. The CNA looked at the resident hand and said it looks like a skin tear. She said I don't care for Resident #108 that often indicating it had been a while and she didn't know what had happened. Medical record review was conducted for Resident #108 that revealed on the Admission Record information form that she was in her early nineties and been residing at the facility for over a year. The [DIAGNOSES REDACTED]. The assessment section of the record included a weekly skin check/nurse form was reviewed that was dated on 1/27/2020. The box was checked 'no' indicating the resident doesn't have any new skin impairments that have not been previously noted. The resident's care plan was reviewed with a focus for a potential of skin impairment/ pressure ulcers related to impaired mobility, incontinence of bowel and bladder, fragile skin that was dated on 6/19/2018 with a goal date of 3/23/2020. Interventions included to observe skin for an s/sx (signs and/or symptoms) of breakdown during cares and notify physician of any s/sx of skin breakdown/pressure ulcer if noted. The nursing process notes were reviewed that were found without an entry related to the skin tear to Resident #108's right hand. On 01/30/20 at 10:33 a.m. an interview was conducted with CNA B as she was in Resident #108's bedroom. Resident #108 smiled when approached and was cooperative with the CNA as she combed her hair and placed a scarf around her neck. The CNA was asked about the resident's right hand. She stated I worked on Saturday and that wasn't there. I was off on Sunday and when I came in on Monday, I seen it right away it was torn. She stated I told the nurse right way. So, she could cover it up or put something on it. I wanted to know what happened. She was asked if she had found out what had happened. She said no one has told me anything. At 10:56 a.m. an interview was conducted with the Resident #108's Unit Manager (UM) about the process of skin checks. She said that there is a form that is performed weekly we call the skin sweep. And if there are concerns in between the weekly skin sweep it would be documented at that time. She was asked if there was one for Resident #108. The UM at that time reviewed the electronic medical record and stated, I didn't find one. She confirmed at that time it is her expectation that if a skin tear was found the MD(physician) is notified to obtain a treatment. The UM said additionally, an incident report would be started along with an investigation. The UM confirmed that there was no report or notification to the MD. A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer). Skin tears are acute wounds, which have a high probability of becoming complex chronic wounds, if not properly managed. https://www.woundsource.com/patientcondition/skin-tears

Based on interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, resident's physician, resident's son, review of clinical and hospital records, and the facility's policies and procedures it was determined that the facility administration failed to utilize resources effectively and efficiently to protect the safety of 1 (#1) out of 10 sampled residents to have physician orders [REDACTED]. The facility administration failed to ensure that Resident #1's orders were communicated to staff and followed for the diet status of nothing by mouth. Facility administration failed to ensure that policies and procedures were in place that identified residents with nothing by mouth status. The facility provided a tray of food to Resident #1 which was observed by staff as she consumed it and her son who found food fragments on her clothing. The facility failed to provide supervised care to keep the resident safe in her environment which resulted in an emergent hospitalization and Resident #1 becoming dependent on the use of oxygen supplementation within 24 hours of the inaccurate oral intake. The facility then failed to provide Resident #1 with the correct ordered oxygen level that resulted in respiratory arrest and a return to the hospital just hours after readmission. The administration failed to respond to ensure other residents were protected from similar problems after discovering errors in carrying out the resident's diet and oxygen orders. This resulted in findings of Immediate Jeopardy on 11/30/2018 which were removed and reduced to a D on 11/30/2018. Findings Included: 1. The facility provided a copy of their job description for Administrator dated on 1/1/2015. Purpose of your job position: The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with the current federal, state, and local standards guidelines and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times. Delegation of Authority: As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the facilities programs and activities in accordance with guidelines issued by the VP of Operations. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Assist department directors in the development, use, and implementation of departmental polies and procedures and professional standards of practice. Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. Interpret the facility's policy and procedure to employees, residents, family members, visitors, government agencies, etc., as necessary. Resident Rights Ensure that the residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. Report all allegations of resident abuse and/or misappropriation of resident property. 2. The facility provided a copy of Director of Nursing Services job description that was dated on 1/1/2015. Purpose of your job position: The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority: As Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. You are charged with carrying out the resident care polices established by the facility. Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop and implement a nursing service organization structure. Make written and oral reports and recommendations to the administrator concerning the operation of the Nursing Service Department. Develop methods for coordination of nursing services with other resident's services to ensure the continuity of the resident's total regimen of care. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Nursing Care Function: Provide the administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs. Ensure that direct nursing care be provided by LPNs, CNAs, and/ or a nurse aid trainee qualified to perform the procedure. Review nurses notes to ensure that they are informative and descriptive of the nursing care being provided. That they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Develop a written care plan of care (preliminary and comprehensive) for each resident that identifies the problems or needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care. Ensure that all personnel involved in providing care to the resident are aware of the residents care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident Review nurses notes to determine of the care plan is being followed. Resident Rights: Review complaints and grievances made by the resident and make a written or oral report to the administrator. Follow facility's established procedures. Maintain a written record of the resident's compliant and or grievances that indicates the action taken to resolve the complaint and the current status of the compliant. Report all allegations of resident abuse and or misappropriation of resident's property. 3. On 11/28/2018 at 12:10 p.m. an interview was conducted with the Director of Nursing (DON) after asking for copies of Resident #1's medical record. At that time she confirmed she was aware of the narrative nursing note that was dated on 10/21/2018 stating that Resident #1 had been witnessed eating a meal tray. The DON said that LPN C had been orienting LPN A to the unit on 10/20/2018. She stated that we spoke to LPN C and she denied seeing a tray of food in front of the resident. She said that we could not find out if anyone had given her a tray. She stated that we looked at Resident #1's hospital reports and it didn't identify aspiration as she pointed to the record. It said [MEDICAL CONDITION]. 4. Resident #1 was admitted to the facility on [DATE]. She was transferred out to the hospital on three separate occasions during her forty one days at the facility. Her last transfer to the hospital was on 10/22/2018. She never returned to the facility. The facility Cumulative [DIAGNOSES REDACTED]. Resident #1's Brief Interview for Mental Status was conducted on 9/13/2018. It was determined at that time that the score was 11. Total Score of 8-12 indicated moderately impaired cognition. Medical record indicated that she was dependent on the facility licensed staff to provide her nutritional intake through her [MEDICAL CONDITION] tube. The 3008 form dated 9/12/2018 contained Dietary Instructions: NPO Tube Feeding Insertion date: 8/30/2018. 5. The Resident's History and Physical dated on 8/27/2018 reflected: [AGE] year old female with a history of dysphagia and mild dementia. She was getting out of bed when she had a fall and complained of right lower extremity pain and patient brought to Emergency Department (ED) for further evaluation. The case was also discussed with the patient's son who stated the patient was confused at the time of the fall and in the last few weeks the patient had problems with eating. A Swallow evaluation (eval) was done at the bedside by the speech therapist who recommended a video assisted swallow test which showed the patient had a large Zenker's Diverticulum. Zenker's Diverticulum (ZD) is an outpouching of tissue through Killian's triangle thought to be due to cricopharyngeal muscle dysfunction. This relatively uncommon disorder, which occurs more commonly in the elderly, presents with symptoms of dysphagia. Dysphagia (is the medical term used to describe difficulty swallowing) occurs in 80-90% of patients. Regurgitation of undigested foods, halitosis (bad breath), and hoarseness can also occur. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30-40% of patients describe chronic cough and repeated episodes of aspiration (the accidental sucking in of food particles or fluids into the lungs), some with subsequent pneumonia. Ryan Law, Todd H. Baron, in Clinical Gastrointestinal Endoscopy (Third Edition), 2019 https://www.sciencedirect.com/topics/medicine-and-dentistry/zenkers-diverticulum. 6. On 10/19/2018 the resident returned to the facility and the staff rescinded her previous orders. admission orders [REDACTED]. The facility was not able to provide written orders from the hospital admission. Review of the resident's progress notes dated 10/19/2018 showed [MEDICATION NAME] 1.2 can bolus 5 times a day flush peg with 240 ml every shift. Continue diet orders per RD (Registered Dietitian). Review of the MAR (Medication Administration Record) showed the initial physician orders [REDACTED]. There was no order for NPO status. 7. On 11/27/2018 at 1:00 p.m. an interview was conducted with Speech Language Pathologist, Staff N, For Resident #1, she stated that she had a [MEDICATION NAME] Swallow test conducted at the hospital. Which showed strictures and Zenker's Diverticulum. So she was not able to have any oral intake. She was not a candidate for Speech services and she remained on an NPO per diet order while here. When asked if she was present for all her meal times for Resident #1, she stated no. 8. On 10/21/2018 at 3:44 p.m. (15:44) Resident #1's Narrative Nursing Notes showed: Writer went into resident's room to assess lung sounds due to sounds of congestion upon entering resident's room. Bilateral lobes where auscultated and adventitious lungs sounds noted. Blood pressure 145/84, heart rate - 87, Temperature - 97.7 (oral) and resident's oxygen (O2) stats were fluctuating between 84%-87% Room Air (RA). Oxygen (O2) at (@) 2 Liters (2L) applied (writer bumped O2 to 3L). Writer notified supervisor and placed call to the resident's doctor and notified her of change in condition as well as writer witnessing resident eating lunch on 10/20. Per the doctor transfer patient to emergency room (ER). Writer rechecked resident O2 sats (saturation) and they were 77% NC (nasal cannula) @ 3L (3 liters of oxygen). Writer called 911 to transport resident to hospital and son was notified. A review of the Nursing Home to Hospital Transfer form dated 10/21/2018 showed: Reason for transfer: Respiratory Arrest. 9. Review of The Transporting County Fire Rescue report showed that a call was received on 10/21/18 at 12:54:04 p.m. Patient contact occurred at 1:01 p.m. (13:01:06) Upon arrival 96 y/o (year old) found sitting upright in nursing home bed. Pt. is alert to her normal mentation per staff. ABC (airway, breathing, circulation) intact. Pt. has a regular and normal radial pulse. Staff explained they noticed prior to calling EMS that pt's O2 saturation (sats) were in the seventies. Lung sounds assessed and rales present globally. 1:04 p.m. (13:04:08) Oxygen saturation level (SaO2) 75% (on room air) Respiration (Resp): 27 1:09 p.m. (13:09:31) SaO2 74% Resp: 27 1:14 p.m. (13:14:14) SaO2 93% Resp: 24 Normal pulse oximeter (SaO2) readings usually range from 95 to 100 percent. Values under 90 percent are considered low, according to: https://www.mayoclinic.org/symptoms/hypoxemia 10. Review of the emergency room Report dated 10/21/2018 at 1:19 p.m. (13:19) History of Present Illness: The patient presents with difficulty breathing. The onset was today. The course/duration of symptoms is constant. Degree at present moderate. The exacerbating factors are none. The relieving factors are none. Risk factors consistent of immobility. Prior episodes: none. [AGE] year old female from Excel Rehab with Past Medical History (PMHx) including [DIAGNOSES REDACTED], dysphagia, malnutrition, and dementia presents to ED (Emergency Department) via EMS (Emergency Medical Services) for evaluation of dyspnea onset today. Patient is on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) upon arrival to the ED. Patient denies hx (history) of [MEDICAL CONDITIONS]. General: Alert, moderate distress, nontoxic appearing, very frail, very debilitated, not anxious. Respiratory: Breath sounds are equal, respirations: dyspneic (having difficulty breathing), tachypnea (abnormal rapid breathing), breath sounds: crackles throughout entire lung fields bilaterally. CXR performed on 10/21/2018. Radiograph demonstrates vascular congestion and interstitial [MEDICAL CONDITION] suggestive [MEDICAL CONDITION]. 11. On 11/27/2018 at 2:45 p.m. an interview took place with Resident #1's Primary Physician. When asked about familiarity with Resident #1, the Physician said Yes, I saw Resident #1. She was admitted in September. She had a history of [REDACTED]. She was a very sweet lady, but she was very demented. I remember her well because she was always hungry. The Physician stated that the resident would say frequently 'that they forgot about me. They didn't bring me my breakfast or lunch' she was not aware that she couldn't eat. The Physician confirmed that whatever you put in front of her she would eat. When asked if the resident had any history or [DIAGNOSES REDACTED]. As far as my evaluations of her, she did not have heart failure. I saw her at least two times each week. The only symptom she had, was some bilateral lower extremity [MEDICAL CONDITION]. But she was on tube feeding and mostly sitting up, so it was not such a surprise if she had some [MEDICAL CONDITION] in her legs. She had no other signs that would indicate [MEDICAL CONDITIONS]. She had no shortness of breath or respiratory issues. She was not on any oxygen. When asked about the resident's multiple visits to the hospital during her stay at the facility, the Physician said I don't have her records in front of me, but she did have between two to three visits to the hospital while she was here. When she was admitted on (MONTH) 19th, she had just come back from the hospital. She had abdominal pain, and it was believed that her gastrostomy tube had dislodged. She had a Zenker's Diverticulum and dysphagia. So she was on a strict NPO diet; with full enteral nutrition. The Physician was asked about the resident's last hospital visit in October. She stated So, the resident returned from the hospital on [DATE]. I was notified by the nurse on 10/21/18, I believe it was before lunchtime, that Resident #1 had a change in her condition. The nurse told me that Resident #1 was in respiratory distress, and her oxygen saturation was very low. She also told me that the resident had been fed the day before (10/20/18), and that Resident #1 had eaten almost 100% of her meal. I told her, if that is the case, then we need to send the resident to the emergency room (ER) because she might have [MEDICAL CONDITION]. She had Zenker's Diverticulum and dysphagia, so giving her oral food could cause [MEDICAL CONDITION], because of aspiration, and also from food being stuck in there. In regards to oxygen orders, the Physician said I never ordered oxygen for this resident. I saw the nursing note stating that the nurse put Resident #1 on two to three Liters of oxygen before sending her to the hospital. If there was an order for [REDACTED]. I just told them to send her straight to the emergency room . Then on Monday, (10/22/18), the facility called me to let me know that the resident had returned, with orders from the hospital for 7 liters of oxygen. I was told that the resident looked very cyanotic. I called the hospital and told them that I could not accept a resident that needed more than 5 Liters of oxygen. I did not accept the resident and she was returned to the ER. I didn't hear anything else from the hospital until the next day, Tuesday. The ER physician called and informed me that the resident had passed away, and asked if I could sign the death certificate. I told him I was not in the hospital and the resident was not in my care when she passed away, so I would not sign the death certificate. That same day, I received calls from both the hospital and the funeral director, regarding signing the death certificate. But I refused to sign it. I told the Director of Nursing (DON) at this facility that the medical examiner would question why I did not sign the death certificate. The Physician stated that I told the DON that an adverse event had occurred at the facility and she needed to report it. She was informed that the facility did not have an adverse report for Resident #1 related to eating a meal. The Physician said that she wasn't aware it had not been reported. She then stated at one time I was a Medical Director for a facility and I know what needs to be reported. 12. On 11/29/2018 at 10:00 a.m. a phone interview was conducted with Licensed Practical Nurse A. She confirmed that she worked at the facility on an as needed basis. LPN A was able to recall the weekend and the events that transpired with Resident #1. She stated that Saturday (10/20/18) was her first day at the facility. She was training on Resident #1's unit with LPN C. She recalled that it was around the mid-morning time when they entered Resident #1's bedroom. She stated that a tray of food was in front of Resident #1 and she watched while Resident #1 ate. She was asked and stated that she did not recall seeing any issues with the resident chewing and swallowing the food. She was unable to recall if it was a breakfast or lunch tray. LPN A was unsure if LPN C saw the tray of food. She stated that the next day, Sunday (10/21/18), she worked the same unit on her own. She said that Resident #1 did not receive a meal tray so we called the kitchen for her breakfast tray. The kitchen said that they didn't have a diet order for her. We didn't receive a tray for her. LPN A stated that she had given the resident her medications and her tube feeding that morning and she was alert and comfortable at that time. She stated that right before lunch she entered Resident #1's bedroom and she could hear her having adventitious breathing immediately upon entering the room. She said, I called the MD and then 911. 13. On at 11/28/2018 at 1:15 p.m. an interview was conducted with LPN C. She confirmed that she trained LPN A on Saturday (10/20/2018). She stated that I don't ever remember seeing this women (Resident #1) with a tray in front of her. She said she recalled that the resident kept saying that she was hungry. She wanted food and wished she could have food. I don't know if she really understood what I was telling her about the food. I tried to explain to her when I would give her food in her tube. I knew that she was not supposed to get a tray of food. 14. The facility provided a copy of their Menu that was dated for (MONTH) 19 - (MONTH) 20, (YEAR). Regular diet: 10/19/18 Friday: Breakfast: Blueberry Pancake Squares, Choice of Eggs, Syrup, Margarine, OJ/Apple/Cranberry juice, 2% Milk, and Coffee/Tea. Lunch: Oven Baked Fish, Paprika Roasted Potato, Broccoli, Biscuit, and Oreo Cookie Blondies. Alternative: Black Jack Burger, Lettuce/Tomato & Onions. Dinner: Hot Open-faced Turkey Sandwich, Mashed Potatoes, California Vegetable Blend, Strawberry and Banana Cup, and Margarine. Alternative: Sausage and Sauerkraut. 10/20/18 Saturday: Breakfast: Hot or Cold Cereal, Scrambled Eggs, Harvest Pumpkin Muffin, Margarine, OJ/Apple/Cranberry, 2% Milk, Coffee/Tea. Lunch: BBQ Chicken Breast, Green Beans and Mushrooms, Macaroni and Cheese, Wheat Bread, Fruited Gelatin. Alternative: Cottage Cheese Fruit Plate. 15. On 11/28/2018 at 4:15 p.m. a phone interview was conducted with Certified Nursing Assistant (CNA) B, she stated that she worked the second shift at the facility, and worked on 10/20/2018. She explained her normal routine after she arrived at the facility, which is at 3:00 p.m. She makes rounds to see all of the residents that she will be caring for. She stated that on 10/20/2018 right after the start of her rounds Resident #1's roommate put on the call light. She said that she entered the room and a therapist also entered at the same time. CNA B confirmed that Resident #1 had a tray of food in front of her and was eating it when she approached her. She said that the tray contained regular food and added that it was not mechanical or pureed. She was unable to recall what food was on the tray. She said that food was missing from the tray. She could not recall how much was missing or had remained. CNA B said that the therapist removed the tray from the resident and took it outside, out of the room. She said she did not know the therapist's name. 16. Medical record review of the meal intake that was documented by the Certified Nursing Assistants for Resident #1 revealed: On 10/19/2018 the dinner meal was documented at 76-100% (coded as a 3). On 10/20/2018 her breakfast and lunch amount eaten was 76-100%. And her dinner meal was documented at 26-50 % (coded as a 1). On 10/21/2018 the amount eaten 51-75% for breakfast and for lunch. The documentation of the two day meal intake indicated four separate staff members. 17. During a phone interview on 11/29/2018 at 2:00 p.m., the Physical Therapist (PTO) who evaluated Resident #1 on 10/20/18, said I am familiar with Resident #1, but I do not have her records in front of me. I have a full-time job elsewhere, so I only work at the facility on a PRN (as needed) basis, and mostly just on the weekends. I will have to answer based on memory from that time. The PTO was asked about her familiarity with Resident #1, and she said I believe she was able to communicate, at least enough to answer simple questions, like 'do you have any pain?' She was able to nod or say yes or no. She needed maximum assistance with mobility and transfers. I do not know about the level of assistance she needed for feeding, because that is not my area, and I do not deal with that. When asked to describe her visit with Resident #1 on (MONTH) 20, (YEAR), the PTO said I can't remember exactly what time I entered her room. I entered the facility around 12:00 p.m. and saw her shortly after that. I entered the room by myself, there was no one with me. She said that she was alone in her room. Resident #1 was sitting at the bedside. She was not eating, and there was no tray in front of her. If she had been eating, I would not have entered her room, because that is not polite. In regards to removal of food trays from resident rooms, the PTO stated I would never remove a tray from the room. That is not part of my job. 18. Review of Hospital Discharge Summary dated 10/22/2018 Showed: Nursing home called EMS because the patient was congested and had an O2 saturation in the 70s. Discharge Diagnosis: [REDACTED]. Weaned from [MEDICAL CONDITION] to nasal cannula. Remains stable on nasal cannula and oxygen is arranged for her home living situation. Intravenous (IV) to Oral (PO) [MEDICATION NAME] had promoted good diuresis (an increased excretion of urine). Breathing improved. 19. On 10/22/2018 the resident was transferred back to the Nursing Home. The time she arrived to the facility was not documented in Resident #1's medical record. Review of Transportation records from the Transcare Non-Emergency Transport Service show: Patient (Pt.) is found at hospital on humidified O2 @ 10 LPM via Nasal Cannula (NC) due to SPO2 90%. Time: 14:11 Monday, (MONTH) 22, (YEAR) -event transfer of patient care time. 20. Review of Nursing Home to Hospital Transfer Form dated 10/22/2018 time 6:54 p.m. Reason for transfer: Respiratory Arrest HR 102 O2 Sat 84% Nursing Home to Hospital Transfer Form (additional information) dated on 10/22/2018 time 7:16 p.m.: Additional Relevant information: Resident re-admit from hospital with O2 sat between 80-85% on 5 liters of O2 continuous via nasal cannula, orders from MD send resident back to the ER. 21. On 11/27/2018 at 9:57 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated that the facility had only two Five Day Reportings since their last annual recertification survey that commenced on 11/02/2018. She stated that the first Five Day Report was sent in during the annual survey. That report was about herself and a resident that currently resides at the facility. The NHA stated that the second Five Day Report was for Resident #1. She revealed after their investigation it was determined as neglect (# ). The NHA described the results of their investigation on 10/22/2018 Resident #1 was readmitted to the facility. The admitting Registered Nurse (RN) U went to the nursing meeting while Resident #1 was still on the stretcher. The NHA stated Instead of the nurse assessing the patient to see if she had everything that she needed. She opted to go to the nursing meeting. The NHA said that they conducted an investigation that revealed at 4:00 p.m. the second shift nurse informed RN U that Resident #1 was having problems breathing. They immediately went to her bedroom and found Resident #1's skin color ashen in appearance. At that time they increased the oxygen up to 5 liters. She stated Resident #1 had been on oxygen at 2 liters for 90 minutes during that time. Her SPO2 was at 84%. They contacted the Physician and told him of the resident's vital signs. The Physician ordered them to transfer Resident #1 back to the hospital. The NHA stated she had asked RN U if she informed the Director of Nursing that she was getting a new admission. She stated that she had not. The NHA said that she had then asked RN U what she thought was a greater priority going to the nursing meeting or admitting a resident. She told me going to the nursing meeting. RN U had denied that the transportation personnel told her that Resident #1's oxygen level needed to be at 7 liters. The NHA said that RN U no longer works at that facility. Prior to the oxygen incident RN U had received several other disciplinary actions. One was related to a [MEDICAL TREATMENT], post fall education, safe medication administration, and education on the admission process. She stated that according to our disciplinary process the first thing we did was suspend her. The NHA said after our investigation, we ended up terminating her. We additionally reported her to the Florida Board of Nursing. The NHA stated that on all new admissions we strive to ensure that the equipment is here and available for the residents when they arrive. She said that we had a concentrator that delivers up to 10 Liters. The NHA was asked if the oxygen concentrator could be observed. She called a staff member on the phone and stated out loud that it had been returned to the supplier. 22. Review of the emergency room Report showed: That the Mode of arrival: ambulance 10/22/2018 8:08 p.m. (20:08:00) The patient presents with difficulty breathing. The onset 2 days ago. The course duration of symptoms is constant and worsening. Degree of onset moderate. Degree at present is moderate. The relieving factor is oxygen. Prior episodes: multiple ED visits. [AGE] year old female with a past history including dementia, femur fracture, [DIAGNOSES REDACTED], dysphagia, and malnutrition presents to the ED via EMS from Excel Rehab for evaluation of worsening shortness of breath and difficulty breathing that has been going on for 2 days. She was discharged from the hospital 6 hours prior to ED arrival. She was sent back to her rehab facility on 7L O2 nasal cannula, but per EMS the facility is only able to administer up to 5L and placed her on that. The patient rapidly fell into dyspnea, so the facility sent her back to the ED. Patient refused [MEDICAL CONDITION] en route to the ED and is currently refusing any interventions. Review of Chest x-ray dated on 10/22/2018 at 8:52 p.m. (comparison: 10/21/2018) showed: Impression: Worsening bilateral lung infiltrates and effusions either all related to [MEDICAL CONDITION] or a combination of [MEDICAL CONDITION] and pneumonitis. Initially patient was refusing ER care except for oxygen via NC. After some time, she agreed to labs and IV. Patient chest x-ray reviewed with her [MEDICAL CONDITION]- changes present. Patient states she does not want any further treatment as in refusing [MEDICATION NAME] after receiving [MEDICATION NAME]. She stated nitro makes her very nauseated. She is agreeable to hospice and has mental capacity to make this decision. She had been a hospice patient before. emergency room addendum: (dated 10/23/2018 at 6:26:00) She was sent to ED by the facility for further evaluation by hospice. Pt is awaiting evaluation by hospice who told previous ED physicians that they could not come until later this morning. Shortly after sign-out I called case management, 7:00 a.m., clinically the patient appears to be activity dying. I discussed the case with case management day shift and they recommended stat palliative care consultation she will attempt to get hospice to come in and see the patient. Re-examination/Revaluation Time: 10/23/18 07:40 Notes: Palliative care at bedside. Requesting de-escalation of oxygen. Awaiting hospice. Time: 10/23/18 08:24:00 Notes: Patient passed away peacefully. Nursing at bedside. 23. On 11/29/2018 at 11:45 a.m. a phone call was received from a state agency Investigator. She stated that she had received a copy of Resident #1's death certificate. The cause of death per the Investigator: [MEDICAL CONDITIONS]. 24. On 12/03/2018 at 11:16 a.m. a phone interview was conducted with Resident #1's son. He said that his mother had lived with him for two years prior to her falling. The son stated that she had only taken one type of medication before going into the hospital. That was for swelling to her ankles. He denied that she ever used oxygen. He stated that he went to the facility to see her. When he arrived there was food all over her and in the bed. He stated that was two or three days before she passed. Resident #1's son said that normally they had a sign up on the wall or the door that said not to feed her but there was no sign that night. The son stated that she is not supposed to get any food by mouth. He added that she also had water on her bedside table that was positioned right in front of her. And that she was capable of picking it up and drinking from it. He was asked what she had eaten. He said that it looked like bread crumbs. She must have had something that was bread. She did not say what the food was, just that it was lousy. Resident #1's son was asked if he had told anyone of his concern when he was at the facility. He said that he had told the assistant. And you know how that goes they just tell you to talk to the nurse. The son was asked if

Based on interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, resident's physician, and review of clinical and hospital records and the facility policies and procedure it was determined that the facility failed to ensure an alleged violation of neglect was identified, and reported immediately, to the governing agency, in accordance with the State Law and thoroughly investigated for one (#1) out of ten sampled residents. The facility failed to protect Resident #1 from consuming a tray of food that could cause [MEDICAL CONDITION], as confirmed by the resident's Physician. Failure of the facility administrative staff to identify and immediately report an alleged violation of neglect resulted in findings of Immediate Jeopardy on 11/30/2018 which was removed on 11/30/2018 and reduced to the scope and severity of D. Findings Included: 1. A review of the facility Policy/Procedure titled Reporting Accidents and incidents that did not contain a date. Intent: It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal regulations. Procedure: The facility will ensure that: b. Each resident receives adequate supervision and assistance devices to prevent accidents. The facility will develop and implement an accident and incident reporting system that will report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. The facility will develop appropriate measures to minimize the risk for adverse incidents to residents, including, but not limited to, education and training in risk management and risk prevention for all non-physician personnel, as follows: The facility will conduct an internal risk management and quality assurance program which will include the use of incident reports to be filed with the risk manager and facility administrator. The risk manager shall have free access to all resident records of the licensed facility. As part of the each internal risk management and quality assurance program, the incident reports shall be used to develop categories of incidents, which identify problem areas. Once identified, procedures will be adjusted to correct the problem areas. The facility will for purposes of reporting to the agency will use the term adverse incident which means: an event over which facility personnel could exercise control and which is associated in whole or in part with the facility's intervention, rather that the condition for which such intervention occurred, and which results in one of the following: Death Any condition that required the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather that the resident's condition prior to the adverse incident. The facility will initiate an investigation and will notify the agency within 1 business day after the risk manager or his or her designee has received a report. Abuse, neglect or exploitation must be reported to the agency as requires by 42 C.F.R.s. 483.13 © and to the department as required n chapters 39 and 415. 2. The facility was entered on 11/27/2018, at 9:00 a.m., the Nursing Home Administrator and Director of Nursing were asked for a copy of their accident/incident monthly log. The facility provided a copy of their Accident/Incident Monthly Log Follow -Up. The log did not contain Resident #1 on it for the month of (MONTH) (YEAR). Review of an Abuse Protection and Response Policy provided by the facility that did not contain a date showed: Neglect: is the failure of the facility, its employees or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. On 11/27/2018 at 9:57 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated that the facility had only two Five Day Reportings since their last annual recertification survey that commenced on 11/02/2018. She stated that the first Five Day Report was sent in during the annual survey. That report was about herself and a resident that currently resides at the facility. The NHA stated that the second Five Day Report was for Resident #1. She revealed after their investigation it was determined as neglect (# ). The investigation was related to Resident #1 not receiving her ordered oxygen. 4. Medical record review was conducted for Resident #1 which indicated she was admitted to the facility on [DATE]. She was transferred out to the hospital on three separate occasions during her forty one days at the facility. Her last transfer to the hospital was on 10/22/2018. She never returned to the facility. The facility Cumulative [DIAGNOSES REDACTED]. The Resident's History and Physical dated on 8/27/2018 showed: [AGE] year old female with a history of dysphagia and mild dementia. She was getting out of bed when she had a fall and complained of right lower extremity pain and patient brought to Emergency Department (ED) for further evaluation. The case was also discussed with the patient's son who stated the patient was confused at the time of the fall and in the last few weeks the patient had problems with eating. A Swallow evaluation (eval) was done at the bedside by the speech therapist who recommended a video assisted swallow test which showed the patient had a large Zenker's Diverticulum. Upon further review of History and Physical, completed radiology imaging studies had been performed on 8/26/2018 which revealed a chest x-ray. Final Impression: no acute cardiopulmonary disease. Chronic changes similar to 10/13/14 exam. Resident #1's Brief Interview for Mental Status was conducted on 9/13/2018. It was determined at that time that the score was 11. Total Score of 8-12 indicated moderately impaired cognition. Resident #1 was dependent on the facility licensed staff to provide her nutritional intake through her [MEDICAL CONDITION] tube. The 3008 form, dated 9/12/2018, contained Dietary Instructions: NPO Tube Feeding Insertion date: 8/30/2018. 5. On 10/19/2018 the resident returned to the facility from the hospital and the staff rescinded her previous orders. admission orders [REDACTED]. The facility was not able to provide written orders from the hospital admission. Review of the resident's progress notes dated 10/19/2018 reflected [MEDICATION NAME] 1.2 can bolus 5 times a day flush peg with 240 ml every shift. Continue diet orders per RD (Registered Dietitian). Review of the MAR indicated [REDACTED]. There was no order for NPO status. 6. On 10/21/2018 at 3:44 p.m. (15:44) Resident #1's Narrative Nursing Notes showed: Writer went into resident's room to assess lung sounds due to sounds of congestion upon entering resident's room. Bilateral lobes where auscultated and adventitious lungs sounds noted. Blood pressure 145/84, heart rate - 87, Temperature - 97.7 (oral) and resident's oxygen (O2) stats were fluctuating between 84%-87% Room Air (RA). Oxygen (O2) at (@) 2 Liters (2L) applied (writer bumped O2 to 3L). Writer notified supervisor and placed call to the resident's doctor and notified her of change in condition as well as writer witnessing resident eating lunch on 10/20. Per the doctor transfer patient to emergency room (ER). Writer rechecked resident O2 sats (saturation) and they were 77% NC (nasal cannula) @ 3L (3 liters of oxygen). Writer called 911 to transport resident to hospital and son was notified. A review of the Nursing Home to Hospital Transfer form, dated 10/21/2018, showed: Reason for transfer: Respiratory Arrest. 7. On 11/27/2018 at 1:00 p.m. an interview was conducted with Speech Language Pathologist, Staff N, For Resident #1, she stated that she had a [MEDICATION NAME] Swallow test conducted at the hospital. Which showed strictures and Zenker's Diverticulum. So she was not able to have any oral intake. She was not a candidate for Speech services and she remained on an NPO per diet order while here. When asked if she was present for all her meal times for Resident #1, she stated no. 8. On 11/29/2018 at 10:00 a.m. a phone interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that she worked at the facility on an as needed basis. LPN A was able to recall the weekend and the events that transpired with Resident #1. She stated that Saturday (10/20/18) was her first day at the facility. She was training on Resident #1's unit with LPN C. She recalled that it was around the mid-morning time when they entered Resident #1's bedroom. She stated that a tray of food was in front of Resident #1 and she watched while Resident #1 ate. She was asked and stated that she did not recall seeing any issues with the resident chewing and swallowing the food. She was unable to recall if it was a breakfast or lunch tray. LPN A was unsure if LPN C saw the tray of food. She stated that the next day, Sunday (10/21/18), she worked the same unit on her own. She said that Resident #1 did not receive a meal tray so we called the kitchen for her breakfast tray. The kitchen said that they didn't have a diet order for her. We didn't receive a tray for her. LPN A stated that she had given the resident her medications and her tube feeding that morning and she was alert and comfortable at that time. She stated that right before lunch she entered Resident #1's bedroom and she could hear her having adventitious breathing immediately upon entering the room. She said, I called the MD and then 911. 9. On 11/28/2018 at 4:15 p.m. a phone interview was conducted with Certified Nursing Assistant (CNA) B, she stated that she worked the second shift at the facility, and worked on 10/20/2018. She explained her normal routine after she arrives at the facility, which is at 3:00 p.m. She makes rounds to see all of the residents that she will be caring for. She stated that on 10/20/2018 right after the start of her rounds Resident #1's roommate put on the call light. She said that she entered the room and a therapist also entered at the same time. CNA B confirmed that Resident #1 had a tray of food in front of her and was eating it when she approached her. She said that the tray contained regular food and added that it was not mechanical or pureed. She was unable to recall what food was on the tray. She said that food was missing from the tray. She could not recall how much was missing or had remained. CNA B said that the therapist removed the tray from the resident and took it outside, out of the room. She said she did not know the therapist's name. 10. The facility provided a copy of their Menu that was dated for (MONTH) 19- (MONTH) 20, (YEAR). Regular diet: 10/19/18 Friday: Breakfast: Blueberry Pancake Squares, Choice of Eggs, Syrup, Margarine, OJ/Apple/Cranberry juice, 2% Milk, and Coffee/Tea. Lunch: Oven Baked Fish, Paprika Roasted Potato, Broccoli, Biscuit, and Oreo Cookie Blondies. Alternative: Black Jack Burger, Lettuce/Tomato & Onions. Dinner: Hot Open-faced Turkey Sandwich, Mashed Potatoes, California Vegetable Blend, Strawberry and Banana Cup, and Margarine. Alternative: Sausage and Sauerkraut. 10/20/18 Saturday: Breakfast: Hot or Cold Cereal, Scrambled Eggs, Harvest Pumpkin Muffin, Margarine, OJ/Apple/Cranberry, 2% Milk, Coffee/Tea. Lunch: BBQ Chicken Breast, Green Beans and Mushrooms, Macaroni and Cheese, Wheat Bread, Fruited Gelatin. Alternative: Cottage Cheese Fruit Plate. 11. Medical record review of the meal intake that was documented by the Certified Nursing Assistants for Resident #1 revealed: On 10/19/2018 the dinner meal was documented at 76-100% (coded as a 3). On 10/20/2018 her breakfast and lunch amount eaten was 76-100%. And her dinner meal was documented at 26-50 % (coded as a 1). On 10/21/2018 the amount eaten 51-75% for breakfast and for lunch. The documentation of the two day meal intake indicated four separate staff members. 12. Review of The Transporting County Fire Rescue report showed that a call was received on 10/21/18 at 12:54:04 p.m. Patient contact occurred at 1:01 p.m. (13:01:06) Upon arrival 96 y/o (year old) found sitting upright in nursing home bed. Pt. is alert to her normal mentation per staff. ABC (airway, breathing, circulation) intact. Pt. has a regular and normal radial pulse. Staff explained they noticed prior to calling EMS that pts's O2 saturation (sats) were in the seventies. Lung sounds assessed and rales present globally. 1:04 p.m. (13:04:08) Oxygen saturation level (SaO2) 75% (on room air) Respiration (Resp): 27 1:09 p.m. (13:09:31) SaO2 74% Resp: 275. Review of the emergency room Report dated 10/21/2018 at 1:19 p.m. (13:19): History of Present Illness: The patient presents with difficulty breathing. The onset was today. The course/duration of symptoms is constant. Degree at present moderate. The exacerbating factors are none. The relieving factors are none. Risk factors consistent of immobility. Prior episodes: none. [AGE] year old female from Excel Rehab with Past Medical History (PMHx) including [DIAGNOSES REDACTED], dysphagia, malnutrition, and dementia presents to ED (Emergency Department) via EMS (Emergency Medical Services) for evaluation of dyspnea onset today. Patient is on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) upon arrival to the ED. Patient denies hx of [MEDICAL CONDITIONS]. General: Alert, moderate distress, nontoxic appearing, very frail, very debilitated, not anxious. Respiratory: Breath sounds are equal, respirations: dyspneic (having difficulty breathing), tachypnea (abnormal rapid breathing), breath sounds: crackles throughout entire lung fields bilaterally. CXR performed on 10/21/2018. Radiograph demonstrates vascular congestion and interstitial [MEDICAL CONDITION] suggestive [MEDICAL CONDITION]. 1:14 p.m. (13:14:14) SaO2 93% Resp: 24. Normal pulse oximeter (SaO2) readings usually range from 95 to 100 percent. Values under 90 percent are considered low, according to: https://www.mayoclinic.org/symptoms/hypoxemia 13. On 11/27/2018 at 2:45 p.m. an interview took place with Resident #1's Primary Physician. When asked about familiarity with Resident #1, the Physician said Yes, I saw Resident #1. She was admitted in September. She had a history of [REDACTED]. She was a very sweet lady, but she was very demented. I remember her well because she was always hungry. The Physician stated that the resident would say frequently 'that they forgot about me. They didn't bring me my breakfast or lunch.' She was not aware that she couldn't eat. The Physician confirmed that whatever you put in front of her she would eat. When asked if the resident had any history or [DIAGNOSES REDACTED]. As far as my evaluations of her, she did not have heart failure. I saw her at least two times each week. The only symptom she had, was some bilateral lower extremity [MEDICAL CONDITION]. But she was on tube feeding and mostly sitting up, so it was not such a surprise if she had some [MEDICAL CONDITION] in her legs. She had no other signs that would indicate [MEDICAL CONDITIONS]. She had no shortness of breath or respiratory issues. She was not on any oxygen. When asked about the resident's multiple visits to the hospital during her stay at the facility, the Physician said I don't have her records in front of me, but she did have between two to three visits to the hospital while she was here. When she was admitted on (MONTH) 19th, she had just come back from the hospital. She had abdominal pain, and it was believed that her gastrostomy tube had dislodged. She had a Zenker's Diverticulum and dysphagia. So she was on a strict NPO diet; with full enteral nutrition. The Physician was asked about the resident's last hospital visit in October. She stated So, the resident returned from the hospital on [DATE]. I was notified by the nurse on 10/21/18, I believe it was before lunchtime, that Resident #1 had a change in her condition. The nurse told me that Resident #1 was in respiratory distress, and her oxygen saturation was very low. She also told me that the resident had been fed the day before (10/20/18) and that Resident #1 had eaten almost 100% of her meal. I told her, if that is the case, then we need to send the resident to the emergency room (ER) because she might have [MEDICAL CONDITION]. She had Zenker's Diverticulum and dysphagia, so giving her oral food could cause [MEDICAL CONDITION], because of aspiration, and also from food being stuck in there. In regards to oxygen orders, the Physician said I never ordered oxygen for this resident. I saw the nursing note stating that the nurse put Resident #1 on two to three Liters of oxygen before sending her to the hospital. If there was an order for [REDACTED]. I just told them to send her straight to the emergency room . Then on Monday (10/22/18) the facility called me to let me know that the resident had returned, with orders from the hospital for 7 liters of oxygen. I was told that the resident looked very cyanotic. I called the hospital and told them that I could not accept a resident that needed more than 5 Liters of oxygen. I did not accept the resident and she was returned to the ER. I didn't hear anything else from the hospital until the next day, Tuesday. The ER physician called and informed me that the resident had passed away, and asked if I could sign the death certificate. I told him I was not in the hospital and the resident was not in my care when she passed away, so I would not sign the death certificate. That same day, I received calls from both the hospital and the funeral director, regarding signing the death certificate. But I refused to sign it. I told the Director of Nursing (DON) at this facility that the medical examiner would question why I did not sign the death certificate. The Physician stated that I told the DON that an adverse event had occurred at the facility and she needed to report it. She was informed that the facility did not have an adverse report for Resident #1 related to eating a meal. The Physician said that she wasn't aware it had not been reported. She then stated at one time I was a Medical Director for a facility and I know what needs to be reported. 14. On 12/03/2018 at 11:16 a.m. a phone interview was conducted with Resident #1's son. He said that his mother had lived with him for two years prior to her falling. The son stated that she had only taken one type of medication before going into the hospital. That was for swelling to her ankles. He denied that she ever used oxygen. He stated that he went to the facility to see her. When he arrived there was food all over her and in the bed. He stated that was two or three days before she passed. Resident #1's son said that normally they had a sign up on the wall or the door that said not to feed her but there was no sign that night. The son stated that she is not supposed to get any food by mouth. He added that she also had water on her bedside table that was positioned right in front of her. And that she was capable of picking it up and drinking from it. He was asked what she had eaten. He said that it looked like bread crumbs. She must have had something that was bread. She did not say what the food was, just that it was lousy. Resident #1's son was asked if he had told anyone of his concern when he was at the facility. He said that he had told the assistant. And you know how that goes they just tell you to talk to the nurse. The son was asked if his mother had ever been diagnosed with [REDACTED]. He also denied that his mother had any lung issues. When I was planning the funeral I found out that neither the rehab center nor the hospital would sign the death certificate. They had to get Vital Statistics involved and the cause of death was listed as [MEDICAL CONDITION]. I looked it up, it's lack of oxygen. It doesn't make sense to me. I do feel the facility was negligent in the way they handled her. 15. Further interviews were conducted on at 11/28/2018 at 1:15 p.m. with LPN C. She confirmed that she trained LPN A on Saturday (10/20/2018). She stated that I don't ever remember seeing this women (Resident #1) with a tray in front of her. She said she recalled that the resident kept saying that she was hungry. She wanted food and wished she could have food. I don't know if she really understood what I was telling her about the food. I tried to explain to her when I would give her food in her tube. I knew that she was not supposed to get a tray of food. 16. During a phone interview on 11/29/2018 at 2:00 p.m., the Physical Therapist (PTO) who evaluated Resident #1 on 10/20/18, said I am familiar with Resident #1, but I do not have her records in front of me. I have a full-time job elsewhere, so I only work at the facility on a PRN (as needed) basis, and mostly just on the weekends. I will have to answer based on memory from that time. The PTO was asked about her familiarity with Resident #1, and she said I believe she was able to communicate, at least enough to answer simple questions, like 'do you have any pain?' She was able to nod or say yes or no. She needed maximum assistance with mobility and transfers. I do not know about the level of assistance she needed for feeding, because that is not my area, and I do not deal with that. When asked to describe her visit with Resident #1 on (MONTH) 20, (YEAR), the PTO said I can't remember exactly what time I entered her room. I entered the facility around 12:00 p.m. and saw her shortly after that. I entered the room by myself, there was no one with me. She said that she was alone in her room. Resident #1 was sitting at the bedside. She was not eating, and there was no tray in front of her. If she had been eating, I would not have entered her room, because that is not polite. In regards to removal of food trays from resident rooms, PTO stated, I would never remove a tray from the room. That is not part of my job. 17. On 11/28/2018 at 12:10 p.m. an interview was conducted with the Director of Nursing (DON) after asking for copies of Resident #1's medical record. At that time she confirmed she was aware of the narrative nursing note that was dated on 10/21/2018 stating that Resident #1 had been witnessed eating a meal tray. The DON said that LPN C had been orienting LPN A to the unit on 10/20/2018. She stated that we spoke to LPN C and she denied seeing a tray of food in front of the resident. She said that we could not find out if anyone had given her a tray. She stated that we looked at Resident #1's hospital reports and it didn't identify aspiration as she pointed to the record. It said [MEDICAL CONDITION]. At 2:54 p.m. an interview was conducted with the NHA and the DON. They stated they were both responsible for the facility Abuse and Neglect. The NHA confirmed at that time they saw the documentation that Resident #1 had a tray of food. She stated that we needed to conduct an investigation and that had started on Monday on the 22nd. She said that their process is to have a care management meeting and that includes going over the weekend events. The NHA stated that on Monday the 22nd the resident returned to the facility and that O2 situation happened. And then that kind of compounded it. We were still investigating with the staff. Not to say that it was a heightened issue, but everything that surrounded the resident we started educating. The NHA stated that, during their investigation into Resident #1 receiving a meal tray, We spoke with the dietary department and that they indicated that they didn't send out a tray for Resident #1. They had no record of printing out a tray card for her. The NHA said that they had spoken with LPN A and she was asked why there hadn't been any documentation of Resident #1 eating. She told us that she was orientating with LPN C on that day. She told us that LPN C was also in room during her observation. CNA B indicated she and a PTO entered Resident #1 bedroom to answer the resident's roommate call light. That was when the tray of food was noted. But the PTO stated that did not happen. We interviewed the CNA she said that she passed meal trays out, but she was unsure if she had given Resident #1 a tray. The NHA stated that we had seen that a certified nursing assistant had documented a meal amount % for Resident #1. We spoke to the CNA and she normally doesn't work that hall. So, we educated about documentation on meals. The NHA said that then we looked at all of the hospital record and it had only indicated [MEDICAL CONDITION] and plural effusion. And with the conflicting statements from staff, We ruled out adverse. The DON at that time confirmed that Resident #1 didn't have a previous [DIAGNOSES REDACTED]. The DON went on to say that we had determined she had not aspirated. It was basically inconsistent from there. I had seen the medical record that indicated she was refusing all treatments. The NHA said, We wanted to focus on the training after we identified that there were two nurses who needed additional education. The DON stated that we brought it to our QA & A meeting and with that information and we rolled out a plan. The plan included following MD orders, accurate assessments, oxygen, meal trays, and documentation. The NHA then stated we had a staff meeting last week. That included our staff not being able to go in and request a tray. You have to physically have a dietary slip in your hand for the dietary department. Then the dietary department will look in the computer system to see if the resident has an order. The NHA said during an investigation we have to look at all of the statements and the facts. We have a therapist and a nurse (LPN C) that tell us there was not a tray in the resident's room. And then we have a nurse (LPN A) and a CNA (CNA B) saying that there was. If nothing is solidified we determined it wasn't adverse based on the medical record that we received from the hospital. 18. On 10/22/2018 the resident was transferred back to the Nursing Home. The time she arrived to the facility was not documented in Resident #1's medical record. Review of Transportation records from the Non-Emergency Transport Service show: Patient (Pt.) is found at hospital on humidified O2 @ 10 LPM via Nasal Cannula (NC) due to SPO2 90%. Time: 14:11 Monday, (MONTH) 22, (YEAR) - event transfer of patient care time. 18. Review of the Hospital Discharge Summary dated 10/22/2018 showed: Nursing home called EMS because the patient was congested and had an O2 saturation in the 70s. Discharge Diagnosis: [REDACTED]. Weaned from [MEDICAL CONDITION] to nasal cannula. Remains stable on nasal cannula and oxygen is arranged for her home living situation. Intravenous (IV) to Oral (PO) [MEDICATION NAME] had promoted good diuresis. Breathing improved. 19. Review of Nursing Home to Hospital Transfer Form dated 10/22/2018 time 6:54 p.m. Reason for transfer: Respiratory Arrest HR 102 O2 Sat 84%. 20. Nursing Home to Hospital Transfer Form (additional information) dated on 10/22/2018 time 7:16 p.m.: Additional Relevant information: Resident re-admit from hospital with O2 sat between 80-85% on 5 liters of O2 continuous via nasal cannula, orders from MD send resident back to the ER. 21. Review of the emergency room Report showed: That the Mode of arrival: ambulance 10/22/2018 8:08 p.m. (20:08:00). The patient presents with difficulty breathing. The onset 2 days ago. The course duration of symptoms is constant and worsening. Degree of onset moderate. Degree at present is moderate. The relieving factor is oxygen. Prior episodes: multiple ED visits. [AGE] year old female with a past history including dementia, femur fracture, [DIAGNOSES REDACTED], dysphagia, and malnutrition presents to the ED via EMS from Excel Rehab for evaluation of worsening shortness of breath and difficulty breathing that has been going on for 2 days. She was discharged from the hospital 6 hours prior to ED arrival. She was sent back to her rehab facility on 7L O2 nasal cannula, but per EMS the facility is only able to administer up to 5L and placed her on that. The patient rapidly fell into dyspnea, so the facility sent her back to the ED. Patient refused [MEDICAL CONDITION] en-route to the ED and is currently refusing any interventions. Review of Chest x-ray dated on 10/22/2018 at 8:52 p.m. (comparison: 10/21/2018) showed: Impression: Worsening bilateral lung infiltrates and effusions either all related to [MEDICAL CONDITION] or a combination of [MEDICAL CONDITION] and pneumonitis. Initially patient was refusing ER care except for oxygen via NC. After some time, she agreed to labs and IV. Patient chest x-ray reviewed with her [MEDICAL CONDITION]- changes present. Patient states she does not want any further treatment as in refusing [MEDICATION NAME] after receiving [MEDICATION NAME]. She stated nitro makes her very nauseated. She is agreeable to hospice and has mental capacity to make this decision. She had been a hospice patient before. emergency room addendum: (dated 10/23/2018 at 6:26:00). She was sent to ED by the facility for further evaluation by hospice. Pt is awaiting evaluation by hospice who told previous ED physicians that they could not come until later this morning. Shortly after sign-out I called case management, 7:00 a.m., clinically the patient appears to be activity dying. I discussed the case with case management day shift and they recommended stat palliative care consultation she will attempt to get hospice to come in and see the patient. Re-examination/Revaluation Time: 10/23/18 07:40 Notes: Palliative care at bedside. Requesting de-escalation of oxygen. Awaiting hospice. Time: 10/23/18 08:24:00 Notes: Patient passed away peacefully. Nursing at bedside. 22. Endoscopic [DIAGNOSES REDACTED]. Zenker's Diverticulum (ZD) is an outpouching of tissue through Killian's triangle thought to be due to cricopharyngeal muscle dysfunction. This relatively uncommon disorder, which occurs more commonly in the elderly, presents with symptoms of dysphagia. Symptoms Dysphagia (is the medical term used to describe difficulty swallowing) occurs in 80-90% of patients. Regurgitation of undigested foods, halitosis (bad breath), and hoarseness can also occur. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30-40% of patients describe chronic cough and repeated episodes of aspiration (the accidental sucking in of food particles or fluids into the lungs), some with subsequent pneumonia. Ryan Law, Todd H. Baron, in Clinical Gastrointestinal Endoscopy (Third Edition), 2019 https://www.sciencedirect.com/topics/medicine-and-dentistry/zenkers-diverticulum. 23. Past History noted per Hospital Record Review: On 8/27/2018 Resident #1 had an Echocardiogram performed at the hospital. Summary: Left ventricle was of normal size. a. Systolic function was normal Ejection fraction was estimated in the range of 60% to 65%. (Normal range: 50-75%) Mitral valve: There no evidence of stenosis. Aortic valve: There was no stenosis. Tricuspid valve: There was no evidence for tricuspid stenosis. Pulmonic valve: normal thickness no calcification. 24. On 11/29/2018 at 11:45 a.m. a phone call was received from a state agency Investigator. She stated that she had received a copy of Resident #1's death certificate. The cause of death per the Investigator: [MEDICAL CONDITIONS]. 25. On 11/27/2018 the facility provided a list of ten residents who currently reside at the facility a

Based on interviews with the Nursing Home Administrator, Director of Nursing, nursing staff, resident's physician, resident's son, review of clinical and hospital records, and the facility's policies and procedures it was determined that the facility failed to ensure an alleged violation of neglect was thoroughly investigated in accordance with the State Law, including reporting to the State Survey Agency within 5 working days of the incident. The alleged violation of neglect was identified on 10/20/2018. Licensed Practical Nurse A documented in Resident #1's medical record that the resident had consumed a tray of food. The resident had a physician ordered nothing by mouth status. The Resident's Physician stated that consuming regular food could cause [MEDICAL CONDITION]. The Nursing Home Administrator and the Director of Nursing said that they determined, after their investigation that the facility had not caused anything adverse to happen to the resident. The facility failed to provide the proper care and oxygen services to Resident #1 who became dependent on oxygen within 24 hours after a witnessed account of oral intake. The facility then deprived Resident #1 of her ordered oxygen level after being readmitted . That resulted in respiratory arrest and a return back to the hospital just hours after being readmitted . Failure to thoroughly investigate an alleged violation of neglect resulted in findings of Immediate Jeopardy on 11/30/2018 which was removed on 11/30/2018 and reduced to the scope and severity of D. Findings Included: 1. On 12/03/2018 at 11:16 a.m. a phone interview was conducted with Resident #1's son. He stated that the facility never called him during the facility's investigation into his mother consuming a tray of food orally. The resident's son spoke about how he found his mother at the nursing home after she was readmitted from the hospital. He described her as having food on her face and in her bed. He stated that it was two or three days before she passed. Resident #1's son said that normally they had a sign up on the wall or the door that said not to feed her but there was no sign that night. The son stated that she is not supposed to get any food by mouth. He added that she also had water on her bedside table that was positioned right in front of her. And that she was capable of picking it up and drinking from it. He was asked what she had eaten, he said that it looked like bread crumbs. She must have had something that was bread. She did not say what the food was, just that it was lousy. Resident #1's son went on to say that his mother had lived with him for the past two years prior to her falling. He stated that she had only taken one type of medication before going into the hospital and that was for swelling to her ankles. He denied that she ever used oxygen. The son was asked if his mother had ever been diagnosed with [REDACTED]. He also denied that his mother had any lung issues. When I was planning the funeral I found out that neither the rehab center nor the hospital would sign the death certificate. They had to get Vital Statistics involved and the cause of death was listed as [MEDICAL CONDITION]. I looked it up, it's lack of oxygen. It doesn't make sense to me. I do feel the facility was negligent in the way they handled her. 2. Review of an Abuse Protection and Response Policy provided by the facility that did not contain a date showed: Neglect: is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. On 11/28/2018 at 12:10 p.m. an interview was conducted with the Director of Nursing (DON) after asking for copies of Resident #1's medical record. At that time she confirmed she was aware of the narrative nursing note that was dated on 10/21/2018 stating that Resident #1 had been witnessed eating a meal tray. The DON said that LPN C had been orienting LPN A to the unit on 10/20/2018. She stated that we spoke to LPN C and she denied seeing a tray of food in front of the resident. She said that we could not find out if anyone had given her a tray. She stated that we looked at Resident #1's hospital reports and it didn't identify aspiration as she pointed to the record. It said [MEDICAL CONDITION]. At 2:54 p.m. an interview was conducted with the NHA and the DON. They stated they were both responsible for the facility Abuse and Neglect. The NHA confirmed at that time they saw the documentation that Resident #1 had a tray of food. She stated that we needed to conduct an investigation and that had started on Monday on the 22nd. She said that their process is to have a care management meeting and that includes going over the weekend events. The NHA stated that on Monday the 22nd the resident returned to the facility and that O2 situation happened. And then that kind of compounded it. We were still investigating with the staff. Not to say that it was a heightened issue but everything that surrounded the resident we started educating. The NHA stated that, during their investigation into Resident #1 receiving a meal tray, We spoke with the dietary department and they indicated that they didn't send out a tray for Resident #1. They had no record of printing out a tray card for her. The NHA said that they had spoken with LPN A and she was asked why there hadn't been any documentation of Resident #1 eating. She told us that she was orientating with LPN C on that day. She told us that LPN C was also in room during her observation. CNA B indicated she and a PTO entered Resident #1 bedroom to answer the resident's roommate call light. That was when the tray of food was noted. But the PTO stated that did not happen. We interviewed the CNA, she said that she passed meal trays out, but she was unsure if she had given Resident #1 a tray. The NHA stated that we had seen that a certified nursing assistant had documented a meal amount % for Resident #1. We spoke to the CNA and she normally doesn't work that hall. So, we educated about documentation on meals. The NHA said that then we looked at all of the hospital record and it had only indicated [MEDICAL CONDITION] and plural effusion. And with the conflicting statements from staff. We ruled out adverse. The DON at that time confirmed that Resident #1 didn't have a previous [DIAGNOSES REDACTED]. The DON went on to say that we had determined she had not aspirated. It was basically inconsistent from there. I had seen the medical record that indicated she was refusing all treatments. The NHA said, We wanted to focus on the training after we identified that there were two nurses who needed additional education. The DON stated that we brought it to our QA & A meeting and with that information and we rolled out a plan. The plan included following MD orders, accurate assessments, oxygen, meal trays and documentation. The NHA then stated we had a staff meeting last week. That included our staff not being able to go in and request a tray. You have to physically have a dietary slip in your hand for the dietary department. Then the dietary department will look in the computer system to see if the resident has an order. The NHA said during an investigation we have to look at all of the statements and the facts. We have a therapist and a nurse (LPN C) that tell us there was not a tray in the resident's room. And then we have a nurse (LPN A) and a CNA (CNA B) say that there was. If nothing is solidified we determined it wasn't adverse based on the medical record that we received from the hospital. 4. The facility provided a copy of their Accident/Incident Monthly Log Follow -Up. The log did not contain Resident #1 on it for the month of (MONTH) (YEAR). 5. A review of the facility Policy/Procedure titled Reporting Accidents and incidents that did not contain a date. Intent: It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal regulations. Procedure: The facility will ensure that: The facility will develop and implement an accident and incident reporting system that will report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. The facility will develop appropriate measures to minimize the risk for adverse incidents to residents, including, but not limited to, education and training in risk management and risk prevention for all non-physician personnel, as follows: The facility will conduct an internal risk management and quality assurance program which will include the use of incident reports to be filed with the risk manager and facility administrator. The risk manager shall have free access to all resident records of the licensed facility. As part of the each internal risk management and quality assurance program, the incident reports shall be used to develop categories of incidents, which identify problem areas. Once identified, procedures will be adjusted to correct the problem areas. The facility will for purposes of reporting to the agency will use the term adverse incident which means: an event over which facility personnel could exercise control and which is associated in whole or in part with the facility's intervention, rather that the condition for which such intervention occurred, and which results in one of the following: Death Any condition that required the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather that the resident's condition prior to the adverse incident. The facility will initiate an investigation and will notify the agency within1 business day after the risk manager or his or her designee has received a report. Abuse, neglect or exploitation must be reported to the agency as requires by 42 C.F.R.s. 483.13(c) and to the department as required n chapters 39 and 415. 6. Resident #1 was admitted to the facility on [DATE]. She was transferred out to the hospital on three separate occasions during her forty one days at the facility. Her last transfer to the hospital was on 10/22/2018. She never returned to the facility. The facility Cumulative [DIAGNOSES REDACTED]. The Resident's History and Physical dated on 8/27/2018 reflected: [AGE] year old female with a history of dysphagia and mild dementia. She was getting out of bed when she had a fall and complained of right lower extremity pain and patient brought to Emergency Department (ED) for further evaluation. The case was also discussed with the patient's son who stated the patient was confused at the time of the fall and in the last few weeks the patient had problem with eating. A Swallow evaluation (eval) was done at the bedside by the speech therapist who recommended a video assisted swallow test which showed the patient had a large Zenker's Diverticulum. Zenker's Diverticulum (ZD) is an outpouching of tissue through Killian's triangle thought to be due to cricopharyngeal muscle dysfunction. This relatively uncommon disorder, which occurs more commonly in the elderly, presents with symptoms of dysphagia. Dysphagia (is the medical term used to describe difficulty swallowing) occurs in 80-90% of patients. Regurgitation of undigested foods, halitosis (bad breath), and hoarseness can also occur. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30-40% of patients describe chronic cough and repeated episodes of aspiration (the accidental sucking in of food particles or fluids into the lungs), some with subsequent pneumonia. Ryan Law, Todd H. Baron, in Clinical Gastrointestinal Endoscopy (Third Edition), 2019 https://www.sciencedirect.com/topics/medicine-and-dentistry/zenkers-diverticulum. 7. Resident #1's Brief Interview for Mental Status was conducted on 9/13/2018. It was determined at that time that the score was 11. Total Score of 8-12 indicated moderately impaired cognition. Resident #1 was dependent on the facility licensed staff to provide her nutritional intake through her [MEDICAL CONDITION] tube. The 3008 form dated 9/12/2018 contained Dietary Instructions: NPO Tube Feeding Insertion date: 8/30/2018. Past History noted per Hospital Record Review: On 8/27/2018 Resident #1 had an Echocardiogram performed at the hospital. Summary: Left ventricle was of normal size. Systolic function was normal Ejection fraction was estimated in the range of 60% to 65%. (Normal range: 50-75%) Mitral valve: There no evidence of stenosis. Aortic valve: There was no stenosis. Tricuspid valve: There was no evidence for tricuspid stenosis. Pulmonic valve: normal thickness no calcification. 8. On 11/27/2018 at 1:00 p.m. an interview was conducted with Speech Language Pathologist, Staff N, for Resident #1, she stated that she had a [MEDICATION NAME] Swallow test conducted at the hospital. Which showed strictures and Zenker's Diverticulum. So she was not able to have any oral intake. She was not a candidate for Speech services and she remained on an NPO per diet order while here. When asked if she was present for all her meal times for Resident #1, she stated no. 9. On 10/19/2018 the resident returned to the facility and the staff rescinded her previous orders. admission orders [REDACTED]. The facility was not able to provide written orders from the hospital admission. Review of the resident's progress notes dated 10/19/2018 showed [MEDICATION NAME] 1.2 can bolus 5 times a day flush peg with 240 ml every shift. Continue diet orders per RD (Registered Dietitian). Review of the MAR (Medication Administration Record) showed the initial physician orders for the Resident: Graduate [MEDICATION NAME] and orders for flushing [DEVICE] and medication. There was no order for NPO status. 10. On 11/27/2018 at 2:45 p.m. an interview took place with Resident #1's Primary Physician. When asked about familiarity with Resident #1, the Physician said Yes, I saw Resident #1. She was admitted in September. She had a history of [REDACTED]. She was a very sweet lady, but she was very demented. I remember her well because she was always hungry. The Physician stated that the resident would say frequently 'that they forgot about me. They didn't bring me my breakfast or lunch'. She was not aware that she couldn't eat. The Physician confirmed that whatever you put in front of her she would eat. When asked if the resident had any history or [DIAGNOSES REDACTED]. As far as my evaluations of her, she did not have heart failure. I saw her at least two times each week. The only symptom she had, was some bilateral lower extremity [MEDICAL CONDITION]. But, she was on tube feeding and mostly sitting up, so it was not such a surprise if she had some [MEDICAL CONDITION] in her legs. She had no other signs that would indicate [MEDICAL CONDITIONS]. She had no shortness of breath or respiratory issues. She was not on any oxygen. When asked about the resident's multiple visits to the hospital during her stay at the facility, the Physician said I don't have her records in front of me, but she did have between two to three visits to the hospital while she was here. When she was admitted on (MONTH) 19th, she had just come back from the hospital. She had abdominal pain, and it was believed that her gastrostomy tube had dislodged. She had a Zenker's diverticulum and dysphagia. So she was on a strict NPO diet; with full enteral nutrition. The Physician was asked about the resident's last hospital visit in October. She stated So, the resident returned from the hospital on [DATE]. I was notified by the nurse on 10/21/18, I believe it was before lunchtime, that Resident #1 had a change in her condition. The nurse told me that Resident #1 was in respiratory distress, and her oxygen saturation was very low. She also told me that the resident had been fed the day before (10/20/18), and that Resident #1 had eaten almost 100% of her meal. I told her, if that is the case, then we need to send the resident to the emergency room (ER) because she might have [MEDICAL CONDITION]. She had Zenker's Diverticulum and dysphagia, so giving her oral food could cause [MEDICAL CONDITION], because of aspiration, and also from food being stuck in there. In regards to oxygen orders, the Physician said I never ordered oxygen for this resident. I saw the nursing note stating that the nurse put Resident #1 on two to three Liters of oxygen before sending her to the hospital. If there was an order for [REDACTED]. I just told them to send her straight to the emergency room . Then on Monday (10/22/18), the facility called me to let me know that the resident had returned, with orders from the hospital for 7 liters of oxygen. I was told that the resident looked very cyanotic. I called the hospital and told them that I could not accept a resident that needed more than 5 Liters of oxygen. I did not accept the resident and she was returned to the ER. I didn't hear anything else from the hospital until the next day, Tuesday. The ER physician called and informed me that the resident had passed away, and asked if I could sign the death certificate. I told him I was not in the hospital and the resident was not in my care when she passed away, so I would not sign the death certificate. That same day, I received calls from both the hospital and the funeral director, regarding signing the death certificate. But I refused to sign it. I told the Director of Nursing (DON) at this facility that the medical examiner would question why I did not sign the death certificate. The Physician stated that I told the DON that an adverse event had occurred at the facility and she needed to report it. She was informed that the facility did not have an adverse report for Resident #1 related to eating a meal. The Physician said that she wasn't aware it had not been reported. She then stated at one time I was a Medical Director for a facility and I know what needs to be reported. 11. On 10/21/2018 at 3:44 p.m. (15:44) Resident #1's Narrative Nursing Notes showed: Writer went into resident's room to assess lung sounds due to sounds of congestion upon entering resident's room. Bilateral lobes where auscultated and adventitious lungs sounds noted. Blood pressure 145/84, heart rate - 87, Temperature - 97.7 (oral) and resident's oxygen (O2) stats were fluctuating between 84%-87% Room Air (RA). Oxygen (O2) at (@) 2 Liters (2L) applied (writer bumped O2 to 3L). Writer notified supervisor and placed call to the resident's doctor and notified her of change in condition as well as writer witnessing resident eating lunch on 10/20. Per the doctor transfer patient to emergency room (ER). Writer rechecked resident O2 sats (saturation) and they were 77% NC (nasal cannula) @ 3L (3 liters of oxygen). Writer called 911 to transport resident to hospital and son was notified. A review of the Nursing Home to Hospital Transfer form dated 10/21/2018 showed: Reason for transfer: Respiratory Arrest. 12. Review of The Transporting County Fire Rescue report showed that a call was received on 10/21/18 at 12:54:04 p.m. Patient contact occurred at 1:01 p.m. (13:01:06) Upon arrival 96 y/o (year old) found sitting upright in nursing home bed. Pt. is alert to her normal mentation per staff. ABC (airway, breathing, circulation) intact. Pt. has a regular and normal radial pulse. Staff explained they noticed prior to calling EMS that pt's O2 saturation (sats) were in the seventies. Lung sounds assessed and rales present globally. 1:04 p.m. (13:04:08) Oxygen saturation level (SaO2) 75% (on room air) Respiration (Resp): 27 1:09 p.m. (13:09:31) SaO2 74% Resp: 27 1:14 p.m. (13:14:14) SaO2 93% Resp: 24 Normal pulse oximeter (SaO2) readings usually range from 95 to 100 percent. Values under 90 percent are considered low, according to: https://www.mayoclinic.org/symptoms/hypoxemia 13. On 11/29/2018 at 10:00 a.m. a phone interview was conducted with Licensed Practical Nurse (LPN) A. She confirmed that she worked at the facility on an as needed basis. LPN A was able to recall the weekend and the events that transpired with Resident #1. She stated that Saturday (10/20/18) was her first day at the facility. She was training on Resident #1's unit with LPN C. She recalled that it was around the mid-morning time when they entered Resident #1's bedroom. She stated that a tray of food was in front of Resident #1 and she watched while Resident #1 ate. She was asked and stated that she did not recall seeing any issues with the resident chewing and swallowing the food. She was unable to recall if it was a breakfast or lunch tray. LPN A was unsure if LPN C saw the tray of food. She stated that the next day, Sunday (10/21/18), she worked the same unit on her own. She said that Resident #1 did not receive a meal tray so we called the kitchen for her breakfast tray. The kitchen said that they didn't have a diet order for her. We didn't receive a tray for her. LPN A stated that she had given the resident her medications and her tube feeding that morning and she was alert and comfortable at that time. She stated that right before lunch she entered Resident #1's bedroom and she could hear her having adventitious breathing immediately upon entering the room. She said, I called the MD and then 911. 14. On at 11/28/2018 at 1:15 p.m. an interview was conducted with LPN C. She confirmed that she trained LPN A on Saturday (10/20/2018). She stated that I don't ever remember seeing this women (Resident #1) with a tray in front of her. She said she recalled that the resident kept saying that she was hungry. She wanted food and wished she could have food. I don't know if she really understood what I was telling her about the food. I tried to explain to her when I would give her food in her tube. I knew that she was not supposed to get a tray of food. 15. On 11/28/2018 at 4:15 p.m. a phone interview was conducted with Certified Nursing Assistant (CNA) B, she stated that she worked the second shift at the facility, and worked on 10/20/2018. She explained her normal routine after she arrived at the facility, which is at 3:00 p.m. She makes rounds to see all of the residents that she will be caring for. She stated that on 10/20/2018 right after the start of her rounds Resident #1's roommate put on the call light. She said that she entered the room and a therapist also entered at the same time. CNA B confirmed that Resident #1 had a tray of food in front of her and was eating it when she approached her. She said that the tray contained regular food and added that it was not mechanical or pureed. She was unable to recall what food was on the tray. She said that food was missing from the tray. She could not recall how much was missing or had remained. CNA B said that the therapist removed the tray from the resident and took it out side out of the room. She said she did not know the therapist's name. 16. During a phone interview on 11/29/2018 at 2:00 p.m., the Physical Therapist (PTO) who evaluated Resident #1 on 10/20/18, said I am familiar with Resident #1, but I do not have her records in front of me. I have a full-time job elsewhere, so I only work at the facility on a PRN (as needed) basis, and mostly just on the weekends. I will have to answer based on memory from that time. The PTO was asked about her familiarity with Resident #1, and she said I believe she was able to communicate, at least enough to answer simple questions, like 'do you have any pain?' She was able to nod or say yes or no. She needed maximum assistance with mobility and transfers. I do not know about the level of assistance she needed for feeding, because that is not my area, and I do not deal with that. When asked to describe her visit with Resident #1 on (MONTH) 20, (YEAR), the PTO said I can't remember exactly what time I entered her room. I entered the facility around 12:00 p.m. and saw her shortly after that. I entered the room by myself, there was no one with me. She said that she was alone in her room. Resident #1 was sitting at the bedside. She was not eating, and there was no tray in front of her. If she had been eating, I would not have entered her room, because that is not polite. In regards to removal of food trays from resident rooms, PTO stated I would never remove a tray from the room. That is not part of my job. 17. The facility provided a copy of their Menu that was dated for (MONTH) 19 - (MONTH) 20, (YEAR). Regular diet: 10/19/18 Friday: Breakfast: Blueberry Pancake Squares, Choice of Eggs, Syrup, Margarine, OJ/Apple/Cranberry juice, 2% Milk, and Coffee/Tea. Lunch: Oven Baked Fish, Paprika Roasted Potato, Broccoli, Biscuit, and Oreo Cookie Blondies. Alternative: Black Jack Burger, Lettuce/Tomato & Onions. Dinner: Hot Open-faced Turkey Sandwich, Mashed Potatoes, California Vegetable Blend, Strawberry and Banana Cup, and Margarine. Alternative: Sausage and Sauerkraut. 10/20/18 Saturday: Breakfast: Hot or Cold Cereal, Scrambled Eggs, Harvest Pumpkin Muffin, Margarine, OJ/Apple/Cranberry, 2% Milk, Coffee/Tea. Lunch: BBQ Chicken Breast, Green Beans and Mushrooms, Macaroni and Cheese, Wheat Bread, Fruited Gelatin. Alternative: Cottage Cheese Fruit Plate. 18. Medical record review of the meal intake that was documented by the Certified Nursing Assistants for Resident #1 revealed: On 10/19/2018 the dinner meal was documented at 76-100% (coded as a 3). On 10/20/2018 her breakfast and lunch amount eaten was 76-100%. And her dinner meal was documented at 26-50% (coded as a 1). On 10/21/2018 the amount eaten 51-75% for breakfast and for lunch. The documentation of the two day meal intake indicated four separate staff members. 19. Review of the emergency room Report dated 10/21/2018 at 1:19 p.m. (13:19) History of Present Illness: The patient presents with difficulty breathing. The onset was today. The course/duration of symptoms is constant. Degree at present moderate. The exacerbating factors are none. The relieving factors are none. Risk factors consistent of immobility. Prior episodes: none. [AGE] year old female from Excel Rehab with Past Medical History (PMHx) including [DIAGNOSES REDACTED], dysphagia, malnutrition, and dementia presents to ED (Emergency Department) via EMS (Emergency Medical Services) for evaluation of dyspnea onset today. Patient is on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) upon arrival to the ED. Patient denies hx (history) of [MEDICAL CONDITIONS]. General: Alert, moderate distress, nontoxic appearing, very frail, very debilitated, not anxious. Respiratory: Breath sounds are equal, respirations: dyspneic (having difficulty breathing), tachypnea (abnormal rapid breathing), breath sounds: crackles throughout entire lung fields bilaterally. CXR performed on 10/21/2018. Radiograph demonstrates vascular congestion and interstitial [MEDICAL CONDITION] suggestive [MEDICAL CONDITION]. 20. Review of Hospital Discharge Summary dated 10/22/2018 Showed: Nursing home called EMS because the patient was congested and had an O2 saturation in the 70s. Discharge Diagnosis: [REDACTED]. Weaned from [MEDICAL CONDITION] to nasal cannula. Remains stable on nasal cannula and oxygen is arranged for her home living situation. Intravenous (IV) to Oral (PO) [MEDICATION NAME] had promoted good diuresis. Breathing improved. 21. On 10/22/2018 the resident was transferred back to the Nursing Home. The time she arrived to the facility was not documented in Resident #1's medical record. Review of Transportation records from the Transcare Non-Emergency Transport Service show: Patient (Pt.) is found at hospital on humidified O2 @ 10 LPM via Nasal Cannula (NC) due to SPO2 90%. Time: 14:11 Monday, (MONTH) 22, (YEAR) - event transfer of patient care time. 22. On 11/27/2018 at 9:57 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated that the facility had only two Five Day Reportings since their last annual recertification survey that commenced on 11/02/2018. She stated that the first Five Day Report was sent in during the annual survey. That report was about herself and a resident that currently resides at the facility. The NHA stated that the second Five Day Report was for Resident #1. She revealed after their investigation it was determined as neglect (# ). The NHA described the results of their investigation on 10/22/2018 Resident #1 was readmitted to the facility. The admitting Registered Nurse U (RN U) went to the nursing meeting while Resident #1 was still on the stretcher. The NHA stated Instead of the nurse assessing the patient to see if she had everything that she needed. She opted to go to the nursing meeting. The NHA said that they conducted an investigation that revealed at 4:00 p.m. the second shift nurse informed RN U that Resident #1 was having problems breathing. They immediately went to her bedroom and found Resident #1's skin color ashen in appearance. At that time they increased the oxygen up to 5 liters. She stated Resident #1 had been on oxygen at 2 liters for 90 minutes during that time. Her SPO2 was at 84%. They contacted the Physician and told him of the resident's vital signs. The Physician ordered them to transfer Resident #1 back to the hospital. The NHA stated she had asked RN U if she informed the Director of Nursing that she was getting a new admission. She stated that she had not. The NHA said that she had then asked RN U what she thought was a greater priority going to the nursing meeting or admitting a resident. She told me going to the nursing meeting. RN U had denied that the transportation personnel told her that Resident #1's oxygen level needed to be at 7 liters. The NHA said that RN U no longer works at that facility. Prior to the oxygen incident RN U had received several other disciplinary actions. One was related to a [MEDICAL TREATMENT], post fall education, safe medication administration, and education on the admission process. She stated that according to our disciplinary process the first thing we did was suspend her. The NHA said after our investigation, we ended up terminating her. We additionally reported her to the Florida Board of Nursing. The NHA stated that on all new admissions we strive to ensure that the equipment is here and available for the residents when they arrive. She said that we had a concentrator that delivers up to 10 Liters. The NHA was asked if the oxygen concentrator could be observed. She called a staff member on the phone and stated out loud that it had been returned to the supplier. 23. Review of Nursing Home to Hospital Transfer Form dated 10/22/2018 time 6:54 p.m. Reason for transfer: Respiratory Arrest HR 102 O2 Sat 84% Nursing Home to Hospital Transfer Form (additional information) dated on 10/22/2018 time 7:16 p.m.: Additional Relevant information: Resident re-admit from hospital with O2 sat between 80-85% on 5 liters of O2 continuous via nasal cannula, orders from MD send resident back to the ER. 24. Review of the emergency room Report showed: That the Mode of arrival: ambulance 10/22/2018 8:08 p.m. (20:08:00) The patient presents with difficulty breathing. The onset 2 days ago. The course duration of symptoms is constant and worsening. Degree of onset moderate. Degree at present is moderate. The relieving factor is oxygen. Prior episodes: multiple ED visits. [AGE] year old female with a past history including dementia, femur fracture, [DIAGNOSES REDACTED], dysphagia, and malnutrition presents to the ED via EMS from Excel Rehab for evaluation of

Based on observations, interviews with the Nursing Home Administrator, the Director of Nursing, nursing staff, the resident's physician, and review of clinical and medical records, policies and procedures, it was determined that the facility failed to provide a systematic process to ensure residents were free from harm and neglect. On 10/19/2018 the facility failed to process an admission order for Resident #1 Nothing by Mouth. On 10/20/2018 Resident #1 was witnessed by two staff members consuming food. Her son found the food remnants on her clothing and bed as the resident reports that she ate food. Within twenty four hours after Resident #1 was observed eating she became hypoxic. The Resident's Physician confirmed if food was consumed this could cause the resident to go into [MEDICAL CONDITION]. Resident #1 was emergently transported to the hospital. On 10/22/2018 Resident #1 was readmitted to the facility with oxygen orders at 7 liters per nasal cannula. The admitting nurse failed to provide the necessary care, service, and meet the needs of the resident by not following the hospital ordered oxygen level. The admitting nurse attended a scheduled nursing meeting at the time of the Resident's readmission. The Nursing Home Administrator indicated that the facility had identified neglect for Resident #1 related to not providing the correct oxygen dose. Resident #1 was administered 2 liters of oxygen for 90 minutes on admission. Failure of the facility administrative staff to identify neglect related to providing food to a resident on NPO status and not providing oxygen at the ordered 7 liters resulted in findings of Immediate Jeopardy on 11/30/2018 at 3:15 p.m., which were removed on 11/30/3018 at 5:32 p.m. and reduced to the scope and severity of D. Findings Included: 1. Review of an Abuse Protection and Response Policy provided by the facility that did not contain a date showed: Neglect: is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #1 was admitted to the facility on [DATE]. She was transferred out to the hospital on three separate occasions during her forty one days at the facility. Her last transfer to the hospital was on 10/22/2018. She never returned to the facility. The facility Cumulative [DIAGNOSES REDACTED]. The Resident's History and Physical dated on 8/27/2018 reflected: [AGE] year old female with a history of dysphagia and mild dementia. She was getting out of bed when she had a fall and complained of right lower extremity pain and patient brought to Emergency Department (ED) for further evaluation. The case was also discussed with the patient's son who stated the patient was confused at the time of the fall and in the last few weeks the patient had problem with eating. A Swallow evaluation (eval) was done at the bedside by the speech therapist who recommended a video assisted swallow test which showed the patient had a large Zenker's Diverticulum. Zenker's Diverticulum (ZD) is an outpouching of tissue through Killian's triangle thought to be due to cricopharyngeal muscle dysfunction. This relatively uncommon disorder, which occurs more commonly in the elderly, presents with symptoms of dysphagia. Dysphagia (is the medical term used to describe difficulty swallowing) occurs in 80-90% of patients. Regurgitation of undigested foods, halitosis (bad breath), and hoarseness can also occur. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30-40% of patients describe chronic cough and repeated episodes of aspiration (the accidental sucking in of food particles or fluids into the lungs), some with subsequent pneumonia. Ryan Law, Todd H. Baron, in Clinical Gastrointestinal Endoscopy (Third Edition), 2019 https://www.sciencedirect.com/topics/medicine-and-dentistry/zenkers-diverticulum. 2. Resident #1's Brief Interview for Mental Status was conducted on 9/13/2018. It was determined at that time that the score was 11. Total Score of 8-12 indicated moderately impaired cognition. Resident #1 was dependent on the facility licensed staff to provide her nutritional intake through her [MEDICAL CONDITION] tube. The 3008 form dated 9/12/2018 contained Dietary Instructions: NPO Tube Feeding Insertion date: 8/30/2018. 3. On 10/19/2018 the resident returned to the facility and the staff rescinded her previous orders. admission orders [REDACTED]. The facility was not able to provide written orders from the hospital admission. Review of the resident's progress notes dated 10/19/2018 showed [MEDICATION NAME] 1.2 can bolus 5 times a day flush peg with 240 ml every shift. Continue diet orders per RD (Registered Dietitian). Review of the MAR (Medication Administration Record) showed the initial physician orders [REDACTED]. There was no order for NPO status. On 10/21/2018 at 3:44 p.m. (15:44) Resident #1's Narrative Nursing Notes showed: Writer went into resident's room to assess lung sounds due to sounds of congestion upon entering resident's room. Bilateral lobes where auscultated and adventitious lungs sounds noted. Blood pressure 145/84, heart rate - 87, Temperature - 97.7 (oral) and resident's oxygen (O2) stats were fluctuating between 84%-87% Room Air (RA). Oxygen (O2) at (@) 2 Liters (2L) applied (writer bumped O2 to 3L). Writer notified supervisor and placed call to the resident's doctor and notified her of change in condition as well as writer witnessing resident eating lunch on 10/20. Per the doctor transfer patient to emergency room (ER). Writer rechecked resident O2 sats (saturation) and they were 77% NC (nasal cannula) @ 3L (3 liters of oxygen). Writer called 911 to transport resident to hospital and son was notified. A review of the Nursing Home to Hospital Transfer form dated 10/21/2018 showed: Reason for transfer: Respiratory Arrest. 4. Review of The Transporting County Fire Rescue report showed that a call was received on 10/21/18 at 12:54:04 p.m. Patient contact occurred at 1:01 p.m. (13:01:06) Upon arrival 96 y/o (year old) found sitting upright in nursing home bed. Pt. is alert to her normal mentation per staff. ABC (airway, breathing, circulation) intact. Pt. has a regular and normal radial pulse. Staff explained they noticed prior to calling EMS that pt's O2 saturation (sats) were in the seventies. Lung sounds assessed and rales present globally. 1:04 p.m. (13:04:08) Oxygen saturation level (SaO2) 75% (on room air) Respiration (Resp): 27 1:09 p.m. (13:09:31) SaO2 74% Resp: 27 1:14 p.m. (13:14:14) SaO2 93% Resp: 24 Normal pulse oximeter (SaO2) readings usually range from 95 to 100 percent. Values under 90 percent are considered low, according to: https://www.mayoclinic.org/symptoms/hypoxemia 5. Review of the emergency room Report dated 10/21/2018 at 1:19 p.m. (13:19) History of Present Illness: The patient presents with difficulty breathing. The onset was today. The course/duration of symptoms is constant. Degree at present moderate. The exacerbating factors are none. The relieving factors are none. Risk factors consistent of immobility. Prior episodes: none. [AGE] year old female from Excel Rehab with Past Medical History (PMHx) including [DIAGNOSES REDACTED], dysphagia, malnutrition, and dementia presents to ED (Emergency Department) via EMS (Emergency Medical Services) for evaluation of dyspnea onset today. Patient is on [MEDICAL CONDITION] (Continuous Positive Airway Pressure) upon arrival to the ED. Patient denies hx (history) of [MEDICAL CONDITIONS]. General: Alert, moderate distress, nontoxic appearing, very frail, very debilitated, not anxious. Respiratory: Breath sounds are equal, respirations: dyspneic (having difficulty breathing), tachypnea (abnormal rapid breathing), breath sounds: crackles throughout entire lung fields bilaterally. CXR performed on 10/21/2018. Radiograph demonstrates vascular congestion and interstitial [MEDICAL CONDITION] suggestive [MEDICAL CONDITION]. 6. On 11/27/2018 at 1:00 p.m. an interview was conducted with Speech Language Pathologist, Staff N, For Resident #1, she stated that she had a [MEDICATION NAME] Swallow test conducted at the hospital. Which showed strictures and Zenker's Diverticulum. So she was not able to have any oral intake. She was not a candidate for Speech services and she remained on an NPO per diet order while here. When asked if she was present for all her meal times for Resident #1, she stated no. 7. On 11/29/2018 at 10:00 a.m. a phone interview was conducted with Licensed Practical Nurse A. She confirmed that she worked at the facility on an as needed basis. LPN A was able to recall the weekend and the events that transpired with Resident #1. She stated that Saturday (10/20/18) was her first day at the facility. She was training on Resident #1's unit with LPN C. She recalled that it was around the mid-morning time when they entered Resident #1's bedroom. She stated that a tray of food was in front of Resident #1 and she watched while Resident #1 ate. She was asked and stated that she did not recall seeing any issues with the resident chewing and swallowing the food. She was unable to recall if it was a breakfast or lunch tray. LPN A was unsure if LPN C saw the tray of food. She stated that the next day, Sunday (10/21/18), she worked the same unit on her own. She said that Resident #1 did not receive a meal tray so we called the kitchen for her breakfast tray. The kitchen said that they didn't have a diet order for her. We didn't receive a tray for her. LPN A stated that she had given the resident her medications and her tube feeding that morning and she was alert and comfortable at that time. She stated that right before lunch she entered Resident #1's bedroom and she could hear her having adventitious breathing immediately upon entering the room. She said, I called the MD and then 911. 8. On at 11/28/2018 at 1:15 p.m. an interview was conducted with LPN C. She confirmed that she trained LPN A on Saturday (10/20/2018). She stated that I don't ever remember seeing this women (Resident #1) with a tray in front of her. She said she recalled that the resident kept saying that she was hungry. She wanted food and wished she could have food. I don't know if she really understood what I was telling her about the food. I tried to explain to her when I would give her food in her tube. I knew that she was not supposed to get a tray of food. 9. On 11/28/2018 at 4:15 p.m. a phone interview was conducted with Certified Nursing Assistant (CNA) B, she stated that she worked the second shift at the facility, and worked on 10/20/2018. She explained her normal routine after she arrived at the facility, which is at 3:00 p.m. She makes rounds to see all of the residents that she will be caring for. She stated that on 10/20/2018 right after the start of her rounds Resident #1's roommate put on the call light. She said that she entered the room and a therapist also entered at the same time. CNA B confirmed that Resident #1 had a tray of food in front of her and was eating it when she approached her. She said that the tray contained regular food and added that it was not mechanical or pureed. She was unable to recall what food was on the tray. She said that food was missing from the tray. She could not recall how much was missing or had remained. CNA B said that the therapist removed the tray from the resident and took it out side out of the room. She said she did not know the therapist's name. 10. During a phone interview on 11/29/2018 at 2:00 p.m., the Physical Therapist (PTO) who evaluated Resident #1 on 10/20/18, said I am familiar with Resident #1, but I do not have her records in front of me. I have a full-time job elsewhere, so I only work at the facility on a PRN (as needed) basis, and mostly just on the weekends. I will have to answer based on memory from that time. The PTO was asked about her familiarity with Resident #1, and she said I believe she was able to communicate, at least enough to answer simple questions, like 'do you have any pain?' She was able to nod or say yes or no. She needed maximum assistance with mobility and transfers. I do not know about the level of assistance she needed for feeding, because that is not my area, and I do not deal with that. When asked to describe her visit with Resident #1 on (MONTH) 20, (YEAR), the PTO said I can't remember exactly what time I entered her room. I entered the facility around 12:00 p.m. and saw her shortly after that. I entered the room by myself, there was no one with me. She said that she was alone in her room. Resident #1 was sitting at the bedside. She was not eating, and there was no tray in front of her. If she had been eating, I would not have entered her room, because that is not polite. In regards to removal of food trays from resident rooms, PTO stated I would never remove a tray from the room. That is not part of my job. 11. The facility provided a copy of their Menu that was dated for (MONTH) 19 - (MONTH) 20, (YEAR). Regular diet: 10/19/18 Friday: Breakfast: Blueberry Pancake Squares, Choice of Eggs, Syrup, Margarine, OJ/Apple/Cranberry juice, 2% Milk, and Coffee/Tea. Lunch: Oven Baked Fish, Paprika Roasted Potato, Broccoli, Biscuit, and Oreo Cookie Blondies. Alternative: Black Jack Burger, Lettuce/Tomato & Onions. Dinner: Hot Open-faced Turkey Sandwich, Mashed Potatoes, California Vegetable Blend, Strawberry and Banana Cup, and Margarine. Alternative- Sausage and Sauerkraut. 10/20/18 Saturday: Breakfast: Hot or Cold Cereal, Scrambled Eggs, Harvest Pumpkin Muffin, Margarine, OJ/Apple/Cranberry, 2% Milk, Coffee/Tea. Lunch: BBQ Chicken Breast, Green Beans and Mushrooms, Macaroni and Cheese, Wheat Bread, Fruited Gelatin. Alternative: Cottage Cheese Fruit Plate. 12. Medical record review of the meal intake that was documented by the Certified Nursing Assistants for Resident #1 revealed: On 10/19/2018 the dinner meal was documented at 76-100% (coded as a 3). On 10/20/2018 her breakfast and lunch amount eaten was 76-100%. And her dinner meal was documented at 26-50 % (coded as a 1). On 10/21/2018 the amount eaten 51-75% for breakfast and for lunch. The documentation of the two day meal intake indicated four separate staff members. 13. On 11/27/2018 the facility provided a list of ten residents who currently reside at the facility and receive enteral tube feedings. The list was reviewed and it was identified that six of the residents were also able to receive food by mouth. Four residents were not able to receive any oral intake. Medical record review was conducted that revealed the three residents out of the four Residents (#3, 5, and 7) did not have a current order in place for oral intake. They additionally did not have an active Physician order [REDACTED].>On 11/28/2018 at 10:45 a.m. an interview was conducted with RN E. She confirmed that Resident #3 was NPO. She said that the order was in their electronic medical record. RN E demonstrated on the computer system where the physician orders [REDACTED]. The RNS went to the back of the hard chart. A plastic sheet was noted that contained two pockets. One pocket contained two diet change slips. She was asked if diet change slips are orders, and she answered yes. RN E confirmed that if there were no diet orders in the electronic medical record then the diet change slips should be followed. The nurse told the surveyor that if a resident asks for a tray or says they didn't get a tray that she would first confirm the diet to make sure they could eat and then ask dietary if a tray was sent out. If the resident wants more food and is hungry, there are snacks available nutritional rooms. 14. Review of Hospital Discharge Summary dated 10/22/2018 Showed: Nursing home called EMS because the patient was congested and had an O2 saturation in the 70s. Discharge Diagnosis: [REDACTED]. Weaned from [MEDICAL CONDITION] to nasal cannula. Remains stable on nasal cannula and oxygen is arranged for her home living situation. Intravenous (IV) to Oral (PO) [MEDICATION NAME] had promoted good diuresis. Breathing improved. 15. On 10/22/2018 the resident was transferred back to the Nursing Home. The time she arrived to the facility was not documented in Resident #1's medical record. Review of Transportation records from the Transcare Non-Emergency Transport Service show: Patient (Pt.) is found at hospital on humidified O2 @ 10 LPM via Nasal Cannula (NC) due to SPO2 90%. Time: 14:11 Monday, (MONTH) 22, (YEAR) -event transfer of patient care time. 16. Review of Nursing Home to Hospital Transfer Form dated 10/22/2018 time 6:54 p.m. Reason for transfer: Respiratory Arrest HR 102 O2 Sat 84% Nursing Home to Hospital Transfer Form (additional information) dated on 10/22/2018 time 7:16 p.m.: Additional Relevant information: Resident re-admit from hospital with O2 sat between 80-85% on 5 liters of O2 continuous via nasal cannula, orders from MD send resident back to the ER. 17. Review of the emergency room Report showed: That the Mode of arrival: ambulance 10/22/2018 8:08 p.m. (20:08:00) The patient presents with difficulty breathing. The onset 2 days ago. The course duration of symptoms is constant and worsening. Degree of onset moderate. Degree at present is moderate. The relieving factor is oxygen. Prior episodes: multiple ED visits. [AGE] year old female with a past history including dementia, femur fracture, [DIAGNOSES REDACTED], dysphagia, and malnutrition presents to the ED via EMS from Excel Rehab for evaluation of worsening shortness of breath and difficulty breathing that has been going on for 2 days. She was discharged from the hospital 6 hours prior to ED arrival. She was sent back to her rehab facility on 7L O2 nasal cannula, but per EMS the facility is only able to administer up to 5L and placed her on that. The patient rapidly fell into dyspnea, so the facility sent her back to the ED. Patient refused [MEDICAL CONDITION] en route to the ED and is currently refusing any interventions. Review of Chest x-ray dated on 10/22/2018 at 8:52 p.m. (comparison: 10/21/2018) showed: Impression: Worsening bilateral lung infiltrates and effusions either all related to [MEDICAL CONDITION] or a combination of [MEDICAL CONDITION] and pneumonitis. Initially patient was refusing ER care except for oxygen via NC. After some time, she agreed to labs and IV. Patient chest x-ray reviewed with her [MEDICAL CONDITION]- changes present. Patient states she does not want any further treatment as in refusing [MEDICATION NAME] after receiving [MEDICATION NAME]. She stated nitro makes her very nauseated. She is agreeable to hospice and has mental capacity to make this decision. She had been a hospice patient before. emergency room addendum: (dated 10/23/2018 at 6:26:00) She was sent to ED by the facility for further evaluation by hospice. Pt is awaiting evaluation by hospice who told previous ED physicians that they could not come until later this morning. Shortly after sign-out I called case management, 7:00 a.m., clinically the patient appears to be activity dying. I discussed the case with case management day shift and they recommended stat palliative care consultation she will attempt to get hospice to come in and see the patient. Re-examination/Revaluation Time: 10/23/18 07:40 Notes: Palliative care at bedside. Requesting de-escalation of oxygen. Awaiting hospice. Time: 10/23/18 08:24:00 Notes: Patient passed away peacefully. Nursing at bedside. 18. Past History noted per Hospital Record Review: On 8/27/2018 Resident #1 had an Echocardiogram performed at the hospital. Summary: Left ventricle was of normal size. a. Systolic function was normal Ejection fraction was estimated in the range of 60% to 65%. (Normal range: 50-75%) Mitral valve: There no evidence of stenosis. Aortic valve: There was no stenosis. Tricuspid valve: There was no evidence for tricuspid stenosis. Pulmonic valve: normal thickness no calcification. 19. On 11/27/2018 at 9:57 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated that the facility had only two Five Day Reportings since their last annual recertification survey that commenced on 11/02/2018. She stated that the first Five Day Report was sent in during the annual survey. That report was about herself and a resident that currently resides at the facility. The NHA stated that the second Five Day Report was for Resident #1. She revealed after their investigation it was determined as neglect. (# ) The NHA described the results of their investigation on 10/22/2018 Resident #1 was readmitted to the facility. The admitting Registered Nurse U (RN U) went to the nursing meeting while Resident #1 was still on the stretcher. The NHA stated Instead of the nurse assessing the patient to see if she had everything that she needed. She opted to go to the nursing meeting. The NHA said that they conducted an investigation that revealed at 4:00 p.m. the second shift nurse informed RN U that Resident #1 was having problems breathing. They immediately went to her bedroom and found Resident #1's skin color ashen in appearance. At that time they increased the oxygen up to 5 liters. She stated Resident #1 had been on oxygen at 2 liters for 90 minutes during that time. Her SPO2 was at 84%. They contacted the Physician and told him of the resident's vital signs. The Physician ordered them to transfer Resident #1 back to the hospital. The NHA stated she had asked RN U if she informed the Director of Nursing that she was getting a new admission. She stated that she had not. The NHA said that she had then asked RN U what she thought was a greater priority going to the nursing meeting or admitting a resident. She told me going to the nursing meeting. RN U had denied that the transportation personnel told her that Resident #1's oxygen level needed to be at 7 liters. The NHA said that RN U no longer works at that facility. Prior to the oxygen incident RN U had received several other disciplinary actions. One was related to a [MEDICAL TREATMENT], post fall education, safe medication administration, and education on the admission process. She stated that according to our disciplinary process the first thing we did was suspend her. The NHA said after our investigation, we ended up terminating her. We additionally reported her to the Florida Board of Nursing. The NHA stated that on all new admissions we strive to ensure that the equipment is here and available for the residents when they arrive. She said that we had a concentrator that delivers up to 10 Liters. The NHA was asked if the oxygen concentrator could be observed. She called a staff member on the phone and stated out loud that it had been returned to the supplier. 20. On 11/27/2018 at 2:45 p.m. an interview took place with Resident #1's Primary Physician. When asked about familiarity with Resident #1, the Physician said Yes, I saw Resident #1. She was admitted in September. She had a history of [REDACTED]. She was a very sweet lady, but she was very demented. I remember her well because she was always hungry. The Physician stated that the resident would say frequently 'that they forgot about me. They didn't bring me my breakfast or lunch' she was not aware that she couldn't eat. The Physician confirmed that whatever you put in front of her she would eat. When asked if the resident had any history or [DIAGNOSES REDACTED]. As far as my evaluations of her, she did not have heart failure. I saw her at least two times each week. The only symptom she had, was some bilateral lower extremity [MEDICAL CONDITION]. But she was on tube feeding and mostly sitting up, so it was not such a surprise if she had some [MEDICAL CONDITION] in her legs. She had no other signs that would indicate [MEDICAL CONDITIONS]. She had no shortness of breath or respiratory issues. She was not on any oxygen. When asked about the resident's multiple visits to the hospital during her stay at the facility, the Physician said I don't have her records in front of me, but she did have between two to three visits to the hospital while she was here. When she was admitted on (MONTH) 19th, she had just come back from the hospital. She had abdominal pain, and it was believed that her gastrostomy tube had dislodged. She had a Zenker's Diverticulum and dysphagia. So she was on a strict NPO diet; with full enteral nutrition. The Physician was asked about the resident's last hospital visit in October. She stated So, the resident returned from the hospital on [DATE]. I was notified by the nurse on 10/21/18, I believe it was before lunchtime, that Resident #1 had a change in her condition. The nurse told me that Resident #1 was in respiratory distress, and her oxygen saturation was very low. She also told me that the resident had been fed the day before (10/20/18), and that Resident #1 had eaten almost 100% of her meal. I told her, if that is the case, then we need to send the resident to the emergency room (ER) because she might have [MEDICAL CONDITION]. She had Zenker's Diverticulum and dysphagia, so giving her oral food could cause [MEDICAL CONDITION], because of aspiration, and also from food being stuck in there. In regards to oxygen orders, the Physician said I never ordered oxygen for this resident. I saw the nursing note stating that the nurse put Resident #1 on two to three Liters of oxygen before sending her to the hospital. If there was an order for [REDACTED]. I just told them to send her straight to the emergency room . Then on Monday, (10/22/18), the facility called me to let me know that the resident had returned, with orders from the hospital for 7 liters of oxygen. I was told that the resident looked very cyanotic. I called the hospital and told them that I could not accept a resident that needed more than 5 Liters of oxygen. I did not accept the resident and she was returned to the ER. I didn't hear anything else from the hospital until the next day, Tuesday. The ER physician called and informed me that the resident had passed away, and asked if I could sign the death certificate. I told him I was not in the hospital and the resident was not in my care when she passed away, so I would not sign the death certificate. That same day, I received calls from both the hospital and the funeral director, regarding signing the death certificate. But I refused to sign it. I told the Director of Nursing (DON) at this facility that the medical examiner would question why I did not sign the death certificate. The Physician stated that I told the DON that an adverse event had occurred at the facility and she needed to report it. She was informed that the facility did not have an adverse report for Resident #1 related to eating a meal. The Physician said that she wasn't aware it had not been reported. She then stated at one time I was a Medical Director for a facility and I know what needs to be reported. 21. On 11/29/2018 at 11:45 a.m. a phone call was received from a state agency Investigator. She stated that she had received a copy of Resident #1's death certificate. The cause of death per the Investigator: [MEDICAL CONDITIONS]. 22. On 12/03/2018 at 11:16 a.m. a phone interview was conducted with Resident #1's son. He said that his mother had lived with him for two years prior to her falling. The son stated that she had only taken one type of medication before going into the hospital. That was for swelling to her ankles. He denied that she ever used oxygen. He stated that he went to the facility to see her. When he arrived there was food all over her and in the bed. He stated that was two or three days before she passed. Resident #1's son said that normally they had a sign up on the wall or the door that said not to feed her but there was no sign that night. The son stated that she is not supposed to get any food by mouth. He added that she also had water on her bedside table that was positioned right in front of her. And that she was capable of picking it up and drinking from it. He was asked what she had eaten. He said that it looked like bread crumbs. She must have had something that was bread. She did not say what the food was, just that it was lousy. Resident #1's son was asked if he had told anyone of his concern when he was at the facility. He said that he had told the assistant. And you know how that goes they just tell you to talk to the nurse. The son was asked if his mother had ever been diagnosed with [REDACTED]. He also denied that his mother had any lung issues. When I was planning the funeral I found out that neither the rehab center nor the hospital would sign the death certificate. They had to get Vital Statistics involved and the cause of death was listed as [MEDICAL CONDITION]. I looked it up, it's lack of oxygen. It doesn't make sense to me. I do feel the facility was negligent in the way they handled her. 23. On 11/28/2018 at 12:10 p.m. an interview was conducted with the Director of Nursing (DON) after asking for copies of Resident #1's medical record. At that time she confirmed she was aware of the narrative nursing note that was dated on 10/21/2018. That Resident #1 had been witnessed eating a meal tray. The DON said that LPN C had been orienting LPN A to the unit on 10/20/2018. She stated that we spoke to the LPN C and she denied seeing a tray of food in front of the resident. She said that we could not find out if anyone had given her a tray. She stated that we looked at Resident #1's hospital reports and it didn't identify aspiration as she pointed to the record. It said [MEDICAL CONDITION]. At 2:54 p.m. an interview was conducted with the NHA and the DON. They stated they were both responsible for the facility Abuse and Neglect. The NHA confirmed at that time they saw the documentation that Resident #1 had a tray of food. She stated that we needed to conduct an investigation and that had started on Monday on the 22nd. She said that their process is to have a care management meeting and that includes going over the weekend events. The NHA stated that on Monday the 22nd the resident returned to the facility and that O2 situation happened. And then that kind of compounded it. We were still investigating with the staff. Not to say that it was a heightened issue but everything that surrounded the resident we started educating. The NHA stated that, during their investigation into Resident #1 receiving a meal tray, We spoke with the dietary department and that they indicated that they didn't send out a tray for Resident #1. They had no record of printing out a tray card for her. The NHA said that they had spoken with LPN A and she was asked why there hadn't been any documentation of Resident #1 eating. She told us that she was orientating with LPN C on that day. She told us that LPN C was also in room during her observation. CNA B had indicated she and a PTO entered Resident #1 bedroom to answer the resident's roommate call light. That was when the tray of food was noted. But the PTO stated that did not happen. We interviewed the CNA she said that she passed meal trays out. But she was unsure if she had given Resident #1 a tray. The NHA stated that we had seen that a certified nursing assistant had documented a meal amount % for Resident #1. We spoke to the CNA and she normally doesn't work that hall. So, we educated about documentation on meals. The NHA said that then we looked at all of the hospital record and i

Based on resident record review, review of the Advance Directives facility policy (Revised [DATE]) and interviews with the resident ' s father, the facility ' s nursing, medical, administrative staff, and Medical Director it was determined that the facility failed to protect the rights of a resident to have Cardio [MEDICAL CONDITION] Resuscitation (CPR) initiated in the event of [MEDICAL CONDITION] for one (#1) of 7 sampled residents of 81 residents identified as having Full Code status, according to the Advanced Directives List, provided by the facility and dated [DATE]. The facility did not initiate CPR on Resident #1, who was [AGE] years old and had not expressed wishes to have CPR withheld, nor had his Health Care Proxy expressed wishes for CPR to be withheld if he was found unresponsive. On [DATE], the resident was found unresponsive and absent of pulse and respirations, less than 24 hours after admission. The facility did not initiate CPR as per the resident ' s wishes and his Health Care Proxy ' s wishes. The facility failed to honor the resident ' s Advance Directives and he died without the opportunity to be resuscitated by receiving the services of CPR. Additionally, the facility failed to protect the right to form an Advance Directive for 2 (#2, #4) of 6 sampled residents out of a total of 29 residents listed as a full code and recently admitted (after [DATE]) in regards to residents who were documented as a full code on their medical record but wished to have a Do Not Resuscitate order (DNR). The failure to perform CPR when Resident #1 was found unresponsive resulted in findings of Immediate Jeopardy which were removed [DATE], and the severity and scope was reduced to a D. Findings include: 1. A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE], Wednesday, for skilled services with [DIAGNOSES REDACTED]. Review of the Physician ' s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (Resident ' s Overall Expectation): Expects to remain in this facility; by family. Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the CNA, who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the Resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the resident lived by himself for a while, and then he started living with his girlfriend . He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him. He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. A review of the facility policy: Advance Directives (Revised [DATE]), revealed a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 1. When a resident is admitted to our facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 3. When a resident is admitted to our facility, SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Policy Interpretation and implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Review of the resident ' s [DATE] Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other:, Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the resident and witnessed by Employee H on [DATE]. Review of the resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the residents initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and the physicians at this facility will not be able to follow the term on my Advanced Directives until I provide a copy of it to the staff; or I have not executed an Advanced Directive and do not wish to discuss Advanced Directives further at this time. The spaces to check either statement were blank. The form was signed by the resident and the Admissions Representative Employee H and dated [DATE]. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s physician orders dated [DATE] revealed a Code Status of Full Code. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s complete medical record including the closed record revealed no DNR form was present. Further review of Resident #1 ' s medical record revealed a document titled Activated Medical Decision Maker signed by the resident ' s father and mother and witnessed by two signatures on [DATE]. The document included the following language: The Determination of Incapacity form has been completed on [DATE]. I do hereby attest that I am at least [AGE] years of age or older and am willing to become involved in the above stated resident ' s health care decisions. I have maintained regular contact and am familiar with the resident ' s activities, health, religious and moral beliefs, so that I can make health care decisions, including withholding/withdrawing life prolonging decisions that would be the decisions the resident would have made, if capable. I am willing to produce clear and convincing evidence upon request. I understand that my role has become active and accept my responsibility, which is one of the following Medical Decision Maker designations: checked were Proxy and A parent of the resident. Review of Resident #1 ' s medical record revealed a Determination of Incapacity document dated [DATE] and signed by his attending physician. It included the following language: As attending physician for the above stated resident (Resident #1), I have evaluated and determined the above stated resident lacks the capacity to give informed consent to make medical decisions and does not have the reasonable medical probability of recovering mental and physical capacity to directly exercise rights. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the ADON had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. 2. Review of the medical record for Resident #2 revealed she was a [AGE] year old admitted originally on [DATE] (Friday) discharged on [DATE] against medical advice and was re-admitted on [DATE] ( Thursday) from the hospital, [DIAGNOSES REDACTED]. Review of the resident ' s [DATE] Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 13; indicating the resident was cognitively intact. Review of Resident #2 ' s Admission Agreement dated [DATE] (Friday) revealed an Advanced Directives Acknowledgement form. All blanks on the form for initials to signify that the resident had received the information and designated a choice of Full Code or DNR were not filled in. The form was signed by the resident on [DATE](Tuesday). Review of Resident #2 ' s medical record revealed an Admission Evaluation Tool dated [DATE]: admitted for [MEDICAL CONDITION]; Hypertension; History of [MEDICAL CONDITION] (remission); [MEDICAL CONDITION]; arrived via stretcher from hospital; weight 94 pounds; height: 5 ' 6 ; alert; bruising; assist with bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing; assistive device with a walker. The sections Living will, Organ Donor and Advance Directives Explained were all blank. Review of Resident #2 ' s medical record (for her first admission) revealed a Social Services Admission Evaluation Tool assessment dated [DATE] at 4:09 PM: lived with granddaughter for many years; no advanced directives at this time; resident makes her own decisions at this time; full code; sad mood; anticipated length of stay for 2 to 4 weeks, signed by the SSD. Review of Resident #2 ' s medical record (for her second admission) revealed an Admission Evaluation Tool dated [DATE](Thursday): arrived via stretcher from hospital due to weakness, UTI, status [REDACTED]. Extensive assistance for transfers, dressing, toileting, personal hygiene; bruising on upper bilateral arms; alert and oriented x 3. Review of Resident #2 ' s medical record revealed a Social Service Admission Evaluation Tool dated [DATE] at 5:32 PM: [AGE] year old female; no advanced directives at this time; resident makes her own decisions at this time; full code; sad mood; anticipated discharge 4 weeks to home with son and daughter-in-law. Review of the resident ' s medical record revealed a [DATE] Physician Order Sheet, under Code Status, there was a blank line. Neither Full Code nor DNR were written on the line provided to designate the Code Status. Review of Resident #2 ' s medical record revealed a Discharge Summary dated [DATE] at 10:55 AM: resident left the facility Against Medical Advice (AMA) resident ' s son was in the facility and took resident home. Resident able to make her decisions independently and had no cognitive deficit, signed by the SSD. Review of Resident #2 ' s medical record revealed a nursing progress note dated [DATE] at 6:58 PM: resident admitted from hospital with admitting [DIAGNOSES REDACTED]. Data collection stated findings as follow: old and new bruising noted on the upper extremities and lower extremities lung sounds clear to auscultation; bowel sounds heard all 4 quads; abdomen non-distended oriented to room, signed by the Unit manager. On [DATE] (one week after admission) at 7:45 AM an interview was conducted with Resident # 2. She was observed siting in a wheelchair at the bedside. When the resident was asked about her wishes for CPR if needed, she stated she did not want CPR. After conversing about other subjects the resident was asked again about advance directives, she stated, They have not asked me about that. When asked if she wanted CPR, she stated, don ' t want that. Don ' t want my family to suffer through that. On [DATE] at 1:49 PM an interview was conducted with the SSD. She stated in regards to Resident #2, like I showed you yesterday, I spoke with her (Resident #2) about advance directives and she doesn ' t have any. She does have a son. She doesn ' t want her son to make decisions for her. SSD was informed the advance directives acknowledgement form in Resident #2 ' s admission agreement packet was blank. She stated, Well I wouldn ' t know that. On [DATE] at 1:00 PM an interview was conducted with the NHA, the DON, and the Corporate Nurse (CN). The NHA stated that SS should be documenting discussions regarding advance directives in a progress note. On review of the electronic progress notes it was revealed that for Resident #2 there was no documentation from SS in the progress notes, and The NHA verified this. Review of Resident #2 ' s medical record revealed Social Service Progress Note dated [DATE] at 2:39 PM; which was a week after Resident #2 ' s latest re-admission found the following notation. Social Service Director and Social Services Assistant together went to speak with the resident about advanced directives. Resident stated she does not have any advanced directives at home. Do Not Resuscitation (DNR) order was explained. Resident was agreeable at this time to sign DNR order. Will follow up with DNR order. Signed by SSD. 3. Review of the medical record revealed Resident #4 was an [AGE] year old male admitted on [DATE](Friday) from the hospital with [DIAGNOSES REDACTED]. Review of Resident #4 ' s medical record, on [DATE], since admission ([DATE]) revealed there was no DNR form in the record. Review of Resident #4 ' s Admission Agreement dated [DATE], revealed an Advanced Directives Acknowledgement form signed by the resident ' s daughter. All the blank lines on the form for initials to signify that the daughter had received the information and designating a choice of Full Code or DNR were not filled in. Review of the resident ' s medical record revealed an undated Physician Order Sheet, page 1 of 2; under Code Status, there was a blank line. Neither Full Code nor DNR were written on the line provided to designate the Code Status. Review of Resident #4 ' s Admission Evaluation Tool dated [DATE] (Sunday) (admission date of [DATE]) revealed: arrived via wheel chair from hospital; [DIAGNOSES REDACTED]. situation; patient long term memory not good per family, [DIAGNOSES REDACTED].¼ side rails for bed mobility, signed by Employee C, an LPN. Review of the resident ' s [DATE] Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 6; indicating severe cognitive impairment. Review of the Social Service Admission Evaluation Tool dated [DATE] (Monday) revealed: [AGE] year old male born in Puerto Rico, lived in Puerto Rico until [DATE] when came to live with other daughter; no advanced directives on file at this time; Full Code; family visits daily; planning for Long Term Care. A review of the nursing progress notes revealed the following relevant entries, [DATE] at 2:47 PM: patient admitted via wheelchair from hospital; patient transported by family; Alert and oriented x 2; Speaks Spanish only; Daughters at bedside. Further review of Resident #4 ' s medical record revealed the resident went back to the hospital for a follow up visit on [DATE] and spent one night there. The record included a document of a verbal report given to the facility nurse from the hospital nurse titled Nurse to Nurse . It included the following documentation, [DATE] (Saturday, 8 days after admission) the resident ' s name , DNR/Do Not Intubate (DNI), Diagnoses, fatigue, low hemoglobin, hematocrit, dementia, [MEDICAL CONDITIONS], Hematology clinic, 2 units of Red Blood Cells, alert, oriented. Review of the Nurse ' s notes revealed [DATE] at 11:45 AM (Saturday, 8 days after admission), resident admitted from the hospital with a [DIAGNOSES REDACTED]. Skin has some abnormal findings right temple mass noted; nurse from hospital stated that a consult with dermatology/oncology was ordered for bone marrow shave/biopsy. Further review of the nurse ' s notes revealed [DATE] at 2:30 PM: attending physician was called by the supervisor. Supervisor updated physician on re-admit. No new orders; it is okay to resume previous orders. On [DATE] at 12:20 PM (Thursday, 13 days after admission and 5 days after returning from overnight stay at hospital) an interview was conducted with Resident #4 ' s daughter. When asked if the facility had spoken with her regarding her father ' s advance directives, she stated, no, no one had spoken with her on admission, [DATE] or on [DATE]. She stated she took her father to the hospital on [DATE] and the staff at the hospital spoke with her about advance directives due to his condition. The hospital physician stated we may need to think about DNR/DNI. We (the family) discussed the DNR the weekend after his visit to the hospital. We decided that a DNR order is what we wanted; we want him to be comfortable. I would

Based on facility policy review, review of clinical records, and interviews with the facility staff, Medical Director, physician and family it was determined that the facility failed to implement their own policies and procedures for Advanced Directives, Emergency Procedure-Cardiopulmonary Resuscitation (CPR) and failed to honor the wishes to receive CPR for one (#1) of 7 sampled residents of 81 residents identified as having Full Code status, according to an Advanced Directives List, provided by the facility and dated [DATE]. The facility failed to initiate CPR, in accordance with their Admission Agreement, on Resident #1, a [AGE] year old male. The resident had a current physician order documenting his code status as Full , meaning that he wanted CPR if found unresponsive. On [DATE], Resident #1 was found unresponsive, without a pulse or respirations, less than 24 hours after admission. The Facility failed to honor the wishes of the resident to be resuscitated. The facility failed to honor Resident #1 ' s advance directives and denied the resident the opportunity to receive emergency lifesaving services to prolong his life. Additionally, the facility failed to implement the Advance Directives policy for 2 (#2, #4) of 6 sampled residents out of a total of 29 residents listed as full code and recently admitted (after [DATE]). Residents #2 and #4 wished to have a Do Not Resuscitate order (DNR) but it was documented as a full code in their medical records. The failure to honor and carry out the expressed wishes to receive CPR, resulted in findings of Immediate Jeopardy which were removed on [DATE], and the severity and scope was reduced to D. Findings Include: 1. A review of the facility policy: Advance Directives (Revised [DATE]), revealed a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 1. When a resident is admitted to our facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 3. When a resident is admitted to our facility, SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Policy Interpretation and implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Emergency Procedure: Cardio [MEDICAL CONDITION] Resuscitation (CPR) ,(Revised [DATE]), documented the policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Policy and Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] many initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA. 4. The likelihood of recovering from SCA due to an acute event (such as arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that the end result of multi-system failure and advance irreversible or terminal conditions. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. 7. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; Preparation for Cardiopulmonary Resuscitation: 1. Obtain and /or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. Provide periodic Mock Codes (simulations of an actual arrest) for training purposes. 3. Select and identify a CPR team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR team in this facility shall include at least one registered nurse, one LPN/LVN and two CNAs, all of whom have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/ representative upon admission. Emergency Procedure - Cardiopulmonary resuscitation: 1. the facility ' s procedure for administrating CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). 3. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim ' s pulse. 4. Following the initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 5. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 6. Delivering high-quality chest compressions is essential: a. push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. B. Allow full chest recoil after each compression. C. Minimize interruptions in chest compressions. 7. Trained rescuers should also provide ventilations with a compression -ventilation ratio of 30:2. A review of the facility policy: Admission Assessment and Follow Up: Role of the Nurse from the Nursing Services Policy and Procedure Manual (Revised [DATE]). The purpose of this procedure is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the minimum data set (MDS). Steps in the Procedure: 10. Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her right to have advance directives and initiate the process of establishing them. Documentation: the following information should be recorded in the resident ' s medical record: 3. All relevant assessment data obtained during the procedure. 2. Review of the Resident #1 ' s Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other:, Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the resident and witnessed by Employee H on [DATE]. Review of the resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the Residents initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and the physicians at this facility will not be able to follow the term on my Advanced Directives until I provide a copy of it to the staff; or I have not executed an Advanced Directive and do not wish to discuss Advanced Directives further at this time. The spaces to check either statement were blank. The form was signed by the resident and the Admissions Representative Employee H and dated [DATE]. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s physician orders dated [DATE] revealed a Code Status of Full Code. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted on [DATE] (Wednesday). His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s complete medical record including the closed record revealed no Do Not Resuscitate (DNR) form was present. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE] for skilled services with [DIAGNOSES REDACTED]. Review of the Physician ' s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (resident ' s Overall Expectation): Expects to remain in this facility; by family. Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). Further review of Resident #1 ' s medical record revealed a document titled Activated Medical Decision Maker signed by the resident ' s father and mother and witnessed by two signatures on [DATE]. The document included the following language: The Determination of Incapacity form has been completed on [DATE]. I do hereby attest that I am at least [AGE] years of age or older and am willing to become involved in the above stated resident ' s health care decisions. I have maintained regular contact and am familiar with the resident ' s activities, health, religious and moral beliefs, so that I can make health care decisions, including withholding/withdrawing life prolonging decisions that would be the decisions the Resident would have made, if capable. I am willing to produce clear and convincing evidence upon request. I understand that my role has become active and accept my responsibility, which is one of the following Medical Decision Maker designations: checked were Proxy and A parent of the resident. Review of Resident #1 ' s medical record revealed a Determination of Incapacity document dated [DATE] and signed by his attending physician. It included the following language: As attending physician for the above stated resident (Resident #1), I have evaluated and determined the above stated resident lacks the capacity to give informed consent to make medical decisions and does not have the reasonable medical probability of recovering mental and physical capacity to directly exercise rights. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the Certified Nursing Assistant (CNA), who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the resident lived by himself for a while, and then he started living with his girlfriend. He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the ADON had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. 3. Review of the medical record revealed Resident #4 was an [AGE] year old male admitted on [DATE] (Friday) from the hospital with [DIAGNOSES REDACTED]. Review of Resident #4 ' s Admission Agreement, dated [DATE], revealed an Advanced Directives Acknowledgement form signed by the resident ' s daughter. All the blank lines on the form for initials to signify that the daughter had received the information and designating a choice of Full Code or DNR were not filled in. Review of the resident ' s medical record revealed an undated Physician Order Sheet, page 1 of 2; under Code Status, there was a blank line. Neither Full Code nor DNR were written on the line provided to designate the Code Status. On [DATE] at 12:20 PM an interview was conducted with Resident #4 ' s daughter. When asked if the facility had spoken with her regarding her father ' s advance directives, she stated, no, no one had spoken with her on admission, [DATE] or on [DATE]. She stated she took her father to the hospital on [DATE] and the staff at the hospital spoke with her about advance directives due to his condition. The hospital physician stated we may need to think about DNR/DNI. We (the family) discussed the DNR the weekend after his visit to the hospital. We decided that a DNR order is what we wanted; we want him to be comfortable. I would like to respect his wishes. Review of Resident #4 ' s medical record, on [DATE], since admission ([DATE]) revealed there was no DNR form in the record. Review of Resident #4 ' s Admission Evaluation Tool dated [DATE] (Sunday) (admission date of [DATE]) revealed: arrived via wheel chair from hospital; [DIAGNOSES REDACTED]. situation; patient long term memory not good per family, [DIAGNOSES REDACTED].¼ side rails for bed mobility, signed by Employee C, an LPN. Review of the Resident ' s [DATE] Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 6; indicating severe cognitive impairment. Review of the Social Service Admission Evaluation Tool dated [DATE] (Monday) revealed: [AGE] year old male born in Puerto Rico, lived in Puerto Rico until [DATE] when came to live with other daughter; no advanced directives on file at this time; Full Code; family visits daily; planning for Long Term Care. A review of the nursing progress notes revealed the following relevant entries, [DATE] at 2:47 PM: patient admitted via wheelchair from hospital; patient transported by family; Alert and oriented x 2; Speaks Spanish only; Daughters at bedside. Further review of Resident #4 ' s medical record revealed the resident went back to the hospital for a follow up visit on [DATE] and spent one night there. The record included a document of a verbal report given to the facility nurse from the hospital nurse titled Nurse to Nurse . It included the following documentation, [DATE] (Saturday, 8 days after admission) the resident ' s name , DNR/Do Not Intubate (DNI), Diagnoses, fatigue, low hemoglobin, hematocrit, dementia, [MEDICAL CONDITIONS], Hematology clinic, 2 units of Red Blood Cells, alert, oriented. Review of the Nurse ' s notes revealed [DATE] at 11:45 AM (Saturday, 8 days after admission), resident admitted from the hospital, with a [DIAGNOSES REDACTED]. Skin has some abnormal findings right temple mass noted; nurse from hospital stated that a consult with dermatology/oncology was ordered for bone marrow shave/biopsy. Further review of the nurse ' s notes revealed [DATE] at 14:30: attending physician was called by the supervisor. Supervisor updated physician on re-admit. No new orders; it is okay to resume previous orders. On [DATE] at 1:00 PM (Thursday, 13 days after admission and 5 days after returning from overnight stay at hospital): an interview was conducted with the NHA, the DON, and the Corporate Nurse (CN). The NHA, the DON and the CN were shown Resident #4 ' s admission agreement packet, including the Advanced Directives Acknowledgement form, with blank li

Based on review of resident medical and admission records, review of facility policies and procedures and interview with facility staff, a resident ' s family member, the attending physician, and the Medical Director, it was determined the facility failed to honor the advance directives of one (Resident #1) of 7 sampled residents of 81 residents identified as having Full Code orders according to the Advance Directive Audit Tool, provided by the facility and dated [DATE]. The staff did not fulfill a care taking obligation of providing goods and services necessary to avoid physical harm or mental anguish consistent with their Abuse, Neglect and Exploitation policy and procedure (no date). On [DATE], Resident #1, a [AGE] year old male, was found unresponsive, without pulse or respirations, less than 24 hours after admission. The resident had a current physician order documenting his code status as Full , meaning that he wanted CPR, if found unresponsive. The facility failed to honor Resident #1 ' s wishes regarding his advance directives to be resuscitated and denied the resident the opportunity to receive emergency lifesaving services to prolong his life. The facility failed to follow their policy and procedure, in regards to, its Advance Directives (Revised [DATE]), Emergency Procedure-CPR (Revised [DATE]) and Abuse, Neglect and Exploitation (no date). Failure of the facility staff to provide the services necessary to honor and fulfill the expressed wishes of the resident to receive CPR, resulted in findings of Immediate Jeopardy which were removed on [DATE] and the severity and scope was reduced to D. Findings include: 1. A review of the facility policy: Abuse, Neglect and Exploitation: Prevention and Prohibition (Not dated), revealed a Standard: The prevention and prohibition of abuse, neglect and exploitation. To an environment within the facility which promotes resident well-being, safety and prohibits abuse, neglect, involuntary seclusion, and the misappropriation of property for all residents. I. Furthermore, each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. II. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility ' s identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. Definitions: 7. Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CFR 488.301) Procedures: 1. Screening: a. The facility screens potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements a 483.13 © (1) (ii) (A) (B).This includes attempting to obtain information from previous employers and /or current employers and checking with the appropriate licensing boards and registries. Screening is done on all employees prior to hire. 2. Training: a. Each team member is scheduled to attend a general orientation session. b. Each team member is offered and asked to attend a facility in-service where the information is reviewed as needed throughout the year. c. each team member is notified that a mandatory Abuse Prevention in-service is scheduled on an annual basis. This in-service includes: 1. Appropriate interventions to deal with aggressive and / or catastrophic reactions; 4. What constitutes abuse, neglect and misappropriation of resident property. 3. Prevention: Every effort is made on behalf of the resident to prevent abuse. This includes an analysis of: a. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; b. the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that staff assigned have knowledge of the individual residents ' care needs. C. the supervision of staff to identify inappropriate behaviors, such as .ignoring residents while giving care, .and d. the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as resident with communication disorders, those that require heavy nursing care and/or the totally dependent on staff. Each team member reads and signs the Resident Rights upon employment. A copy of the resident rights is given to each team member within his/her probationary period of employment. This information is reviewed on an annual basis by the Social Services staff in an all-staff in-service. Identification: Each team member is encouraged to attend a mandatory Abuse Prevention in--service on an annual basis. This in-service includes methods to identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. Investigation: the Social Services Manager is the facility appointed designee who is the staff member responsible for the initial reporting, investigation of alleged violations and reporting results to proper authorities. The facility policy for any allegation of abuse is for it to be brought immediately to the attention of the immediate supervisor. The supervisor is to notify the Social Services Manager, who is the facility appointed designee, the DON, and the Administrator .the facility will also notify the appropriate agencies, based on the nature of the allegation in accordance with State and Federal Statute. Protection: the facility will make every effort to protect any individual form abuse, .If the allegation of abuse is against a team member, the team member will be immediately removed from duty during the investigation, and until it is complete. Reporting/Response: the facility will report all alleged violations to [DATE]-ABUSE, and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation; report to the state, or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for services; and analyze the occurrences to determine what changes are needed if any, to policies and procedures to prevent further occurrences. Federal abuse, neglect, and exploitation guidelines will also be followed by the abuse reporting designee. 2. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE] (Wednesday) for skilled services with [DIAGNOSES REDACTED]. Review of the Physician ' s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the Certified Nursing Assistant (CNA), who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the Assistant Director of Nursing (ADON) had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the resident lived by himself for a while, and then he started living with his girlfriend. He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him. He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. Review of the Resident #1 ' s Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other: Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the resident and witnessed by Employee H on [DATE]. Review of the resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the resident ' s initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and the physicians at this facility will not be able to follow the term on my Advanced Directives until I provide a copy of it to the staff; or I have not executed an Advanced Directive and do not wish to discuss Advanced Directives further at this time. The spaces to check either statement were blank. The form was signed by the resident and the Admissions Representative Employee H and dated [DATE]. Review of Resident #1 ' s medical record revealed a Determination of Incapacity document dated [DATE] and signed by his attending physician. It included the following language: As attending physician for the above stated resident (Resident #1), I have evaluated and determined the above stated resident lacks the capacity to give informed consent to make medical decisions and does not have the reasonable medical probability of recovering mental and physical capacity to directly exercise rights. Further review of Resident #1 ' s medical record revealed a document titled Activated Medical Decision Maker signed by the resident ' s father and mother and witnessed by two signatures on [DATE]. The document included the following language: The Determination of Incapacity form has been completed on [DATE]. I do hereby attest that I am at least [AGE] years of age or older and am willing to become involved in the above stated resident ' s health care decisions. I have maintained regular contact and am familiar with the resident ' s activities, health, religious and moral beliefs, so that I can make health care decisions, including withholding/withdrawing life prolonging decisions that would be the decisions the resident would have made, if capable. I am willing to produce clear and convincing evidence upon request. I understand that my role has become active and accept my responsibility, which is one of the following Medical Decision Maker designations: checked were Proxy and A parent of the resident. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the Resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. Review of Resident #1 ' s physician orders dated [DATE] revealed a Code Status of Full Code. Review of Resident #1 ' s complete medical record including the closed record revealed no Do Not Resuscitate (DNR) form was present. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (resident ' s Overall Expectation): Expects to remain in this facility; by family. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. 3. A review of the facility policy: Advance Directives (Revised [DATE]), revealed a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 1. When a resident is admitted to our facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 3. When a resident is admitted to our facility, SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Policy Interpretation and implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Emergency Procedure: Cardio [MEDICAL CONDITION] Resuscitation (CPR) ,(Revised [DATE]), documented the policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Policy and Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] many initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA. 4. The likelihood of recovering from SCA due to an acute event (such as arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that the end result of multi-system failure and advance irreversible or terminal conditions. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. 7. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; Preparation for Cardiopulmonary Resuscitation: 1. Obtain and /or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. Provide periodic Mock Codes (simulations of an actual arrest) for training purposes. 3. Select and identify a CPR team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR team in this facility shall include at least one registered nurse, one LPN/LVN and two CNAs, all of whom have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/ representative upon admission. Emergency Procedure - Cardiopulmonary resuscitation: 1. the facility ' s procedure for administrating CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). 3. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim ' s pulse. 4. Following the initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 5. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 6. Delivering high-quality chest compressions is essential: a. push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. B. Allow full chest recoil after each compression. C. Minimize interruptions in chest compressions. 7. Trained rescuers should also provide ventilations with a compression -ventilation ratio of 30:2. A review of the facility policy: Admission Assessment and Follow Up: Role of the Nurse from the Nursing Services Policy and Procedure Manual (Revised [DATE]). The purpose of this procedure is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the minimum data set (MDS). Steps in the Procedure: 10. Determine if the resident has existing advance directives. If so, initiate the process of obtaining a

Based on review of the Florida Nurse Practice Act, the Assistant Director of Nursing job description (Revised [DATE]), resident record review and interviews with facility staff, Medical Director, a resident ' s father, and the attending physician, it was determined that the facility failed to ensure that services being provided met professional standards of quality relating to the initiation of Cardiopulmonary Resuscitation (CPR) as per the resident ' s wishes for one (#1) of 7 sampled residents of 81 total residents, identified as having Full Code orders, according to the facility ' s Advance Directive Audit List, provided by the facility and dated [DATE]. On [DATE], Resident #1, a [AGE] year old male, was observed by staff to be unresponsive and absent of vital signs, less than 24 hours after admission. The Assistant Director of Nursing did not initiate Cardiopulmonary Resuscitation (CPR) and ensure emergency medical services were provided. The clinical record contained a physician order [REDACTED]. The facility failed to honor Resident #1 ' s advance directives and denied the resident the opportunity to receive emergency lifesaving services to prolong his life. Failure of the facility to ensure nurses met professional standards and acted in accordance with the Nurse Practice Act as defined in the Florida Statues, Chapter 464, resulted in Immediate Jeopardy, which were removed on [DATE], and the severity and scope was reduced to D. Findings include: 1. The Florida Nurse Practice Act, Chapter 464.003 defines the (20) practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administrations of medications and treatments a prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. A profession nurse is responsible and accountable for making decisions that are based upon the individual ' s educational preparation and experience in nursing. 2. Review of the Assistant Director of Nursing job description (Revision Date: [DATE]) included: Purpose of Your Job Position: The primary purpose of your position is to assist the Director of Nursing Services (DON) in planning, organizing, developing, and directing the day-to-day function of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and as may be directed by the Administrator, the Medical Director, and/or DON to ensure the highest degree of quality care is maintained at all times. Duties and Responsibilities: Administrative Functions: Assist the DON in planning, developing, organizing, implementing, evaluating, and directing the day-to-day functions of the nursing service department, in accordance with current rules, regulations, and guidelines that govern the Facility. Participate in developing, maintaining, and updating our written policies and procedures that govern the day-to-day functions of the nursing service department. Periodically review the department ' s policies, procedure manuals, job descriptions, etc. Make recommendations for revisions of policies, procedures, etc. to the Director. Participate in the development, maintenance, and implementation of the Facility ' s quality assurance program for the nursing service department. Monitor the Facility ' s QI, QM and survey reports and provide the Director with recommendations that will be helpful in eliminating problem areas. Committee Functions: Serve on the Quality Assurance and Assessment Committee, as directed. Assist the Director in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee (s). Personnel Functions: Assist the Director in determining the staffing needs of the nursing service department. Nursing Care Functions: Provide the Director with information relative to the nursing needs of the resident and to the nursing services department ' s ability to meet those needs. Review nurses ' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident ' s response to the care, and that such care is provided in accordance with the resident ' s wishes. Schedule daily rounds to observe residents and to determine if nursing needs are being met. Report problem areas to the Director. Assist in developing and implementing corrective action. Staff Development: Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department. Develop, implement, and maintain an effective orientation program that orients the new employee to the department, its policies and procedures, and to his/her job position and duties. Assist in developing annual Facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.). Assist in developing advance directive in-service training programs for the staff and community. Care Plan and Assessment Functions: Participate in the development of a written care plan (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional serviced is responsible for each element of care. Encourage the resident and his/her family to participate in the development and review of the resident ' s plan of care. Ensure that all personnel involved in providing care to the resident are aware of the resident ' s care plan. Ensure that nursing personnel refer to the resident ' s care plan prior to administering daily care to the resident. Review nurses ' notes to determine if the care plan is being followed. Be sure that staff members are providing care that reflects the wishes of the resident. Resident Rights: Review complaints and grievance ' s made by the resident and make a written or oral report to the DON. Report all allegations of resident abuse and/or misappropriation of resident property. 3. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the Certified Nursing Assistant (CNA), who found Resident #1 unresponsive on [DATE]. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to Resident #1 when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t ' verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR. Honestly, when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. A review of the closed clinical record for Resident #1 revealed a Nurse ' s Note dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). Review of Resident #1 ' s demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE] (Wednesday) for skilled services with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. Review of Resident #1 ' s physician orders [REDACTED]. Review of Resident #1 ' s complete medical records revealed no Do Not Resuscitate (DNR) form was present. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of Resident #1 ' s Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (Resident ' s Overall Expectation): Expects to remain in this facility; by family. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the resident lived by himself for a while, and then he started living with his girlfriend. He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him. He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the ADON had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. 4. On [DATE] at 5:00 PM an interview was conducted with the NHA. In regards to the facility response to the incident of Resident #1 not receiving CPR when necessary she stated, We started an investigation and a Quality Assurance Performance Plan (QAPI) immediately. We sent the ADON home for the day on suspension. We reviewed the policy and procedures for advance directives, DNR, Code Blue Roles and Responsibilities, and the Emergency Procedure for CPR. We interviewed the staff regarding their ability to verbalize the CPR process. We normally complete an audit of the advance directives and DNR orders monthly. The SSD initiated an immediate audit for Advance Directives and DNR for the entire resident population and it was completed by [DATE]. We were monitoring / reviewing the charts of residents who expired. We started in-service training regarding advance directives and CPR and called a Code Blue Drill. Multiple interviews of the staff were initiated to ensure the direct staff knew about advance directives, CPR and when to call a code. Training was conducted in March for the entire facility. The DON did immediate in-servicing with the ADON and we completed a Federal report. We have been conducting weekly QA meetings regarding the event. These meetings will continue weekly through June and then occur monthly . When asked when staff training had been conducted prior to the last couple of months, she stated, we do it routinely and new hires get it at orientation. When asked how the facility audits the employee records for current CPR she stated, the Human Resource (HR) manager does an audit, which includes reviewing CPR cards. When asked if the event had been presented to the QA committee with an action plan she stated, Yes . On [DATE] the NHA provided a QA Book , it contained the Quality Assurance Performance Improvement Plan for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director on [DATE]. A review of the information provided revealed policy revisions dated [DATE] for Do Not Resuscitate Order , Advance Directives which includes Code Blue Roles and Responsibilities and Emergency Procedure - Cardiopulmonary Resuscitation. Review of these revisions revealed the following relevant changes: Code Blue Roles and Responsibilities (no effective date): In the event that a resident is found in cardiopulmonary arrest the person discovering the arrest should immediately notify a nurse of the situation. A teammate should page overhead that there is a Code Blue and the location of the code. All available teammates are responsible to respond to a Code Blue Page. The nurse is responsible to immediately assess the resident to determine if the resident is in cardiopulmonary arrest. The resident ' s medical record will be obtained to determine if the resident has a (DNR) document in their record. (may check YELLOW BINDERS at each nurses station for DNR status) if the DNR is noted then there will be no further interventions implemented as per the resident ' s advance directives. If there is no DNR in the medical record then CPR is to be initiated on the resident. Nurses are responsible for the implementation of CPR on the resident. The nurse assigned to the resident will act as the TEAM LEADER of the code situation. Certified Nursing Assistants who are CPR certified may be directed to assist with CPR at the direction of the nurse. On [DATE] signature sheets were provided for the following in-services, dated ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. In addition mock Code Blue drills were done on ,[DATE], ,[DATE], ,[DATE], [DATE]. All documents that were provided to the survey team were reviewed. A comparison was made between the in-service signature sheets and the master list of all employees. The comparison revealed that as of [DATE] 91% of licensed nurses and 97% of the unlicensed staff had completed the training. Interviews with the facility staff regarding advanced directives, CPR and Code Blue drills were conducted in order to verify staff knowledge. The following relevant interviews were obtained: On [DATE] at 4:24 PM, an interview was conducted with Employee C a nurse; she stated she worked full time on the 7:00 AM -3:00 PM shift. She stated she had been part of a mock Code Blue drill a couple of months ago and that we just had an in-service on where to find the DNR forms, in the yellow book. When asked how she would respond if a CNA said a resident was unresponsive she stated she would check the resident, have someone at the desk check the DNR book. I would initiate CPR until I determined if the resident had a DNR order then I would stop CPR. On [DATE] at 4:32 PM an interview was conducted with Employee D a nurse, who stated she worked full time on the 7:00 AM -3:00 PM shift. She stated she had training on DNR, advanced directives and participated in mock Code Blue drills a few months ago and again in June. She also stated If I found someone unresponsive; I would start CPR, shout for someone to go to DNR book. If they were a DNR, I would stop CPR. I would call the physician and family. If they were a full code I would keep going until the paramedics come. On [DATE] at 4:40 PM an interview was conducted with Employee E a nurse, she stated she usually worked as needed on the 3:00 PM -11:00 PM shift. She stated that during orientation they discussed advance directives and DNR orders. She had training in the last couple of months on advance directives and did a mock Code Blue drill also. If a resident was found unresponsive she stated she would, check the resident, yell for help, and send someone to get more help. I would start CPR. There is a DNR book; I would send someone to check. If I have started CPR and find out the resident is a DNR, then I would stop. I would start CPR before I knew if they were a DNR or not. [DATE] at 7:22 AM an interview was conducted with Employee F a nurse, he stated he usually worked the 11:00 PM -7:00 AM shift. He stated We had a Mock Code Blue training recently. We recently had a class on advance directives and DNR. The training included: making sure we have advance directives, if resident is confused, speak with the family, check the chart for the yellow DNR form, make sure a POA is in the chart also. He was asked what he would do if he found an unresponsive resident, he stated first assess for breathing, call a code, call somebody by name to call 911. Check Vital signs, call for crash cart. Call another person to look at DNR form. I would start compressions right away, and if found they were a DNR would stop compressions. During the interview conducted on [DATE] at 5:15 PM with the DON she stated that what she would expect that if a resident was found unresponsive and had a Full Code status the nurse should start CPR. She was asked if a nurse should start CPR prior to finding out about a resident ' s DNR order. She stated, The nurse should know if the resident is a DNR or not before they start CPR. If the nurse starts CPR and finds out the resident is a DNR, the nurse can stop. That is what I was told during my CPR class. When asked if that was in the facility policy, she stated, It is not in our policy, so I do not teach that in the in-service classes. The DON was informed that 3 out of 7 nurses interviewed so far stated they would start CPR when they found an unresponsive resident and then stop CPR if they found the resident was a DNR. She was asked if the facility conducted training since the event. She stated yes, we started in March, after the event and we have given in-services again recently. This training covered DNR orders and advance directives. The training is also being done on orientation. She stated, We did the training for the whole month of March, because we had to get everybody. And then we just did it again. In addition, a Quality Assessment Performance Improvement (QAPI) was started, the day of the event. The Quality Assurance (QA) committee was informed. We did training with the CNAs and nurses and also preformed mock code blues. When asked if training had been performed in the past, stated, Yes, the in-service is done yearly and during orientation. In addition, the DON was also asked, how the facility audits the employee records for current CPR, she stated, when we have new employee starting Human Resources (HR) sees the card and then the ADON checks the CPR card after that. All nurses are supposed to be CPR certified. When asked if the facility had audited the employee records for current CPR, she stated Yes, the ADON audits CPR monthly and HR does it on hire. The DON stated the SS department monitors, audits the advance directives, and reviews DNR orders monthly. The DON stated the event had been presented to the Quality Assurance (QA) committee and an action plan and plan of correction was put into place. The DON completed the Federal report and reported it to the corporate nurse. The DON stated, The direction I got was to do education, and do mock codes, and file a federal report. On [DATE] at 2 PM, an interview was conducted with the NHA and the DON to review the content of the training in-services. The NHA and DON stated, we went over the following policies: DNR policy (which included what to look for, DNR orders and book, where to find the DNR paper, etc.), Advance Directive policy and Code Blue policy (described a mock code blue, if staff walk in on an unresponsive resident what you would do), and the Emergency procedure policy. It was a verbal presentation and every nurse received a packet. The expectation was for nursing / CNA staff to receive training by the first QAPI meeting. By the first QAPI we were almost at 100%. The concern regarding interviews with 4 of 8 nurses on [DATE] and [DATE] by the surveyor which revealed the nurses would start CPR prior to knowing the resident ' s code status was discussed. The DON stated, That is not what they were trained to do. The NHA and the DON stated they would begin retraining the nursing staff that day. On [DATE] at 1:00 PM an interview was conducted with the NHA and the Corporate Nurse (CN). When asked when the Policy and Procedure for advance directives and DNR were last reviewed, the Corporate Nurse (CN) stated the Policy and procedure for advance directives and Do Not Resuscitate was reviewed and updated on [DATE] , after the event with Resident #1. He further stated that the Emergency Procedure CPR was also updated, which included the Code Blue Roles and Responsibilities. 5. Record reviews and interviews revealed the following corrective action was taken: On [DATE] in-service signature sheets were reviewed for retraining of the nursing staff, regarding advance directives, CPR, DNR, and code blue drills. The NHA verified that all nursing staff with the exception of one employee that was unavailable had received the in-service retraining. The NHA verified that this employee will not return to work until they have

Based on review of facility ' s policies and procedures, resident record review, and interviews with facility staff, Medical Director, a resident ' s father, and the attending physician, it was determined that the facility failed to implement advance directives of Cardiopulmonary Resuscitation (CPR) in accordance with the written plan of care and physician ' s orders for one (#1) of 7 residents sampled, of 81 total residents, identified as having Full Code orders, according to the facility Advance Directive Audit List, provided by the facility and dated [DATE]. On [DATE], Resident #1, a [AGE] year old male, was discovered by the staff unresponsive, without pulse or respirations less than 24 hours after admission. The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or contact Emergency Medical Services as per the resident ' s wishes. The clinical record contained a physician order for [REDACTED]. The facility failed to honor Resident #1 ' s advance directives and denied the resident the opportunity to receive emergency lifesaving services to prolong his life. The staff did not ensure the resident ' s advance directives, which were in effect for Full Code, were carried out in accordance with the resident ' s plan of care. Additionally, interviews with 4 of 8 licensed nurses (Employees C, D, E, & F) on [DATE] and [DATE] revealed they would begin performing CPR without first verifying the plan of care and physician orders in the event a resident was found without pulse or respirations. Failure to follow the plan of care for Resident #1 and to ensure the facility staff correctly implemented advance directives and initiated CPR resulted in Immediate Jeopardy, which were removed on [DATE], and the severity and scope was reduced to D. Findings Include: 1. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE] (Wednesday) for skilled services with [DIAGNOSES REDACTED]. Review of the Physician ' s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Review of Resident #1 ' s physician orders dated [DATE] revealed a Code Status of Full Code. Review of Resident #1 ' s complete medical record including the closed record revealed no Do Not Resuscitate (DNR) form was present. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM, patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of the facility policy: Admission Assessment and Follow Up: Role of the Nurse from the Nursing Services Policy and Procedure Manual (Revised [DATE]). The purpose of this procedure is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the minimum data set (MDS). Steps in the Procedure: 10. Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her right to have advance directives and initiate the process of establishing them. Documentation: the following information should be recorded in the resident ' s medical record: 3. All relevant assessment data obtained during the procedure. Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. Review of the Resident #1 ' s Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other:, Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the Resident and witnessed by Employee H on [DATE]. Review of the Resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the Residents initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and the physicians at this facility will not be able to follow the term on my Advanced Directives until I provide a copy of it to the staff; or I have not executed an Advanced Directive and do not wish to discuss Advanced Directives further at this time. The spaces to check either statement were blank. The form was signed by the Resident and the Admissions Representative Employee H and dated [DATE]. Further review of Resident #1 ' s medical record revealed a document titled Activated Medical Decision Maker signed by the resident ' s father and mother and witnessed by two signatures on [DATE]. The document included the following language: The Determination of Incapacity form has been completed on [DATE]. I do hereby attest that I am at least [AGE] years of age or older and am willing to become involved in the above stated Resident ' s health care decisions. I have maintained regular contact and am familiar with the Resident ' s activities, health, religious and moral beliefs, so that I can make health care decisions, including withholding/withdrawing life prolonging decisions that would be the decisions the Resident would have made, if capable. I am willing to produce clear and convincing evidence upon request. I understand that my role has become active and accept my responsibility, which is one of the following Medical Decision Maker designations: checked were Proxy and A parent of the resident. Review of Resident #1 ' s medical record revealed a Determination of Incapacity document dated [DATE] and signed by his attending physician. It included the following language: As attending physician for the above stated Resident (Resident #1), I have evaluated and determined the above stated resident lacks the capacity to give informed consent to make medical decisions and does not have the reasonable medical probability of recovering mental and physical capacity to directly exercise rights. A review of the facility policy: Advance Directives (Revised [DATE]), revealed a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 1. When a resident is admitted to our facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 3. When a resident is admitted to our facility, SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Policy Interpretation and implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Review of Resident #1 ' s medical record revealed the Resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the Resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s medical record revealed the Resident was discharged to the hospital on [DATE] and readmitted on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the Resident ' s [DATE] readmission to the facility. A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (Resident ' s Overall Expectation): Expects to remain in this facility; by family. Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the Resident lived by himself for a while, and then he started living with his girlfriend and got on crack . He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him, after he got on that crack. He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the Certified Nursing Assistant (CNA), who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the Resident. On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. A review of the facility policy: Emergency Procedure: Cardio [MEDICAL CONDITION] Resuscitation (CPR) ,(Revised [DATE]), documented the policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Policy and Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] many initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA. 4. The likelihood of recovering from SCA due to an acute event (such as arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that the end result of multi-system failure and advance irreversible or terminal conditions. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. 7. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; Preparation for Cardiopulmonary Resuscitation: 1. Obtain and /or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. Provide periodic Mock Codes (simulations of an actual arrest) for training purposes. 3. Select and identify a CPR team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR team in this facility shall include at least one registered nurse, one LPN/LVN and two CNAs, all of whom have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/ representative upon admission. Emergency Procedure - Cardiopulmonary resuscitation: 1. the facility ' s procedure for administrating CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). 3. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim ' s pulse. 4. Following the initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 5. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 6. Delivering high-quality chest compressions is essential: a. push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. B. Allow full chest recoil after each compression. C. Minimize interruptions in chest compressions. 7. Trained rescuers should also provide ventilations with a compression -ventilation ratio of 30:2. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she states she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the Resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the Resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the Resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the ADON had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 5:15 PM an interview was conducted with the DON, when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the ADON stated that Resident #1 had passed. The DON asked the ADON if she had performed CPR, the ADON, said, no. I stated to the ADON that she should have called a code and the ADON, stated she did not do it. I educated the ADON right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed Employee A who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated she reviewed the medical record and The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the ADON, decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. 2. On [DATE] at 5:00 PM an interview was conducted with the NHA. In regards to the facility response to the incident of Resident #1 not receiving CPR when necessary she stated, We started an investigation and a Quality Assurance Performance Plan (QAPI) immediately. We sent the ADON home for the day on suspension. We reviewed the policy and procedures for advance directives, DNR, Code Blue Roles and Responsibilities, and the Emergency Procedure for CPR. We interviewed the staff regarding their ability to verbalize the CPR process. We normally complete an audit of the advance directives and DNR orders monthly. The SSD initiated an immediate audit for Advance Directives and DNR for the entire resident population and it was completed by [DATE]. We were monitoring / reviewing the charts of residents who expired. We started in-service training regarding advance directives and CPR and called a Code Blue Drill. Multiple interviews of the staff were initiated to ensure the direct staff knew about advance directives, CPR and when to call a code. Training was conducted in March for the entire facility. The DON did immediate in-servicing with the ADON and we completed a Federal report. We have been conducting weekly QA meetings regarding the event. These meetings will continue weekly through June and then occur monthly . When asked when staff training had been conducted prior to the last couple of months, she stated, we do it routinely and new hires get it at orientation. When asked how the facility audits the employee records for current CPR she stated, the Human Resource (HR) manager does an audit, which includes reviewing CPR cards. When asked if the event had been presented to the QA committee with an action plan she stated, Yes . On [DATE] the NHA provided a QA Book , it contained the Quality Assurance Performance Improvement Plan for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director on [DATE]. A review of the information provided revealed policy revisions dated [DATE] for Do Not Resuscitate Order , Advance Directives which includes Code Blue Roles and Responsibilities and Emergency Procedure - Cardiopulmonary Resuscitation. Review of these revisions revealed the following relevant changes: Code Blue Roles and Responsibilities (no effective date): In the event that a resident is found in cardiopulmonary arrest the person discovering the arrest should immediately notify a nurse of the situation. A teammate should page overhead that there is a Code Blue and the location of the code. All available teammates are responsible to respond to a Code Blue Page. The nurse is responsible to immediately assess the resident to determine if the resident is in cardiopulmonary arrest. The resident ' s medical record will be obtained to determine if the resident has a (DNR) document in their record. (may check YELLOW BINDERS at each nurses station for DNR status) if the DNR is noted then there will be no further interventions implemented as per the resident ' s advance directives. If there is no DNR in the medical record then CPR is to be initiated on the resident. Nurses are responsible for the implementation of CPR on the resident. The nurse assigned to the resident will act as the TEAM LEADER of the code situation. Certified Nursing Assistants who are CPR certified may be directed to assist with CPR at the direction of the nurse. On [DATE] signature sheets were provided for the following in-services, dated ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. In addition mock Code Blue drills were done on ,[DATE], ,[DATE], ,[DATE], [DATE]. All documents that were provided to the survey team were reviewed. A comparison was made between the in-service signature sheets and the master list of all employees. The comparison revealed that as of [DATE] 91% of licensed nurses and 97% of the unlicensed staff had completed the training. Interviews with the facility staff regarding advanced directives, CPR and Code Blue drills were conducted in order to verify staff knowledge. The following relevant interviews were obtained: On [DATE] at 4:24 PM, an interview was conducted with Employee C a nurse; she stated she worked full time on the 7:00 AM -3:00 PM shift. She stated she had been part of a mock Code Blue drill a couple of months ago and that we just had an in-service on where to find the DNR forms, in the yellow book. When asked how she would respond if a CNA said a resident was un

Based on clinical record review, policy and procedure review for Advance Directives , Emergency Procedures-Cardiopulmonary Resuscitation (CPR) , Code Blue Roles and Responsibilities and Abuse, Neglect and Exploitation, Nursing Home Administrator job description, and interviews with staff, family and physicians, it was determined the administration of the facility failed to use its resource management to ensure that the resident ' s rights to receive emergency services (CPR) and exercise advance directives was protected for one (#1) of 7 sampled residents of 81 residents identified as having Full Code status, according to the Advance Directive Audit Tool, provided by the facility and dated [DATE]. On [DATE] Resident #1, a [AGE] year old male, was discovered unresponsive, less than 24 hours after admission. The facility failed to ensure that in the event the resident was without a pulse or respirations, that CPR would be initiated or Emergency Medical Services be contacted to honor his wishes. The clinical record contained a physician order for [REDACTED]. The administration ' s failure to ensure that the resident ' s expressed wishes related to advance directives and the right to receive CPR was protected, led to the findings of Immediate Jeopardy which were removed [DATE] and the severity and scope was reduced to a D. Findings Include: 1. Review of the Administrator job description (Revision Date: [DATE]) included: The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities: Administrative Functions: Review the Facility ' s policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. Interpret the Facility ' s policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary. Ensure that all employees, residents, visitors, and the general public follow the Facility ' s established policies and procedures. Committee Functions: Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the Facility ' s committees as necessary. Personnel Functions: Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents. Review and check competence of work force and make necessary adjustments or corrections as required or that may become necessary. Review and check competence of work force and make necessary adjustments or corrections as required or that may become necessary. Council and discipline personnel, as requested or as necessary. Inform the Medical Director of all suspected or known incidents of resident abuse. Staff Development: Assist department directors in the topic selection, planning, conducting, and scheduling of in-service trainings classes and on-the-job training and orientation programs to assure that current material and programs are continuously provided. Resident Rights: Ensure that the resident ' s rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are well established and maintained at all times. Report all allegations of resident abuse and/or misappropriation of resident property. A review of the facility policy: Abuse, Neglect and Exploitation: Prevention and Prohibition (Not dated), revealed a Standard: The prevention and prohibition of abuse, neglect and exploitation. To an environment within the facility which promotes resident well-being, safety and prohibits abuse, neglect, involuntary seclusion, and the misappropriation of property for all residents. I. Furthermore, each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. II. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility ' s identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. Definitions: 7. Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CFR 488.301) Procedures: 1. Screening: a. The facility screens potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements a 483.13 © (1) (ii) (A) (B).This includes attempting to obtain information from previous employers and /or current employers and checking with the appropriate licensing boards and registries. Screening is done on all employees prior to hire. 2. Training: a. Each team member is scheduled to attend a general orientation session. b. Each team member is offered and asked to attend a facility in-service where the information is reviewed as needed throughout the year. c. each team member is notified that a mandatory Abuse Prevention in-service is scheduled on an annual basis. This in-service includes: 1. Appropriate interventions to deal with aggressive and / or catastrophic reactions; 4. What constitutes abuse, neglect and misappropriation of resident property. 3. Prevention: Every effort is made on behalf of the resident to prevent abuse. This includes an analysis of: a. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; b. the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that staff assigned have knowledge of the individual residents ' care needs. C. the supervision of staff to identify inappropriate behaviors, such as .ignoring residents while giving care, .and d. the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as resident with communication disorders, those that require heavy nursing care and/or the totally dependent on staff. Each team member reads and signs the Resident Rights upon employment. A copy of the resident rights is given to each team member within his/her probationary period of employment. This information is reviewed on an annual basis by the Social Services staff in an all-staff in-service. Identification: Each team member is encouraged to attend a mandatory Abuse Prevention in--service on an annual basis. This in-service includes methods to identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of het investigation. Investigation: the Social Services Manager is the facility appointed designee who is the staff member responsible for the initial reporting, investigation of alleged violations and reporting results to proper authorities. The facility policy for any allegation of abuse is for it to be brought immediately to the attention of the immediate supervisor. The supervisor is to notify the Social Services Manager, who is the facility appointed designee, the DON, and the Administrator .the facility will also notify the appropriate agencies, based on the nature of the allegation in accordance with State and Federal Statute. Protection: the facility will make every effort to protect any individual form abuse, .If the allegation of abuse is against a team member, the team member will be immediately removed from duty during the investigation, and until it is complete. Reporting/Response: the facility will report all alleged violations to [DATE]-ABUSE, and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation; report to the state, or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for services; and analyze the occurrences to determine what changes are needed if any, to policies and procedures to prevent further occurrences. Federal abuse, neglect, and exploitation guidelines will also be followed by the abuse reporting designee. A review of the facility policy: Advance Directives (Revised [DATE]), revealed a policy statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, section 1. When a resident is admitted to our facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 3. When a resident is admitted to our facility, SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Policy Interpretation and implementation, section 5: In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. A review of the facility policy: Emergency Procedure: Cardio [MEDICAL CONDITION] Resuscitation (CPR) ,(Revised [DATE]), documented the policy statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Policy and Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] many initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS includes recognizing the atypical presentations of SCA. 4. The likelihood of recovering from SCA due to an acute event (such as arrhythmia) differs substantially from the likelihood of recovering from [MEDICAL CONDITION] that the end result of multi-system failure and advance irreversible or terminal conditions. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness. 7. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; Preparation for Cardiopulmonary Resuscitation: 1. Obtain and /or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. 2. Provide periodic Mock Codes (simulations of an actual arrest) for training purposes. 3. Select and identify a CPR team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR team in this facility shall include at least one registered nurse, one LPN/LVN and two CNAs, all of whom have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. 6. Provide information on CPR/BLS policies and advance directives to each resident/ representative upon admission. Emergency Procedure - Cardiopulmonary resuscitation: 1. the facility ' s procedure for administrating CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). 3. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim ' s pulse. 4. Following the initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 5. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 6. Delivering high-quality chest compressions is essential: a. push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. B. Allow full chest recoil after each compression. C. Minimize interruptions in chest compressions. 7. Trained rescuers should also provide ventilations with a compression -ventilation ratio of 30:2. A review of the facility policy: Admission Assessment and Follow Up: Role of the Nurse from the Nursing Services Policy and Procedure Manual (Revised [DATE]). The purpose of this procedure is to gather information about the resident ' s physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the minimum data set (MDS). Steps in the Procedure: 10. Determine if the resident has existing advance directives. If so, initiate the process of obtaining a copy for the medical record. If not, provide the resident with information on his/her right to have advance directives and initiate the process of establishing them. Documentation: the following information should be recorded in the resident ' s medical record: 3. All relevant assessment data obtained during the procedure. 2. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the Director of Nursing (DON) informed her that the Assistant Director of Nursing (ADON) had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR . The DON, stated the nurse pronounced him dead. On [DATE] at approximately 5:00 PM an interview was conducted via telephone with Employee A, the CNA who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. 3. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE] for skilled services with [DIAGNOSES REDACTED]. Review of the Physician ' s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (resident ' s Overall Expectation): Expects to remain in this facility; by family. Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). Review of Resident #1 ' s complete medical record including the closed record revealed no Do Not Resuscitate (DNR) form was present. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn ' t remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. Review of the Resident #1 ' s Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other:, Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the resident and witnessed by Employee H on [DATE]. Review of the resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the residents initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and the physicians at this facility will not be able to follow the term on my Advanced Directives until I provide a copy of it to the staff; or I have not executed an Advanced Directive and do not wish to discuss Advanced Directives further at this time. The spaces to check either statement were blank. The form was signed by the resident and the Admissions Representative Employee H and dated [DATE]. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Review of Resident #1 ' s physician orders dated [DATE] revealed a Code Status of Full Code. Review of Resident #1 ' s medical record revealed the resident was discharged to the hospital on [DATE] and readmitted on [DATE]. His admission paperwork did not include documentation that his Active Medical Decision Maker, his father, was given information on Advance Directives. There was no Advanced Directives Acknowledgement form in the admission paperwork for the resident ' s [DATE] readmission to the facility. Further review of Resident #1 ' s medical record revealed a document titled Activated Medical Decision Maker signed by the resident ' s father and mother and witnessed by two signatures on [DATE]. The document included the following language: The Determination of Incapacity form has been completed on [DATE]. I do hereby attest that I am at least [AGE] years of age or older and am willing to become involved in the above stated resident ' s health care decisions. I have maintained regular contact and am familiar with the resident ' s activities, health, religious and moral beliefs, so that I can make health care decisions, including withholding/withdrawing life prolonging decisions that would be the decisions the Resident would have made, if capable. I am willing to produce clear and convincing evidence upon request. I understand that my role has become active and accept my responsibility, which is one of the following Medical Decision Maker designations: checked were Proxy and A parent of the resident. Review of Resident #1 ' s medical record revealed a Determination of Incapacity document dated [DATE] and signed by his attending physician. It included the following language: As attending physician for the above stated resident (Resident #1), I have evaluated and determined the above stated resident lacks the capacity to give informed consent to make medical decisions and does not have the reasonable medical probability of recovering mental and physical capacity to directly exercise rights. <br

Based on interviews with facility staff, the Attending Physician, the Medical Director, facility administration, resident record review, QAA (Quality Assessment and Assurance) review, and review of the facility ' s policy and procedures related to its Advance Directives (Revised [DATE]), Emergency Procedure-CPR (Revised [DATE]) and Abuse, Neglect and Exploitation (no date) it was determined the facility failed to demonstrate a system to implement plans of action to correctly identify deficiencies regarding honoring the resident ' s rights to have cardiopulmonary resuscitation (CPR) in the event of [MEDICAL CONDITION]. The facility failed to demonstrate a system to implement plans of action to identify and correct quality deficiencies following the survey of [DATE] as well as the survey on [DATE], which resulted in findings of Immediate Jeopardy. During the survey of [DATE] the facility failed to provide necessary care and services in accordance with acceptable standards of practice, failed to ensure care planning interventions/approaches were implemented as well as the facility administration failed to administer effectively and failed to utilize resources to assure residents were kept safe and received quality of care. During the survey on [DATE], the facility did not initiate CPR on Resident #1, who was [AGE] years old and had not expressed wishes to have CPR withheld, nor had his Health Care Proxy expressed wishes for CPR to be withheld if he was found unresponsive. On [DATE], the resident was found unresponsive and absent of pulse and respirations, less than 24 hours after admission. The facility did not initiate CPR as per the resident ' s wishes and his Health Care Proxy ' s wishes. The facility failed to honor the resident ' s Advanced Directive and he died without the opportunity to be resuscitated by receiving the services of CPR. The facility failed to follow through on measures to ensure sustained compliance with standards of practice (F281); care plan implementation (F282) and the obligation of Administration to manage resources effectively (F490). The lack of a sustained Quality Assurance Plan (F520) placed facility residents at continued risk and resulted in a determination of Immediate Jeopardy on [DATE] at a severity and scope of J. The immediate Jeopardy was removed on [DATE] and the scope and severity was reduced to D. Findings include: 1. The Plan of Correction, following the survey of [DATE], with a completion date of [DATE], for F 490, the facility administration failing to administer effectively and utilize resources to assure residents were safe and received quality of care regarding education and training of staff on QAPI, provided that: Education has been provided to the QAPI committee including the Administrator on the QAPI process by the Nurse Consultant on [DATE] utilizing CMS QAPI at a Glance educational materials. The QAPI Committee will utilize this methodology for continued identification, analysis and planning for identified opportunities for improvement in the facility. The Medical Director also participated in this educational program and is current with the QAPI Methodology. Identified opportunities for improvement will be brought to the QAPI Committee for review and implementation of the QAPI process. Meetings are currently being held on weekly basis times eight weeks and then bi-monthly times eight weeks and the monthly. Facility operations will be overseen by the Administrator/ Medical Director on an ongoing basis. Facility operations will be monitored by the administrator and the Medical Director on a monthly basis and identified areas of concern will be addressed by them through the QAPI Process. The Plan of Correction for F F282, following the survey of [DATE], with a completion date of [DATE], for the facility failing to ensure care planning interventions / approaches were implemented to assure resident safety and quality of care revealed: nursing staff has been re-educated on ,[DATE], 20, 21, and 22, 2015 on assuring that the resident ' s comprehensive care plans are being followed. Additionally, the Plan of Correction for F 282, following the survey of [DATE], with a completion date of [DATE], for the facility failing to identify, implement and monitor a known deficient system revealed: Education has been provided to the QAPI Committee including on [DATE] utilizing CMS QAPI at a Glance educational materials. The QAPI Committee will utilize this methodology for continued identification, analysis and planning for identified opportunities for improvement in the facility. The Medical Director also participated in this educational program and is current with the QAPI Methodology. Identified opportunities for improvement will be brought to the QAPI Committee for review and implementation of the QAPI process. QAPI Meetings are currently being held on a weekly basis times eight weeks and then bi-monthly times eight weeks and the monthly. QAPI will be monitored by the Nurse Consultant bi-monthly for three months and then quarterly. This program will also be over seen by the Administrator and the Medical Director on an ongoing basis. 2. On [DATE] at 5:00 PM, an interview was conducted with the NHA regarding the facility ' s response to the event of Resident #1 not receiving CPR on [DATE] when found unresponsive. She stated, We started an investigation and a Quality Assurance Performance Plan (QAPI) immediately. We sent the ADON home for the day on suspension. We reviewed the policy and procedures for advance directives, DNR, Code Blue Roles and Responsibilities, and the Emergency Procedure for CPR. We interviewed the staff regarding their ability to verbalize the CPR process. We normally complete an audit of the advance directives and DNR orders monthly. The SSD initiated an immediate audit for Advance Directives and DNR for the entire resident population and it was completed by [DATE]. We were monitoring / reviewing the charts of residents who expired. We started in-service training regarding advance directives and CPR and called a Code Blue Drill. Multiple interviews of the staff were initiated to ensure the direct staff knew about advance directives, CPR and when to call a code. Training was conducted in March for the entire facility. The DON did immediate in-servicing with the ADON and we completed a Federal report. We have been conducting weekly QA meetings regarding the event. These meetings will continue weekly through June and then occur monthly . When asked when staff training had been conducted prior to the last couple of months, she stated, we do it routinely and new hires get it at orientation. When asked how the facility audits the employee records for current CPR she stated, the Human Resource (HR) manager does an audit, which includes reviewing CPR cards. When asked if the event had been presented to the QA committee with an action plan she stated, Yes . 3. On [DATE] the NHA provided a QA Book. It contained the Quality Assurance Performance Improvement Plan for review. The tool was dated [DATE] and signed by the Quality Assurance team including the Medical Director on [DATE]. A review of the information provided revealed policy revisions dated [DATE] for Do Not Resuscitate Order , Advance Directives which includes Code Blue Roles and Responsibilities and Emergency Procedure - Cardiopulmonary Resuscitation. Review of these revisions revealed the following relevant changes: Code Blue Roles and Responsibilities (no effective date): In the event that a resident is found in cardiopulmonary arrest the person discovering the arrest should immediately notify a nurse of the situation. A teammate should page overhead that there is a Code Blue and the location of the code. All available teammates are responsible to respond to a Code Blue Page. The nurse is responsible to immediately assess the resident to determine if the resident is in cardiopulmonary arrest. The resident ' s medical record will be obtained to determine if the resident has a (DNR) document in their record. (may check YELLOW BINDERS at each nurses station for DNR status) if the DNR is noted then there will be no further interventions implemented as per the resident ' s advance directives. If there is no DNR in the medical record then CPR is to be initiated on the resident. Nurses are responsible for the implementation of CPR on the resident. The nurse assigned to the resident will act as the TEAM LEADER of the code situation. Certified Nursing Assistants who are CPR certified may be directed to assist with CPR at the direction of the nurse. On [DATE] signature sheets were provided for the following in-services, dated ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. In addition mock Code Blue drills were done on ,[DATE], ,[DATE], ,[DATE], [DATE]. All documents that were provided to the survey team were reviewed. A comparison was made between the in-service signature sheets and the master list of all employees. The comparison revealed that as of [DATE] 91% of licensed nurses and 97% of the unlicensed staff had completed the training. 4. Interviews with the facility staff regarding advanced directives, CPR and Code Blue drills were conducted in order to verify staff knowledge. The following relevant interviews were obtained: On [DATE] at 4:24 PM, an interview was conducted with Employee C a nurse; she stated she worked full time on the 7:00 AM -3:00 PM shift. She stated she had been part of a mock Code Blue drill a couple of months ago and that we just had an in-service on where to find the DNR forms, in the yellow book. When asked how she would respond if a CNA said a resident was unresponsive she stated she would check the resident, have someone at the desk check the DNR book. I would initiate CPR until I determined if the resident had a DNR order then I would stop CPR. On [DATE] at 4:32 PM an interview was conducted with Employee D a nurse, who stated she worked full time on the 7:00 AM -3:00 PM shift. She stated she had training on DNR, advanced directives and participated in mock Code Blue drills a few months ago and again in June. She also stated If I found someone unresponsive; I would start CPR, shout for someone to go to DNR book. If they were a DNR, I would stop CPR. I would call the physician and family. If they were a full code I would keep going until the paramedics come. On [DATE] at 4:40 PM an interview was conducted with Employee E a nurse, she stated she usually worked as needed on the 3:00 PM -11:00 PM shift. She stated that during orientation they discussed advance directives and DNR orders. She had training in the last couple of months on advance directives and did a mock Code Blue drill also. If a resident was found unresponsive she stated she would, check the resident, yell for help, and send someone to get more help. I would start CPR. There is a DNR book; I would send someone to check. If I have started CPR and find out the resident is a DNR, then I would stop. I would start CPR before I knew if they were a DNR or not. [DATE] at 7:22 AM an interview was conducted with Employee F a nurse, he stated he usually worked the 11:00 PM -7:00 AM shift. He stated We had a Mock Code Blue training recently. We recently had a class on advance directives and DNR. The training included: making sure we have advance directives, if resident is confused, speak with the family, check the chart for the yellow DNR form, make sure a POA is in the chart also. He was asked what he would do if he found an unresponsive resident, he stated first assess for breathing, call a code, call somebody by name to call 911. Check Vital signs, call for crash cart. Call another person to look at DNR form. I would start compressions right away, and if found they were a DNR would stop compressions. 5. During the interview conducted on [DATE] at 5:15 PM with the DON she stated that what she would expect that if a resident was found unresponsive and had a Full Code status the nurse should start CPR. She was asked if a nurse should start CPR prior to finding out about a resident ' s DNR order. She stated, The nurse should know if the resident is a DNR or not before they start CPR. If the nurse starts CPR and finds out the resident is a DNR, the nurse can stop. That is what I was told during my CPR class. When asked if that was in the facility policy, she stated, It is not in our policy, so I do not teach that in the in-service classes. The DON was informed that 3 out of 7 nurses interviewed so far stated they would start CPR when they found an unresponsive resident and then stop CPR if they found the resident was a DNR. She was asked if the facility conducted training since the event. She stated yes, we started in March, after the event and we have given in-services again recently. This training covered DNR orders and advance directives. The training is also being done on orientation. She stated, We did the training for the whole month of March, because we had to get everybody. And then we just did it again. In addition, a Quality Assessment Performance Improvement (QAPI) was started, the day of the event. The Quality Assurance (QA) committee was informed. We did training with the CNAs and nurses and also preformed mock code blues. When asked if training had been performed in the past, stated, Yes, the in-service is done yearly and during orientation. In addition, the DON was also asked, how the facility audits the employee records for current CPR, she stated, when we have new employee starting Human Resources (HR) sees the card and then the ADON checks the CPR card after that. All nurses are supposed to be CPR certified. When asked if the facility had audited the employee records for current CPR, she stated Yes, the ADON audits CPR monthly and HR does it on hire. The DON stated the SS department monitors, audits the advance directives, and reviews DNR orders monthly. The DON stated the event had been presented to the Quality Assurance (QA) committee and an action plan and plan of correction was put into place. The DON completed the Federal report and reported it to the corporate nurse. The DON stated, The direction I got was to do education, and do mock codes, and file a federal report. On [DATE] at 2 PM, an interview was conducted with the NHA and the DON to review the content of the training in-services. The NHA and DON stated, we went over the following policies: DNR policy (which included what to look for, DNR orders and book, where to find the DNR paper, etc.), Advance Directive policy and Code Blue policy (described a mock code blue, if staff walk in on an unresponsive resident what you would do), and the Emergency procedure policy. It was a verbal presentation and every nurse received a packet. The expectation was for nursing / CNA staff to receive training by the first QAPI meeting. By the first QAPI we were almost at 100%. The concern regarding interviews with 4 of 8 nurses on [DATE] and [DATE] by the surveyor which revealed the nurses would start CPR prior to knowing the resident ' s code status was discussed. The DON stated, That is not what they were trained to do. The NHA and the DON stated they would begin retraining the nursing staff that day. On [DATE] at 1:00 PM an interview was conducted with the NHA and the Corporate Nurse (CN). When asked when the Policy and Procedure for advance directives and DNR were last reviewed, the Corporate Nurse (CN) stated the Policy and procedure for advance directives and Do Not Resuscitate was reviewed and updated on [DATE] , after the event with Resident #1. He further stated that the Emergency Procedure CPR was also updated, which included the Code Blue Roles and Responsibilities. 6. Review of Resident #1 ' s closed medical record, to include demographic / face sheet, indicated he was initially admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted to the facility from the hospital on [DATE], Wednesday, for skilled services with [DIAGNOSES REDACTED]. Review of the Physician s Order Sheet (POS) dated [DATE] and signed by the physician on [DATE] revealed under Special Needs; Code Status: Full (handwritten). Per the hospital discharge summary for Resident #1 dated [DATE]: Patient was a [AGE] year old admitted to the emergency room at the hospital with acute [MEDICAL CONDITION], HCAP (Healthcare-associated pneumonia),[MEDICAL CONDITION], advance dementia, VRE ([MEDICATION NAME] -Resistant [MEDICATION NAME]) ([DATE]) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) ([DATE]). During his hospital stay, a consultation was performed on [DATE] due to having noted stools that were positive for occult blood. Laboratory data revealed hemoglobin of 8.5 and a platelet count of 335 indicating the patient was anemic with occult gastrointestinal (GI) blood loss. The patient did not show any signs of active bleeding at the time. Recommendations included continue tube feedings as tolerated; monitor the hemoglobin and transfuse on an as needed basis. Resident #1 was discharged from the hospital and transferred to the skilled nursing facility on [DATE]. A review of the Nursing Admission Evaluation Tool dated [DATE] at 3:00 PM revealed: patient arrived via stretcher from hospital [MEDICAL CONDITION] and aspiration pneumonia. The resident has advance directives upon admission? NO. Are advance directives in the chart? NO. Activities of Daily Living: extensive assistance required for bed mobility; transfers; dressing; and personal hygiene. Alert to person and non-verbal, skin pale, warm and dry. Patient not verbal with this nurse, but can make faces for pain. Heart rate regular and audible, pulse rate equal and palpable. Breath sounds clear. Urinary catheter in place. Has referrals for Physical Therapy, Occupational Therapy and Speech Therapy. Signed by Employee C, a Licensed Practical Nurse (LPN). A review of Resident #1 ' s medical record, Social Service Admission Evaluation Tool document dated [DATE] at 5:32 AM (Thursday) included the following information: the resident was [AGE] years old, had resided with his father in the past, was a high school graduate and had been in the Marines for [AGE] years. It also included the questions with corresponding answers written in capital letters, Does the resident have advanced directives? INCAPACITY & HC (health care) PROXY ON CHART; Does the resident have a legal representative? YES, (the resident ' s father ' s name and phone number); What is the resident ' s code status? FULL CODE. It was Electronically signed by Employee G. Review of Resident #1 ' s complete medical record including the closed record revealed no DNR form was present. Review of Resident #1 ' s physician orders [REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C (Cognitive Patterns): Staff Assessment for Mental Status: Short term memory: memory problem. Long term memory: memory problem. Cognitive skills for Daily Decision Making: severely impaired. Under Section D (Mood): Staff Assessment: feeling or appearing down, depressed, hopeless. Trouble falling or staying asleep or sleeping too much; Feeling tired or having little energy; Trouble concentrating. Under Section G (Functional Status): Extensive assistance of one person assistance required for bed mobility and dressing; total dependence required for eating and personal hygiene. Under Section H (Bladder and Bowel): Always incontinent of bowel and bladder. Under Section I (Active Diagnoses): Heart failure and Hypertension. Under Section K (Swallowing and Nutritional Status): Height 66 ; weight 111 pounds; loss of 5% or more in the last month or loss of 10% or more in last 6 months-yes; Feeding tube. Under Section M (Skin Conditions): A risk of developing pressure ulcers. Under Section Q (Resident ' s Overall Expectation): Expects to remain in this facility; by family. Per the Nurse ' s Notes dated [DATE] at 5:45 AM: this nurse called to room by Certified Nursing Assistant (CNA). Resident noted with no respirations, pulse or blood pressure. Noted large amount of frothy saliva on face and chest. Upper extremities cool to touch. Call placed to (attending physician) service, return call received from (covering physician). Order received to release body. Call to family, (Mother), name of funeral home received. Family declined to come to facility. Signed by the Assistant Director of Nursing (ADON). On [DATE] at 1:00 PM an interview was conducted with the ADON, the nurse assigned to the resident when he died . She stated that she was taking care of him for the first time on [DATE]; she took a shift because another employee called off. She stated the resident wasn ' t verbal, he required total care and had been readmitted from the hospital that day. When asked to recall the events that happened on [DATE], the day Resident #1 passed away, the ADON stated, I was working the night shift, I had finished medication pass and around 5:45 AM, the CNA was in the hallway and said, I think he is gone. I went in Resident #1 ' s room, checked him for pulse and respirations, he was very cool to touch. He felt a little stiff in his upper extremities. His lower extremities had sort of contractures. The resident had white frothy stuff around his mouth. There was nothing I could do for him. When asked if she looked at the chart for a DNR order, she stated, I looked at his chart after I called the doctor to tell him the resident had died and I didn ' t see a DNR, Honestly when I saw the resident after the CNA called me he was cool to touch, I don ' t know if there was anything I could do for him. At that point I made the decision to not code him; because he was cold and stiff; I did not know how long he had been like that. The physician covering for the attending physician was called, and informed of the resident ' s death. The ADON was asked if she saw a DNR order on the medical record, she stated, after looking at the chart, no. When asked if she had received training on how to respond when a resident is found without vital signs she stated, we are supposed to do chest compressions and send someone to check on DNR status. When the ADON was asked if she knew how to determine code status, she stated, if a resident is unresponsive, I am supposed to check the pulse and call for someone else to check the chart for DNR orders. I will a call code blue and bring the crash cart. We have a yellow book at the nurses ' station with all the DNR forms. If the resident is a new admission it may be necessary to look in the chart. When asked how the nurse is notified of a resident ' s advance directives, including DNR, she states, It is the nurse ' s responsibility to check the chart on every resident, so they know DNR status. If someone finds someone unresponsive, they have to wait until someone checks the yellow book or the chart to see if they are DNR or not. When asked what she would do in a situation wherein a resident is found non-responsive but there is no Advance directive she stated, I would do a Code. When asked if she had had any training since the event, she stated yes, one-on-one with the Director of Nursing (DON) on DNR, advance directives, Code Blue, and mock drills. The DON reviewed with me when we are supposed to do a code. On [DATE] at approximately 5:00 PM an interview was conducted via telephone, with Employee A, the CNA, who found Resident #1 unresponsive. She stated she no longer worked for the facility. Employee A stated she was making rounds before she went home and found Resident #1 not breathing. She called for the nurse to check on him. The ADON responded and checked on the resident. The ADON said, He was gone. Employee A stated that the ADON did not do Cardiopulmonary Resuscitation (CPR) on Resident #1 and that she did not recall anything else about the resident. On [DATE] at 1:15 PM an interview was conducted with Employee G a Social Services Assistant regarding Resident #1 ' s Social Service Admission Evaluation Tool dated [DATE] and timed 5:32 AM, approximately 13 minutes prior to the resident ' s death. When asked, Employee G stated he probably filled in the information based on prior admissions. He stated he was going to speak with the resident ' s family and he confirmed that the resident had a health care proxy and a Determination of Incapacity. He confirmed that the resident was a Full Code on previous admissions and remained a Full Code because there was not a signed DNR in the medical record. He stated that his plan was to call the family and inform them of their right to formulate an advance directive for the resident. He further stated that the facility procedure in regards to advance directives required the Admissions Department to speak to residents on admission, advance directives are then addressed in the Nursing Admission Assessment and the Social Services Department reviews the information with the resident and/or the family. On [DATE] at 1:20 PM an interview was conducted with the Social Services Director (SSD) regarding Resident #1. Per the SSD, she spoke to the resident ' s father on [DATE] after he was readmitted on [DATE]. She confirmed that his parents were making the decisions regarding his care and were designated as his Activated Medical Decision Makers at that time. She stated that the father was given information in regards to formulating an advance directive. SSD states, If he wanted him to be a DNR, we would have mailed him the paperwork. She also stated that she had not spoken to the father when the resident was admitted on [DATE]. She stated that the Resident was designated as a Full Code since his original admission in March of 2014 and had never had a DNR paper in his medical record. On [DATE] at 12:40 PM, a telephone interview was conducted with Resident #1 ' s father. He stated his son was in the Marines; he got an aneurysm in there and had to have surgery. He stated the resident lived by himself for a while, and then he started living with his girlfriend . He went to the hospital and they sent him to the nursing home. When asked if they were expecting his death, he stated, he could not care for him anymore, that ' s why he went to the nursing home. He was wearing diapers and couldn ' t dress himself anymore. I couldn ' t handle him anymore. He went to the hospital and then the nursing home; he was in and out of the nursing home. I think he died in the hospital, no, the nursing home, I get confused sometimes. I couldn ' t do anything with him. He was having problems breathing, they put him on oxygen. The last time I saw him he was in the hospital, and then someone called and said he was dead. On [DATE] at 5:15 PM an interview was conducted with the Director of Nursing (DON), when asked if she was familiar with Resident #1, she stated, yes. When asked about the day Resident #1 passed away, she stated, When I came in about 5:30 AM the (ADON) stated that Resident #1 had passed. I asked the (ADON) if she had performed CPR, the (ADON), said, no. I stated to the (ADON) that she, should have called a code and the (ADON), and stated she did not do it. I educated the (ADON) right then and there regarding our policy. The policy states, we have to start a code no matter what, on a Full Code resident. I interviewed (Employee A) who stated she was making her rounds, and the resident didn ' t look right, she shook him, and he was not responding, so she got the nurse. The DON stated, The chart revealed the resident was a Full Code. The DON stated, I knew he was a full code because he had been here for so long. The DON stated the (ADON) decided on her own not to do CPR. The DON, stated the nurse pronounced him dead. On [DATE] at 5:00 PM an interview was conducted with the Nursing Home Administrator (NHA). When asked if she could recall the events that happened on [DATE], the day Resident #1 passed away she stated the DON informed her that the ADON had found the resident unresponsive and did not perform CPR. The NHA stated in her opinion the ADON should have looked at the chart and initiated CPR. On [DATE] at 2:40 PM, a telephone interview was conducted with the covering physician who received the call regarding Resident #1 on [DATE]. She stated she was covering for the attending physician on [DATE], but doesn't remember the call as she stated she covers 1000 patients. When asked if she was informed the resident was a Full Code and he was not resuscitated, she stated, I apologize, but I don ' t remember. On [DATE] at approximately 10:00 AM, an interview was conducted with Resident #1 ' s attending physician. The physician stated the resident had multiple problems including: multiple cardiovascular issues, [MEDICAL CONDITIONS], and dementia. He did not look well at all. He was thin and looked 90. He was new to me as a patient. He was back and forth to the hospital. I was not called the day he died the physician covering was called. I found out the next day or so, probably when the funeral home called me. Normally if a patient does not have a DNR on their chart, CPR would be initiated and 911 called. My expectation is that the nurse would start CPR if a DNR was not on the chart. On [DATE] at 12:00 PM, an interview was conducted with the Medical Director. When asked if his expectation was for a nurse to perform CPR on a Full Code resident, he stated, CPR should be done. He has been the Medical Director for almost 4 years. If the resident was unresponsive they have to do CPR. Code Blue is for all non-DNR residents. Review of the resident ' s [DATE] Admission Agreement revealed; page 31 of 39 Advanced Directives Acknowledgement with the following language: I understand that I do not have to sign or implement an Advanced Directive in order to be a resident at this Healthcare Center. I understand that I may implement an Advanced Directive at any time during my stay in the facility. It is also my understanding that I may ask at any time to review Advanced Directive information or my Advanced Directive (s) and ask questions I may have concerning them. I may revoke any Advanced Directive (s) at any time that I have made. I understand the facility ' s staff cannot give legal advice, but can answer questions concerning Advanced Directives. I have the following designations(s) and my copies have been provided to Health Care Center. A line was drawn through the blank spaces in front of all the choices which were: Living Will or Direction to Withhold Life Sustaining Procedures, Do Not Resuscitate Order/DNRO/Yellow HRS Form, Health Care Surrogate, Health Care Proxy, Durable Power of Attorney, Financial Power of Attorney, Medical Power of Attorney, Guardian Financial or Medical, Anatomical Gift, Other:, Physician Statement of Incapacity, Funeral Home Selection. The form was initialed by the resident and witnessed by Employee H on [DATE]. Review of the resident ' s [DATE] Admissions paperwork revealed a second form titled Advanced Directives Acknowledgement (no page number) with the residents initials beside the sections 1. I have been given written material about my right to accept or refuse medical and surgical treatments and my right to form Advanced Directives, 2. I understand that I am not required to have an Advanced Directives in order to receive medical treatment at this health care facility and 3. I understand that the term of any Advanced Directives that I have executed will be followed by the health care facility, physicians and my caregivers to the extent permitted by the law. The form continues with: Please Check one of the following statements: I have executed an Advance Directive and will provide a copy to the facility. I understand t

Based on a review of the Nurse Practice Act, record review, interviews with the facility staff, the Attending Physician, the Medical Director, facility Administration and review of the facility ' s policy and procedures related to medication administration the facility failed to provide the necessary care and services in accordance with acceptable standards of practice. Based on a review of all current residents receiving anticoagulants the facilities Licensed Nursing staff failed to administer to ten of thirty residents their anticoagulants per the physician's order [REDACTED].#2, #6, #10, #14, #15, #16, #17, #18, #19 and #20 were identified as not being administered their anticoagulants that were necessary to prevent blood clots or [MEDICAL CONDITION]. Resident #6 was did not receive her Xarelto for twenty six days. The medication was placed on hold for three days for a dental procedure. The facility ' s Licensed Nurses failed to implement the order and resume the medication on March 5, 2015. Resident #6 reported pain to the nursing staff and reported that the pain was consistent with a [MEDICAL CONDITION]. The physician was notified on 3/28/15 and ordered the necessary tests. The Licensed Nurses at the facility failed to implement those orders for three days, delaying treatment to the resident until 3/31/15. Resident #6 given injections of [MEDICATION NAME] to dissolve the clot. Resident #2 was administered a double dose of [MEDICATION NAME] on 4/8, 9, 12, 13, 14 and 16/2015. His INR was supra-therapeutic on 4/20/2015 at 3.2. Resident #10 was not administered her prescribed [MEDICATION NAME] on 4/9 and 12/2015. Resident #14 was not administered four of six available doses of [MEDICATION NAME]. Resident #15 was not administered her [MEDICATION NAME] on 4/1/2015 and on 4/22/2015. Resident #16 ' s [MEDICATION NAME] was to be discontinued when the International Normalizing Ratio (INR) was greater than 2. On 4/13/2015 the laboratory results indicated that her INR was 2.5 and the [MEDICATION NAME] was continued for four additional doses. Resident #17 was not administered five doses of [MEDICATION NAME] on 3/7, 10, 13, 15, 19/2015. Resident #18 was not administered four doses of [MEDICATION NAME] on 4/2, 11, 13 and 15/2015. Resident #19 missed four doses of [MEDICATION NAME] from 4/3-4/5/15. Resident #20 was not administered seven doses of [MEDICATION NAME] from 4/9/15-4/22/15. The facility ' s Licensed Nursing staff failed follow physician's order [REDACTED]. Based on record review and interview, the nurses also failed to administer medications for two (#2, #8) out of forty-eight (48) residents reviewed for medication accuracy. Resident #2 ' s physician ordered [MEDICATION NAME] and [MEDICATION NAME]were omitted for 10 days. There was a three day delay in starting a physician ordered antibiotic for Resident #8 and two doses were omitted. The nursing staffs failure to administer medications resulted in the findings of Immediate Jeopardy existing in the facility as of 3/5/2015. The facility Administration was informed on 5/1/2015 at 9:50 a.m. The Immediate Jeopardy was removed on 5/1/15 at 5:30 p.m. and the scope and severity was reduced to a " E. " Findings include: The Florida Nurse Practice Act, Section 464.003, Definitions Part (3) (a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. ( b) Practice of practical nursing " means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured , or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician ,a licensed osteopathic physician, a licensed podiatric physician , or a licensed dentist. 1. The facility identified thirty residents receiving anticoagulants. All thirty residents were sampled. The following residents were identified with medications errors by the Licensed Nursing staff at the facility related to anticoagulant therapy. Review of Resident #6 ' s Medication Administration Record dated March 2015 revealed a typed order dated 12/05/2014; Xarelto 15 MG tablet one tablet by mouth once a day. Directly underneath the typed order a hand written entry; resume 3-5-15. The Medication Administration Record (MAR) revealed the Licensed Nurses documented for 03/01/2015, 3/2/2015, 3/3/2015 and 3/4/2015: " HOLD. " On 3/5/2015 the MAR indicated to resume Xarelto. The remainder of the MAR from 3/6/2015 through 3/30/2015 was reviewed with no indication that the medication had been given and no indication as to why the medication was not given. The MAR indicated that six Licensed Nurses were assigned on the 3-11 p.m. shift and failed to administer the Xarelto as ordered by the attending physician. During an interview on 4/29/15 at 4:10 p.m. Employee (Registered Nurse) E, a nurse that cared for the resident on 12 of the 26 evening shifts, stated that she had been a nurse for a long time and worked in long term care. She stated that she was familiar with Resident #6. She stated that she was aware the resident needed Xarelto. The medication was not administered. She stated that she did not think the order was on going. She stated that it was on hold. She stated that she did not have the time to research the order and was aware that Resident #6 was at high risk for [MEDICAL CONDITION]. She stated that she questioned the medication to other staff; however, she did not recall who the staff member was. She stated that the doctor came in and then realized the medication should have been resumed. The nurse stated that when a medication was held, the nurse should write hold on the days that the medication is to be held and then indicate when the medication should be resumed. The nurse confirmed the MAR and confirmed that there was no indication the medication had been given. She stated that she did not recall the 3/5/15 resume date. The nurse stated that " my philosophy is if I don ' t see the medication and don ' t see a stop order, then I question with another nurse as to whether the medication is on hold or should be discontinued. " She stated that she would call the pharmacy. She stated that the medication card was not in the cart. The nurse also confirmed that she did not document any omissions in the chart. She stated that she did not look at the chart to find the original order. An interview was conducted on 4/29/15 at 4:30 p.m. with Employee Licensed Practical Nurse (LPN) D she stated that she worked at the facility 2/13/15-4/26/15. When asked about her training she stated she had trained for two to three days and was on her own by the fourth day. She said she had felt that it was " 50/50 " on her orientation process as far as knowing the processes and was able to always go back and ask questions. Employee (LPN) D stated that she recalled caring for Resident #6. She confirmed that she was on Xarelto and stated that she cared for her several times. The staff member reviewed the MAR and confirmed that she worked on 3/6/15, 3/9/15, 3/10/15, 3/13/15, 3/19/15, 3/23/15, 3/24/15 and 3/29/15. The LPN D. next confirmed the order for Xarelto and then confirmed the order said to resume 3/5/15. The nurse stated that she would not have given a medication without signing the MAR. The DON and NHA on 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #6 medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of the medication errors for Resident #6 only after the Doppler confirmed the positive [MEDICAL CONDITION]. It is unclear due to the lack of the investigation of how and why the medication error was found. During an interview on 4/29/2015 at 3:30 p.m. the DON stated " she checks the MARs two times a week by flipping through all of the MARs", she confirmed there was no documentation related to this process. The DON said that the ADON and Unit Manger check every MAR daily for accuracy and completeness. During an interview on 4/30/15 at 8:50 a.m., Assistant Director of Nurses stated that she randomly checked the MARs on a daily basis for accuracy and completeness. She stated that she checked new admissions and " maybe two others. " She stated that the Unit Manager was responsible for checking at least five residents on each cart on a daily basis. The ADON stated that there was not a definite system of checking the MARs. During an interview on 4/30/15 at 9:30 a.m., Employee (LPN) A Interim Unit Manager, stated that she checked all new admissions for accuracy of orders and double checks with the MAR for accuracy. She stated that she did not do anything with the MARs on a daily basis. No one informed her she was supposed to be checking the MARs. She stated that she gets the new orders and the 24 hour report in the morning and then gives them to the ADON or DON to take them to the morning meeting. She does not usually go to the morning meetings and was not aware of any plan to begin to go. She stated that no education or training was provided to be a Unit Manager. The ADON told her the things that needed to be done and she was " just helping them out not doing the whole position. " The regular Unit Manager (LPN) B on the Long Term Care unit is currently on medical leave and was unable to be contacted. During an interview on 4/29/15 at 10:13 a.m. and 4/30/15 at 10:43 a.m., the DON stated that the process of checking the MARs was an informal process that was implemented inconsistently and the ADON and Unit Manager assist with the process. There is not a written policy or procedure. The DON stated that she had been in the role of DON for one year and the process of checking the MARs had been an expectation since her arrival and she had continued that process since then. The DON also stated on 4/30/15 at 10:43 a.m. that she was unaware the ADON and Unit Managers were not checking the MARs daily. On 5/1/2015 at 9:50 a.m. the Nursing Home Administrator, DON and the facility ' s corporate nurse confirmed that an in service was not conducted related to Resident #6 ' s omissions of her scheduled medications. Review of the Pharmacy Dispensing Record for Resident #6 ' s Xarelto from January 1-April 2015. The pharmacy sent 14 pills at a time. Review of the Dispensing Log revealed the facility last received 14 pills on 2/15/15. All of the medication would have been administered by 3/1/15. Therefore, there was no Xarelto available for administration. The medication was not a routinely stocked medication in the Emergency Drug Kit. The Licensed nursing staff failed to reorder after 3/1/2015. Review of the Drug Manufacturer ' s Pharmaceutical Medication Guide for Xarelto revealed; " XARELTO® is a prescription medicine used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Do not stop taking XARELTO® without talking to your doctor first. Your doctor may stop XARELTO® for a short time before any surgery, medical or dental procedure. Your doctor will tell you when to start taking XARELTO® again after your surgery or procedure. " Further review of the physician orders [REDACTED]. ordered for 5 days. Review of the Physician ' s Progress Notes revealed on 3/28/15, the Attending Physician assessed Resident #6 and diagnosed her with an acute [MEDICAL CONDITION]. The physician documented: " Redness and swelling left leg, 4+ [MEDICAL CONDITION] L > R, Tender left leg. " The physician also documented that the resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error " . Further review of the Attending Physician ' s progress note revealed he documented " Venous Doppler was ordered. " There was no corresponding physician's order [REDACTED]. Review of the Nurses ' Notes on 3/28/15 revealed no documentation of a red, swollen leg. There was no documentation of the omission of the medication, the physician visit or the new orders. On 3/30/15, employee (LPN) A documented: the resident complained of pain and redness to her leg, upon assessment the leg was warm to touch and was swollen. Painful, 2+ pitting. The doctor was paged and made aware and stated he saw her on Saturday. New orders for [MEDICATION NAME] BID were obtained. On 3/31/2015 at 3:25 a.m. the nurse documented at " 12:45 a.m. patient states she thinks she has a [MEDICAL CONDITION] to her LLE. Area of slight redness noted to inner calf to LLE, [MEDICAL CONDITION] to bilateral LE. Skin temp within normal limits. Capillary refill is brisk bilaterally. Unable to assess pulse related to [MEDICAL CONDITION]. Patient rates pain level #1 at this time on a scale of 1-10 with 10 being the worst. Patient states she has had multiple [MEDICAL CONDITION] in the past and knows what it feels like. Notified resident physicians of above and new orders were received for a STAT venous Doppler of the LLE to rule out [MEDICAL CONDITION]. At 0200 (2:00 a.m.)[MEDICATION NAME] 100mg was administered for c/o pain to LLE with a pain level of #9. [MEDICATION NAME] was effective. At 0330 (the mobile radiology service) arrived to perform Doppler. Patient remained on bed rest. Patient remained alert and responding appropriately to verbal and tactile stimuli. No s/s of distress noted. Vitals 97.8-74-18-119/78. Patient received new order on 3/30/15 to restart Xarelto (Xarelto was not discontinued). " Review of Ultra Sound Report dated: 3/31/2015 Examination: Venous Doppler extremity/limb, left. Clinical Indications: Swelling of Limb, Findings: Real time color imaging shows no collateral and augmentation of post tibial vein, popliteal vein, deep femoral vein and common vein of left leg. There are no excessive collateral veins. Left lower Extremity Venous duplex Ultrasound: Impression: Extensive [MEDICAL CONDITION] seen. During a telephone interview on 4/28/2015 at 11:42 a.m., Resident #6 ' s Attending Physician stated; " The nurses did not give her medication Xarelto. The medication was only on hold for a few days for her dental surgery. " The physician was asked why the medication Xarleto was not restarted after her dental surgery. The physician stated he did not understand why the nurses did not restart the medication, " I gave the nurses the order they should have restarted the Xarelto after the dental procedure was completed. The Xarelto is to prevent her from getting a [MEDICAL CONDITION] if she would have received the medication she would not have gotten a ([MEDICAL CONDITION]). " During an interview on 4/30/15 at 12:20 p.m., the Attending Physician confirmed he assessed the resident on 3/28/15 and documented the resident ' s leg was red and swollen. He also ordered a venous Doppler study. The physician stated that he was informed by Employee (LPN) A of the swollen leg and the lack of the Xarelto on 3/28/15. He verbally gave the order to Employee A. The Attending Physician confirmed the venous Doppler order was not completed until 03/31/2015 and also confirmed that no medication was started until 03/31/2015. He was unsure of why there would have been a delay in obtaining treatment, necessary tests or initiating the medication. During an interview on 4/28/2015 at 10:30 a.m. Resident #6 stated she was [DIAGNOSES REDACTED]. She said it was not just a [MEDICAL CONDITION] it was an extensive [MEDICAL CONDITION]. The resident stated that " the doctor said it was from my knee to my foot and I think there was more than one ([MEDICAL CONDITION]). " The resident was asked if the nurse had spoken to her about her [MEDICAL CONDITION] she said " No, the doctor told me the nurses were not giving me my medication, he was really pissed. " They (the nurses) had to give me [MEDICATION NAME] two times a day for five days and I hate needles. " Resident #6 said that when she first had come to the facility she had a [MEDICAL CONDITION] in her left arm " that is why I take the Xarelto every day. " The resident stated that she used to check her medications every day and now has to start checking them again. " It ' s not my job to have to ask if all my medications are there or not is it? " Further review of Resident #6 ' s medical record revealed that she had resided in the facility for approximately fifteen months and was fifty three years old. Resident #6 ' s medical history included [MEDICAL CONDITION] and a history of [MEDICAL CONDITION]. On 12/22/2014 a Brief Interview for Mental Status (BIMS) revealed a Score of 15 indicating no cognitive impairment. An interview was conducted with the facility ' s Director of Nursing (DON) on 4/27/2015 at 3:00 p.m. A list of medication errors for the month of March 2015 was provided by the DON. The DON stated that she was aware of the medication error for Resident #6. She stated that a nurse found the error after performing a " medication review. " The DON stated that she was unsure of why the error occurred. She stated that the facility ' s intervention was the Venous Ultrasound and the physician and the resident were notified of the error. The DON confirmed that no audits or education were provided to the Licensed Nursing staff following the medication error. The DON also confirmed that there was no evidence of an investigation. The DON stated that her conclusion of the omitted medication for Resident #6 was " we performed an ultrasound, and started giving her [MEDICATION NAME] injections and elevated her left leg. " During an interview on 4/29/15 at 2:45 p.m., the Medical Director stated that he had been the Medical Director of the facility since 2012. He stated that he participated in the QA monthly meetings and the facility followed a set agenda. He stated that he was made aware of incidents for his patients and that the attending physician for the other residents would be notified of incidents. He stated that he would expect to be notified of incidents, including medication errors. Specifically for system failures that could affect all residents. He stated that he was here at the facility every Wednesday and Friday. However, someone from his physician group was present daily and should be notified. He expected that the nurses notify the physician of any incident. He confirmed again that he was not made aware of any medication errors for Resident #6. He was not aware of any issues in QA related to medication administration. He stated that he was aware that the facility used a lot of agency staff and had a lot of turnover. The Medical Director stated that there was no action plan identified or implemented related to staffing or staff procedures. He also stated that he was aware of a concern with nurses not implementing physician orders [REDACTED]. He stated that he provided education to the staff " within the year " related to medication implementation. The education was to have a second nurse initial the order to assure implementation. He confirmed that there was nothing in Quality Assurance (QA) related to the medication administration and order implementation process. The Medical Director stated that if the facility had a good system in place, then any staff member should be able to come in and care for the resident with no breaks in the system. He stated that the " system was not perfect and should not have failed. " The Medical Director was asked if it was expected that the facility notify him of negative outcomes; he stated, " I would love to. " When referring to the incident for Resident #6, the Medical Director stated that it was a " negative outcome and that he was afraid for his patients. " He stated that " there was not a plan in place. " During an interview on 4/30/15, at 10:15 a.m., the Administrator stated that she was informed of this medication error on April 1st. She was informed the Unit Manager had educated the staff involved. The DON informed her that she was assembling her investigation and would bring the information to the next QA meeting on 4/28/15. The QA meeting was initially scheduled on 4/21/15 and it was delayed due to a trial. The Nursing Home Administrator (NHA) said usually the QA is scheduled every third Tuesday of the month. The facility has done Ad Hoc meetings in the past but the DON wanted to sure everything was done before hand and an Ad Hoc meeting was not scheduled. The DON informed her that the physician had been notified. The DON also informed her that the facility was still working the concern. The Administrator stated that she was aware the process was in place. The four point process was not completed and had not been presented. A review of Resident #6 ' s Care Plan indicated Focus on Anticoagulation Therapy; has a potential for abnormal bleeding Date Initiated 12/23/2014; updated: 3/12/2015. Goal will be free from signs and symptoms of abnormal bleeding. Interventions: Administer anticoagulant as MD ordered. The Care Plan was not followed. Review of the facility ' s policy entitled " Medication Administration General Guidelines for the Administration of Medications " policy 6.2 (page one of three) (no dated) was reviewed and it is expected that the Licensed Nurses administer medications per the physician's order [REDACTED]. 2. During an interview on 04/27/2015 at 3:45 p.m. the facility ' s Director of Nursing (DON) she stated: " we have had another problem with an anticoagulant, it happened to Resident #2. " The DON said that when Resident #2 was admitted on [DATE] and the nurse had written up the physician orders [REDACTED]. The [MEDICATION NAME] was written on a regular sheet that did not have a carbon copy that was used for the medication administration record. We the (DON and ADON) did not find out about the medication not being given until 04/17/2015. " The DON was asked what the process was on checking admission orders [REDACTED]. The DON was asked who would be responsible to verify the physician ordered medications were accurately transcribed into the Medication Administration Record (MAR) she said the ADON or herself. The DON said " We checked the physician order [REDACTED]. " When the DON confirmed she did not review the MAR to make sure all the physician orders [REDACTED]. " When asked if the facility uses a check off system for newly admitted residents she said " we used to but now it is computerized. The computer tells us what to do. " She stated she was there the day of the verbal teaching but she did not sign the in-service verifying that she had attended. A medical record review was conducted for Resident #2 and revealed he had resided in the facility for approximately three weeks. His [DIAGNOSES REDACTED]. The Medication Administration Record for Resident #2 ' s physician orders [REDACTED]. The MAR indicated that on; 4/8, 4/9, 4/12, 4/13, 4/14, and on 4/16/2015 both orders were initialed/signed as being administered resulting in a total of 6 mg of [MEDICATION NAME]. On 4/17/2015 the order was discontinued and rewritten to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. (The same identical order, this time the initial boxes were outlined indicating which day of the week the medication needed to be given). On 4/28/2015 at 11:45 a.m. a telephone interview was conducted with Resident #2 ' s attending physician. He confirmed he was notified that the resident had been receiving double doses of his [MEDICATION NAME] and confirmed that his International Ratio was 3.2 and not critical (supra-therapeutic) . The physician confirmed the facility did not follow his orders and should have administered the proper dosages of [MEDICATION NAME] on the proper days as ordered. The physician stated " they need to fix it, I don ' t know if it ' s the DON or the corporation they have to fix these things so it doesn ' t happen again. " The DON provided a copy of an in-service that was conducted on 4/20/2015 (three days after the medication omission was found) Teaching Method: Verbal Topic: Anticoagulant and [MEDICATION NAME] Protocol. Make sure PT/INR is done, Call MD with results before giving medication, check orders daily and make sure [MEDICATION NAME] log is accurate. The DON was asked about any in-servicing that was provided to the licensed staff on physician orders [REDACTED]. The DON and NHA on 4/27/2015 confirmed that they were aware of Resident #2 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of Resident #2 ' s medication error on 4/17/2015, however, no negative outcomes occurred. (It was unclear due to the lack of the investigation of how and why the medication error was found.) 3. The facility admitted Resident #10 on 4/3/15 with [DIAGNOSES REDACTED]. Review of the April Medication Administration Record revealed Resident #10 the nurses failed to document the administration of the [MEDICATION NAME] on 4/9 or 4/12/15. There was no documentation on the back side of the MAR as to why the medication was omitted. Review of the Admission Physician order [REDACTED]. Review of the Care Plan dated 4/22/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11:00 a.m. No additional information was provided related to why the medication would not have been given to Resident #10. 4. The facility admitted Resident #14 on 1/23/15 with [DIAGNOSES REDACTED]. Review of Resident #14 ' s Medication Administration Record for February 2015 revealed the nursing staff failed to document the administration of [MEDICATION NAME] for 4 out of the 6 available doses. She did not receive any [MEDICATION NAME] on 2/16/15. The resident did not receive [MEDICATION NAME] on 2/17/15 at 9 a.m., 2/18/15 at 9 a.m. or 2/19/15 at 9 a.m. There was no documentation in the nurses ' notes or the back of the Medication Administration Record as to why the medication was not given. Further review of the medical record revealed a physician ' s telephone order dated 2/16/2015 for [MEDICATION NAME] 30 units subcutaneously twice daily. The resident was placed on [MEDICATION NAME] due to sub-therapeutic INR (International Normalizing Ratio) levels and she was at risk for developing additional blood clots. Review of the Laboratory results revealed on 2/16/15, Resident #14 ' s INR was 1.1. On 2/19/2015 the [MEDICATION NAME] was discontinued. The resident remained sub-therapeutic and the physician was attempting to adjust her [MEDICATION NAME]. On 2/26/15 the resident was noted to have redness and swelling to her right leg. An ultrasound was ordered and the resident was diagnosed with [REDACTED]. Review of the Care Plan dated 2/11/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " During an interview on 4/29/15 at 2:30 p.m., the Nurse Consultant confirmed the missed doses of [MEDICATION NAME]. He stated that the medication should have been available from pharmacy and was unable to determine why the nurses would not have given the medication. He stated that the at least one dose of the [MEDICATION NAME] should have been given on 2/16/15. 5. The facility admitted Resident #15 on 4/15/15 with [DIAGNOSES REDACTED]. Review of Resident #15 ' s Medication Administration Record for April 2015 revealed the nurses failed to document the administration of the [MEDICATION NAME] on 4/17/15 and 4/22/15. Review of the Physician order [REDACTED]. Review of the Care Plan dated 4/29/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11:00 a.m. No additional information was provided related to why the medication would not have been given to Resident #15. 6. The facility admitted Resident #16 on 3/19/15 with [DIAGNOSES REDACTED]. Review of Resident #16 ' s Medication Administration Record for March 2015 revealed the nurses failed to document to review the resident ' s pertinent laboratory data (INR) and administered four extra doses of [MEDICATION NAME] on 4/13, 4/14, 4/15 and 4/16/15. He received four doses of [MEDICATION NAME] after the medication should have been discontinued per the INR value of 2.5. Review of the physician's order [REDACTED].#16 was prescribed " [MEDICATION NAME] 60 units every 12 hours, D/C (discontinue) when INR (international normalizing ratio) above 2. " Review of the Laboratory Data revealed an INR was collected on 2/13/15 that was 2.5. Further review of the Laboratory Data revealed an INR was collected on 4/16/15 and the resident was supra-therapeutic at 3.9. Record review revealed no indication of abnormal bleeding was noted. Review of the Care Plan dated 4/8/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information as provided related to why the resident received the [MEDICATION NAME] when the medication should have been discontinued. 7. The facility admitted Resident #17 on 2/6/15 with [DIAGNOSES REDACTED]. Review of Resident #17 ' s April 2015 Medication Administration Record revealed the nurses did not document the administration of the prescribed [MEDICATION NAME] for 5 doses; 4/7, 4/10, 4/13, 4/15 and 4/19/15. There was no documentation in the nurses ' notes or on the back of the MAR as to why

Based on resident record review, interviews with the facility staff, the Attending Physician, the Medical Director, facility Administration and review of the facility ' s policy and procedures related to medication administration the facility failed to assure residents were free of significant medication errors. Based on a review of all current residents receiving anticoagulants, ten of thirty residents did not receive their anticoagulants per the physician ' s orders. Residents #2, #6, #10, #14, #15, #16, #17, #18, #19 and #20 were identified as not receiving anticoagulants that were necessary to prevent blood clots or [MEDICAL CONDITION]. Resident #6 was not administered Xarelto for twenty six days. The medication was placed on hold for three days for a dental procedure. The facility staff failed to implement the order and resume the medication on March 5, 2015. Resident #6 reported pain to the nursing staff and reported that the pain was consistent with a [MEDICAL CONDITION]. The physician was notified on 3/28/15 and ordered the necessary tests. The facility failed to implement those orders for three days, delaying treatment to the resident until 3/31/15. Resident #6 required injections of [MEDICATION NAME] to dissolve the clot. Resident #2 was administered a double dose of [MEDICATION NAME] on 4/8, 9, 12, 13, 14 and 16/2015. His INR was supra-therapeutic on 4/20/2015 at 3.2. Resident #10 was not administered her prescribed [MEDICATION NAME] on 4/9 and 12/2015. Resident #14 was not administered four of six available doses of [MEDICATION NAME]. Resident #15 was not administered her [MEDICATION NAME] on 4/1/2015 and on 4/22/2015. Resident #16 ' s [MEDICATION NAME] was to be discontinued when the International Normalizing Ratio (INR) was greater than 2. On 4/13/2015 the laboratory results indicated that her INR was 2.5 and the [MEDICATION NAME] was continued for four additional doses. Resident #17 was not administered five doses of [MEDICATION NAME] on 3/7, 10, 13, 15, 19/2015. Resident #18 was not administered four doses of [MEDICATION NAME] on 4/2, 11, 13 and 15/2015. Resident #19 missed four doses of [MEDICATION NAME] from 4/3-4/5/15. Resident #20 was not administered seven doses of [MEDICATION NAME] from 4/9/15-4/22/15. The facility ' s Licensed Nursing staff failed to administer medications in accordance with physician ' s orders. The failure of the nurses to administer anticoagulants resulted in significant medication errors that subsequently caused Resident #6 to develop an avoidable blood clot ([MEDICAL CONDITION]). Based on record review and interview, the nurses failed to administer medications timely and accurately for two (#2, #8) out of forty-eight (48) residents reviewed for medication accuracy. Resident #2 ' s physician ordered [MEDICATION NAME] and [MEDICATION NAME]that were omitted for 10 days. There was a three day delay in starting a physician ordered antibiotic for Resident #8 and two doses were omitted. The facility failed to monitor the administration of medications on a routine basis. The facility failed to systematically identify, investigate and report medication errors. The failure of the facility resulted in the findings of Immediate Jeopardy existing in the facility as of 3/5/2015. The facility Administration was informed on 5/1/2015 at 9:50 a.m. The Immediate Jeopardy was removed on 5/1/15 at 5:30 p.m. and the scope and severity was reduced to an " E. " Findings Include: 1. During an interview on 4/28/2015 at 10:30 a.m. Resident #6 stated she was diagnosed with [REDACTED]. The resident stated that " the doctor said it was from my knee to my foot and I think there was more than one ([MEDICAL CONDITION]). " The resident was asked if the nurse had spoken to her about her [MEDICAL CONDITION] she said " No, the doctor told me the nurses were not giving me my medication, he was really pissed. " They (the nurses) had to give me [MEDICATION NAME] two times a day for five days and I hate needles. " Resident #6 stated that when she first had come to the facility she had a [MEDICAL CONDITION] in her left arm " that is why I take the Xarelto every day. " The resident stated that she used to check her medications every day and now has to start checking them again. " It ' s not my job to have to ask if all my medications are there or not is it? " During a telephone interview on 4/28/2015 at 11:42 a.m., Resident #6 ' s Attending Physician stated; " the nurses did not give her medication Xarelto, the medication was only on hold for a few days for her dental surgery. The physician was asked why the Xarelto was not restarted after her dental surgery. The physician stated he did not understand why the nurses did not restart the medication, " I gave the nurses the order; they should have restarted the Xarelto after the dental procedure was completed. The Xarelto is to prevent her from getting a [MEDICAL CONDITION] if she would have received the medication she would not have gotten a ([MEDICAL CONDITION]). " During an interview on 4/30/15 at 12:20 p.m., the Attending Physician confirmed he assessed the resident on 3/28/15 and documented the resident ' s leg was red and swollen. He also ordered a venous Doppler study. The physician stated that he was informed by Employee (LPN) A of the swollen leg and the lack of the Xarelto on 3/28/15. He verbally gave the order to Employee A. The Attending Physician confirmed the venous Doppler order was not completed until 03/31/2015 and also confirmed that no medication was started until 03/31/2015. He was unsure of why there would have been a delay in obtaining treatment, necessary tests or initiating the medication. Further review of the physician orders dated on 2/11/2015; " Stop blood thinners x 3 days prior to tooth extraction and resume one day post (3/4/2015) p.m. " A telephone order dated 3/31/2015 revealed a Venous Doppler was ordered STAT. Also on 3/31/15, [MEDICATION NAME] 80 MG SQ was ordered (subcutaneously) BID (two times) for 5 days. There were no orders for 3/28/2105 when the physician was first made aware of the [MEDICAL CONDITION]. Review of the Medication Administration Record (MAR) dated March 2015 revealed a typed order dated 12/05/2014 for Xarelto 15 MG tablet one tablet by mouth once a day. Directly underneath the typed order a hand written entry; resume 3-5-15. The Medication Administration Record (MAR) revealed the nurses documented for 03/01/2015, 3/2/2015, 3/3/2015 and 3/4/2015: " HOLD. " The MAR for 3/5/2015, when the Xarelto was to be restarted, indicated the boxes, where an initial should have been written, were empty (indicating the dose was not administered). The remainder of the MAR from 3/6/2015 through 3/30/2015 was reviewed with no indication that the medication had been given and no indication as to why the medication was not given. A review of the Physician ' s Progress Notes revealed on 3/28/15, the Attending Physician assessed Resident #6 and diagnosed her with an acute [MEDICAL CONDITION]. The physician documented: " Redness and swelling left leg, 4+ [MEDICAL CONDITION] L > R, Tender left leg. " The physician also documented that the resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error. " Further review of the Attending Physician ' s progress note revealed he documented " Venous Doppler was ordered. " There was no corresponding physician ' s order for the Doppler Studies until 3/31/15, three days after the physician assessed the resident. Further review of Resident #6 ' s medical record revealed that she had resided in the facility for approximately fifteen months and was fifty three years old. Resident #6 ' s medical history included [MEDICAL CONDITION] and a history of [MEDICAL CONDITION]. On 12/22/2014 a Brief Interview for Mental Status (BIMS) revealed a Score of 15 indicating no cognitive impairment. Review of the Nurses ' Notes on 3/28/15 revealed no documentation of a red, swollen leg. There was no documentation of the omission of the medication, the physician visit or the new orders. On 3/30/15, Employee (LPN) A documented: the resident complained of pain and redness to her leg, upon assessment the leg was warm to touch and was swollen. Painful, 2+ pitting. The doctor was paged and made aware and stated he saw her on Saturday. New orders for [MEDICATION NAME] BID were obtained. On 3/31/2015 at 3:25 a.m. the nurse documented at " 12:45 a.m. patient states she thinks she has a [MEDICAL CONDITION] to her LLE. Area of slight redness noted to inner calf to LLE, [MEDICAL CONDITION] to bilateral LE. Skin temp within normal limits. Capillary refill is brisk bilaterally. Unable to assess pulse related to [MEDICAL CONDITION]. Patient rates pain level #1 at this time on a scale of 1-10 with 10 being the worst. Patient states she has had multiple [MEDICAL CONDITION] in the past and knows what it feels like. Notified resident physicians of above and new orders were received for a STAT venous Doppler of the LLE to rule out [MEDICAL CONDITION]. At 0200 (2:00 p.m.) [MEDICATION NAME] 100mg was administered for c/o pain to LLE with a pain level of 9 out of 10. [MEDICATION NAME] was effective. At 0330 (3:30 a.m.), the mobile radiology service arrived to perform Doppler. Patient remained on bed rest. Patient remained alert and responding appropriately to verbal and tactile stimuli. No s/s of distress noted. Vitals 97.8-74-18-119/78. Patient received new order on 3/30/15 to restart Xarelto (Xarelto was not discontinued). " A review of the Ultrasound Report, dated 3/31/2015 revealed: " Examination: Venous Doppler extremity/limb, left. Clinical Indications: Swelling of Limb, Findings: Real time color imaging shows no collateral and augmentation of post tibial vein, popliteal vein, deep femoral vein and common vein of left leg. There are no excessive collateral veins. Left lower Extremity Venous duplex Ultrasound: Impression: Extensive [MEDICAL CONDITION] seen. " An interview was conducted with the facility ' s Director of Nursing (DON), on 4/27/2015, at 3:00 p.m. A list of medication errors for the month of March 2015 was provided by the DON. The DON stated that she was aware of the medication error for Resident #6. She stated that a nurse found the error after performing a " medication review. " The DON stated that she was unsure of why the error occurred. She stated that the facility ' s intervention was the Venous Ultrasound and the physician and the resident were notified of the error. The DON confirmed that no audits or education were provided to the staff following the medication error. The DON also confirmed that there was no evidence of an investigation. The DON stated that her conclusion of the omitted medication for Resident #6 was " we performed an ultrasound, and started giving her [MEDICATION NAME] injections and elevated her left leg. " On 5/1/2015 at 9:50 a.m. the Nursing Home Administrator, DON and the facility ' s corporate nurse confirmed that an in service was not conducted related to Resident #6 ' s omissions of her scheduled medications. The DON and NHA on 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #6 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of the medication errors for Resident #6 only after the Doppler confirmed the positive [MEDICAL CONDITION]. It was unclear due to the lack of the investigation of how and why the medication error was found. The DON was unable to present any information regarding her investigation, education or audits. No formal action plan had been put in place as of the time of the start of the survey on 4/27/15. During an interview on 4/29/2015, at 3:30 p.m., the DON stated " she checks the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. During an interview on 4/30/15, at 8:50 a.m., the Assistant Director of Nurses stated that she randomly checked the MARs on a daily basis for accuracy and completeness. She stated that she checked new admissions and " maybe two others. " She stated that the Unit Manager was responsible for checking at least five residents on each cart on a daily basis. The ADON stated that there was not a definite system of checking the MARs. During an interview on 4/30/15 at 9:30 a.m., Employee (LPN) A, Interim Unit Manager (started on Monday 4/20/15), stated that she checked all new admissions for accuracy of orders and double checks with the MAR for accuracy. She stated that she did not do anything with the MARs on a daily basis. No one informed her she was supposed to be checking the MARs. She stated that she gets the new orders and the 24 hour report in the morning and then gives them to the ADON or DON to take them to the morning meeting. She does not usually go to the morning meetings and was not aware of any plan to begin to go. She stated that no education or training was provided to be a Unit Manager. The ADON told her the things that needed to be done and she was " just helping them out not doing the whole position. " The regular Unit Manager (LPN) B on the Long Term Care unit was currently on medical leave and was unable to be contacted. During an interview on 4/29/15 at 10:13 a.m. and 4/30/15 at 10:43 a.m., the DON stated that the process of checking the MARs was an informal process that was implemented inconsistently and the ADON and Unit Manager assisted with the process. There was not a written policy or procedure. The DON stated that she had been in the role of DON for one year and the process of checking the MARs had been an expectation since her arrival and she had continued that process since then. The DON also stated on 4/30/15 at 10:43 am that she was unaware the ADON and Unit Managers were not checking the MARs daily. During an interview on 4/29/15 at 2:45 p.m., the Medical Director stated that he had been the Medical Director of the facility since 2012. He stated that he participated in the QA monthly meetings and the facility followed a set agenda. He stated that he was made aware of incidents for his patients and that the attending physician for the other residents would be notified of incidents. He stated that he would expect to be notified of incidents, including medication errors. Specifically, for system failures that could affect all residents. He stated that he was here at the facility every Wednesday and Friday. However, someone from his physician group was present daily and should be notified. He expected that the nurses notify the physician of any incident. He confirmed again that he was not made aware of any medication errors for Resident #6. He was not aware of any issues in QA related to medication administration. He stated that he was aware that the facility used a lot of agency staff and had a lot of turnover. The Medical Director stated that there no action plan identified or implemented related to staffing or staff procedures. He also stated that he was aware of a concern with nurses not implementing physician orders timely. He stated that the nurse would pass off the order to the oncoming shifts and the medication would not be started. He stated that he provided education to the staff " within the year " related to medication implementation. The education was to have a second nurse initial the order to assure implementation. He confirmed that there was nothing in Quality Assurance (QA) related to the medication administration and order implementation process. The Medical Director stated that if the facility had a good system in place, then any staff member should be able to come in and care for the resident with no breaks in the system. He stated that the " system was not perfect and should not have failed. " The Medical Director was asked if it was expected that the facility notify him of negative outcomes; he stated, " I would love to. " When referring to the incident for Resident #6, the Medical Director stated that it was a " negative outcome and that he was afraid for his patients. " He stated that " there was not a plan in place. " During an interview on 4/30/15, at 10:15 a.m., the Administrator stated that she was informed of Resident #6 ' s medication error on April 1, 2015. She was informed that the Unit Manager had educated the staff involved. The DON informed her that she was assembling her investigation and would bring the information to the next QA meeting on 4/28/15. The QA meeting was initially scheduled on 4/21/15 and it was delayed due to a trial. The Nursing Home Administrator (NHA) said usually the QA is scheduled every third Tuesday of the month. The facility has done Ad Hoc meetings in the past but the DON wanted to make sure everything was done before hand and an Ad Hoc meeting was not scheduled. The DON informed her that the physician had been notified. The DON also, informed her that the facility was still working the concern. The Administrator stated that she was aware the process was in place. The four point process was not completed and had not been presented. The MAR indicated that six nurses assigned on the 3-11 p.m. shift failed to administer the Xarelto as ordered by the attending physician. During an interview on 4/29/15 at 4:10 p.m. Employee (RN) E, a nurse that cared for the resident on 12 of the 26 evening shifts, stated that she had been a nurse for a long time and worked in long term care. She stated that she was familiar with Resident #6. She stated that she was aware the resident needed Xarelto. The medication was not administered. She stated that she did not think the order was on going. She stated that it was on hold. She stated that she did not have the time to research the order and was aware that Resident #6 was at high risk for [MEDICAL CONDITION]. She stated that she questioned the medication to other staff; however, she did not recall who the staff member was. She stated that the doctor came in and then realized the medication should have been resumed. The nurse stated that when a medication was held, the nurse should write hold on the days that the medication is to be held and then indicate when the medication should be resumed. The nurse confirmed the MAR and confirmed that there was no indication the medication had been given. She stated that she did not recall the 3/5/15 resume date. The nurse stated that " my philosophy is if I don ' t see the medication and don ' t see a stop order, then I question with another nurse as to whether the medication is on hold or should be discontinued. " She stated that she would call the pharmacy. She stated that the medication card was not in the cart. The nurse also confirmed that she did not document any omissions in the chart. She stated that she did not look at the chart to find the original order. An interview was conducted on 4/29/15 at 4:30 p.m. with Employee (LPN) D. She stated that she worked at the facility 2/13/15-4/26/15. When asked about her training she stated she had trained for two to three days and was on her own by the fourth day. She said she had felt that it was " 50/50 " on her orientation process as far as knowing the processes and was able to always go back and ask questions. Employee (LPN) D stated that she recalled caring for Resident #6. She confirmed that she was on Xarelto and stated that she cared for her several times. The staff member reviewed the MAR and confirmed that she worked on 3/6/15, 3/9/15, 3/10/15, 3/13/15, 3/19/15, 3/23/15, 3/24/15 and 3/29/15. The nurse next confirmed the order for Xarelto and then confirmed the order said to resume 3/5/15. The nurse stated that she would not have given a medication without signing the MAR. These dates were blank, with no initials. Review of the Pharmacy Dispensing Record for Resident #6 ' s Xarelto from January 1-April 2015. The pharmacy sent 14 pills at a time. Review of the Dispensing Log revealed the facility last received 14 pills on 2/15/15. All of the medication would have been administered by 3/1/15. Therefore, there was no Xarelto available for administration. The medication was not a routinely stocked medication in the Emergency Drug Kit. Review of the Drug Manufacturer ' s Pharmaceutical Medication Guide for Xarelto revealed; " XARELTO® is a prescription medicine used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Do not stop taking XARELTO® without talking to your doctor first. Your doctor may stop XARELTO® for a short time before any surgery, medical or dental procedure. Your doctor will tell you when to start taking XARELTO® again after your surgery or procedure. " Review of Resident #6 ' s Care plan Focus on Anticoagulation Therapy reflected the resident had a " potential for abnormal bleeding. " Date Initiated; 12/23/2014 updated: 3/12/2015. Goal will be free from signs and symptoms of abnormal bleeding. Interventions: Administer anticoagulant as MD ordered. " The Care Plan was not followed. Review of the facility policy entitled " Medication Administration General Guidelines for the Administration of Medications " policy 6.2 (page one of three) (no dated) was reviewed and it was expected that the nurses administer medications per the physician ' s orders. The facility identified thirty residents receiving anticoagulants. All thirty residents were sampled. The following residents were identified with medications errors related to anticoagulant therapy. 2. During an interview on 04/27/2015 at 3:45 p.m. the facilities Director of Nursing (DON) she stated: " we have had another problem with an anticoagulant, it happened to Resident #2. " The DON said that when Resident #2 was admitted on [DATE] and the nurse had written up the physician orders on one of our order sheets. The [MEDICATION NAME] was written on a regular sheet that did not have a carbon copy that was used for the medication administration record. We the (DON and ADON) did not find out about the medication not being given until 04/17/2015. " The DON was asked what the process was on checking admission orders [REDACTED]. The DON was asked who would be responsible to verify the physician ordered medications were accurately transcribed into the Medication Administration Record (MAR) she said the ADON or me. The DON said " We checked the physician order sheet and they were written correctly but because the [MEDICATION NAME] order was not put on the physician order sheet that contained a carbon copy it did not show up on the MAR. " The DON confirmed she did not review the MAR to make sure all the physician orders were transcribed. The DON was asked how that had happened she stated; " I ' m still trying to figure out how it happened and when I do find it out it has unfortunately already occurred. " When asked if the facility uses a check off system for newly admitted residents she said " we used to but now it is computerized. The computer tells us what to do. " She stated she was there the day of the verbal teaching but she did not sign the in-service verifying that she had attended. A medical record review was conducted for Resident #2 and revealed he had resided in the facility for approximately three weeks. His [DIAGNOSES REDACTED]. Review of Resident #2 ' s admission orders [REDACTED]. Review of the April 2015 Medication Administration Record for Resident #2 revealed the 4 mg and 2 mg doses were initialed on: 4/8, 4/9, 4/12, 4/13, 4/14, and on 4/16/2015, resulting in a total of 6 mg of [MEDICATION NAME]. On 4/17/2015 the order was discontinued and rewritten to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. (The same identical order, this time the initial boxes were outlined indicating which day of the week the medication needed to be given). On 4/28/2015 at 11:45 a.m. a telephone interview was conducted with Resident #2 ' s Attending Physician. He confirmed he was notified that the resident had been receiving double doses of his [MEDICATION NAME] and confirmed that his International Normalizing Ratio was 3.2 and not critical (supra-therapeutic). The physician confirmed the facility did not follow his orders and should have administered the proper dosages of [MEDICATION NAME] on the proper days as ordered. The physician stated " they need to fix it, I don ' t know if it ' s the DON or the corporation they have to fix these things so it doesn ' t happen again. " The DON provided a copy of an in-service that was conducted on 4/20/2015 (three days after the medication omission was found) Teaching Method: Verbal Topic: Anticoagulant and [MEDICATION NAME] Protocol. Make sure PT/INR is done, Call MD with results before giving medication, check orders daily and make sure [MEDICATION NAME] log is accurate. The DON was asked about any in-servicing that was provided to the licensed staff on physician orders not being transcribed accurately in the residents MAR or not being transcribed at all, she did not respond. The DON and NHA on 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #2 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of Resident #2 ' s medication error on 4/17/2015; however, no negative outcomes occurred. It is unclear due to the lack of the investigation of how and why the medication error was found. On 4/29/2015 the DON stated " she checks the MARs two times a week by flipping through all of the MARs, she confirmed there was no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. 3. The facility admitted Resident #10 on 4/3/15 with [DIAGNOSES REDACTED]. Review of the Admission Physician Orders dated 4/3/2015 revealed the resident was prescribed [MEDICATION NAME] 40 unit subcutaneously daily at 9 a.m. Review of the April Medication Administration Record revealed Resident #10 did not receive [MEDICATION NAME] on 4/9 or 4/12/15. There was no documentation on the back side of the MAR as to why the medication was omitted. Review of the Care Plan dated 4/22/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information was provided related to why the medication would not have been given to Resident #10. 4. The facility admitted Resident #14 on 1/23/15 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #14 was transferred to a Hospice House for end of life care. Further review of the medical record revealed a physician ' s telephone order dated 2/16/2015 for [MEDICATION NAME] 30 units subcutaneously twice daily. The resident was placed on [MEDICATION NAME] due to sub-therapeutic INR (International Normalizing Ratio) levels and she was at risk for developing additional blood clots. Review of the Laboratory results revealed on 2/16/15, Resident #14 ' s INR was 1.1. On 2/19/2015 the [MEDICATION NAME] was discontinued. The resident remained sub-therapeutic and the physician was attempting to adjust her [MEDICATION NAME]. Review of the Medication Administration Record for February 2015 revealed Resident #14 did not receive [MEDICATION NAME] for 4 out of the 6 available doses. She did not receive any [MEDICATION NAME] on 2/16/15. The resident did not receive [MEDICATION NAME] on 2/17/15 at 9 a.m., 2/18/15 at 9 a.m. or 2/19/15 at 9 a.m. There was no documentation in the nurses ' notes or the back of the Medication Administration Record as to why the medication was not given. On 2/26/15 the resident was noted to have redness and swelling to her right leg. An ultrasound was ordered and the resident was diagnosed with [REDACTED]. Review of the Care Plan dated 2/11/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " During an interview on 4/29/15 at 2:30 p.m., the Nurse Consultant confirmed the missed doses of [MEDICATION NAME]. He stated that the medication should have been available from pharmacy and was unable to determine why the nurses would not have given the medication. He stated that the at least one dose of the [MEDICATION NAME] should have been given on 2/16/15. 5. The facility admitted Resident #15 on 4/15/15 with [DIAGNOSES REDACTED]. Review of the Physician Orders for April 2015 revealed Resident #15 was prescribed [MEDICATION NAME] 40 unit subcutaneously daily for two weeks. Review of the Medication Administration Record for April 2015 revealed Resident #15 did not receive her [MEDICATION NAME] on 4/17/15 and 4/22/15. Review of the Care Plan dated 4/29/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11:00 a.m. No additional information as provided related to why the medication would not have been given to Resident #15. 6. The facility admitted Resident #16 on 3/19/15 with [DIAGNOSES REDACTED]. Review of the Physician ' s Orders revealed on 3/23/15 Resident #16 was prescribed " [MEDICATION NAME] 60 units every 12 hours, D/C (discontinue) when INR (international normalizing ratio) above 2. " Review of the Laboratory Data revealed an INR was collected on 2/13/15 that was 2.5. Review of the Medication Administration Record for March 2015 revealed Resident #16 was given [MEDICATION NAME] on 4/13, 4/14, 4/15 and 4/16/15. He received four doses of [MEDICATION NAME] after the medication should have been discontinued per the INR value of 2.5. Further review of the Laboratory Data revealed an INR was collected on 4/16/15 and the resident was supra-therapeutic at 3.9. Record review revealed no indication of abnormal bleeding was noted. Review of the Care Plan dated 4/8/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information as provided related to why the resident received the [MEDICATION NAME] when the medication should have been discontinued. 7. The facility admitted Resident #17 on 2/6/15 with [DIAGNOSES REDACTED]. Review of the Physician ' s Orders for April 2015 revealed the resident was prescribed [MEDICATION NAME] 3 mg PO daily at 5 p.m.. Review of the April 2015 Medication Administration Record revealed Resident #17 did not receive the prescribed [MEDICATION NAME] for 5 doses; 4/7, 4/10, 4/13, 4/15 and 4/19/15. There was no documentation in the nurses ' notes or on the back of the MAR as to why the medication was omitted. Review of the Care Plan dated 2/25/15 revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrato

Based on review of the facility ' s Administrator ' s Job Description, review of the facility ' s policy and procedure for medication administration, resident record review, interviews with the facility staff, the Attending Physician, the Medical Director and Administration, the facility administration failed to administer effectively and failed to utilize resources to assure residents were free from significant errors. Based on a review of all current residents receiving anticoagulants, ten of thirty residents did not receive their anticoagulants per the physician ' s orders. Resident ' s #2, #6, #10, #14, #15, #16, #17, #18, #19 and #20 were identified as not receiving anticoagulants that were necessary to prevent blood clots or [MEDICAL CONDITION]. Resident #6 was not administered Xarelto for twenty six days. The medication was placed on hold for three days for a dental procedure. The facility staff failed to implement the order and resume the medication on March 5, 2015. Resident #6 reported pain to the nursing staff and reported that the pain was consistent with a [MEDICAL CONDITION]. The physician was notified on 3/28/15 and ordered the necessary tests. The facility failed to implement those orders for three days, delaying treatment to the resident until 3/31/15. Resident #6 required injections of [MEDICATION NAME] to dissolve the clot. Resident #2 was administered a double dose of [MEDICATION NAME] on 4/8, 9, 12, 13, 14 and 16/2015. His INR was supra-therapeutic on 4/20/2015 at 3.2. Resident #10 was not administered her prescribed [MEDICATION NAME] on 4/9 and 12/2015. Resident #14 was not administered four of six available doses of [MEDICATION NAME]. Resident #15 was not administered her [MEDICATION NAME] on 4/1/2015 and on 4/22/2015. Resident #16 ' s [MEDICATION NAME] was to be discontinued when the International Normalizing Ratio (INR) was greater than 2. On 4/13/2015 the laboratory results indicated that her INR was 2.5 and the [MEDICATION NAME] was continued for four additional doses. Resident #17 was not administered five doses of [MEDICATION NAME] on 3/7, 10, 13, 15, 19/2015. Resident #18 was not administered four doses of [MEDICATION NAME] on 4/2, 11, 13 and 15/2015. Resident #19 missed four doses of [MEDICATION NAME] from 4/3-4/5/15. Resident #20 was not administered seven doses of [MEDICATION NAME] from 4/9/15-4/22/15. The facility ' s Licensed Nursing staff failed to follow physician ' s orders and administer medications resulting in significant medication errors that subsequently caused Resident #6 to develop an avoidable blood clot ([MEDICAL CONDITION]). Based on record review and interview, the facility administration failed to assure residents were free of medication errors for two (#2, #8) out of forty-eight (48) residents for medication accuracy. Resident #2 ' s physician ordered [MEDICATION NAME] and [MEDICATION NAME]that were omitted for 10 days. There was a three day delay in starting a physician ordered antibiotic for resident #8 and two doses were omitted. The failure of the facility administration to effectively utilize resources related to medication administration resulted in the findings of Immediate Jeopardy existing in the facility as of 3/5/2015. The facility Administration was informed on 5/1/2015 at 9:50 a.m. Based on a Credible Allegation of Compliance the Immediate Jeopardy was removed on 5/1/15 at 5:30 pm and the scope and severity was reduced to an " E. " Findings Include: 1) Review of the Administrator ' s Job Description revealed the Purpose of Your Job Position described as " the primary position is to direct the day to day functions of the facility in accordance with the current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. " The Job Duties and Responsibilities include to " Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. To ensure that all employees follow the established policies and procedures. Committee Functions; Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identify quality deficiencies. " Report problems to the Medical director. " During an interview on 4/30/15 at 10:15 am, the Administrator stated that on 4/1/15 she received a report of a concern with Resident #6. She was informed of a medication error. The Unit Manager had educated the staff involved. The DON informed her that she was assembling her investigation and would bring the information to the next QA meeting on 4/28/15. The meeting was initially scheduled on 4/21/15 and it was delayed due to a trial. The Nursing Home Administrator (NHA) said, usually, the QA is scheduled every third Tuesday of the month. The facility had done Ad Hoc meetings in the past, but, the DON wanted to make sure everything was done before hand. The DON informed her that the physician had been notified. The DON informed her that the facility was still working that process. The Administrator stated that she was aware the process was in place. The four point process was not completed and had not been presented. During an interview on 4/29/15 at 2:45 pm, the Medical Director stated that he had been the Medical Director of the facility since 2012. He stated that he participated in the QA monthly meetings and the facility followed a set agenda. He stated that he was made aware of incidents for his patients and that the attending physician for the other residents would be notified of incidents. He stated that he would expect to be notified of incidents, including medication errors, specifically, for system failures that could affect all residents. He stated that he was here at the facility every Wednesday and Friday. However, someone from his physician group was present daily and should be notified. He expected that the nurses notify the physician of any incident. He confirmed again that he was not made aware of any medication errors for Resident #6. He was not aware of any issues in QA related to medication administration. He stated that he was aware that the facility used a lot of agency staff and had a lot of turnover. The Medical Director stated that there was no action plan identified or implemented related to staffing or staff procedures. He also stated that he was aware of a concern with nurses not implementing physician orders timely. He stated that the nurse would pass off the order to the oncoming shifts and the medication would not be started. He stated that he provided education to the staff " within the year " related to medication implementation. The education was to have a second nurse initial the order to assure implementation. He confirmed that there was nothing in Quality Assurance (QA) related to the medication administration and order implementation process. The Medical Director stated that if the facility had a good system in place, then any staff member should be able to come in and care for the resident with no breaks in the system. He stated that the " system was not perfect and should not have failed. " The Medical Director was asked if it was expected that the facility notify him of negative outcomes; he stated, " I would love to. " When referring to the incident for Resident #6, the Medical Director stated that it was a " negative outcome and that he was afraid for his patients. " He stated that " there was not a plan in place. " Review of the facility policy entitled, " Medication Administration General Guidelines for the Administration of Medications " policy 6.2 (page one of three) (no date) was reviewed and it was expected that the nurses administer medications per the physician ' s orders. An interview was conducted with the facility ' s Director of Nursing (DON), on 4/27/2015, at 3:00 p.m. A list of medication errors for the month of March 2015 was provided by the DON. The DON stated that she was aware of the medication error for Resident #6. She stated that a nurse found the error after performing a " medication review. " The DON stated that she was unsure of why the error occurred. She stated that the facility ' s intervention was the Venous Ultrasound and the physician and the resident were notified of the error. The DON confirmed that no audits or education was provided to the staff following the medication error. The DON also confirmed that there was no evidence of an investigation. The DON stated that her conclusion of the omitted medication for Resident #6 was " we performed an ultrasound, and started giving her [MEDICATION NAME] injections and elevated her left leg. " On 5/1/2015 at 9:50 a.m., the Nursing Home Administrator, DON and the facility ' s corporate nurse confirmed that an in service was not conducted related to Resident #6 ' s omissions of her scheduled medications. The DON and NHA ON 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #6 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of the medication errors for Resident #6 only after the Doppler confirmed the positive [MEDICAL CONDITION]. It was unclear due to the lack of the investigation of how and why the medication error was found. During an interview on 4/29/2015, at 3:30 p.m., the DON stated " she checks the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. During an interview on 4/30/15, at 8:50 a.m., The Assistant Director of Nurses stated that she randomly checked the MARs on a daily basis for accuracy and completeness. She stated that she checked new admissions and " maybe two others. " She stated that the Unit Manager was responsible for checking at least five residents on each cart on a daily basis. The ADON stated that there was not a definite system of checking the MARs. An interview was conducted on 4/30/15 at 9:30 a.m. with Employee (LPN) A Interim Unit Manager (started on Monday 4/20/15). She stated that she checked all new admissions for accuracy of orders and double checks with the MAR for accuracy. She stated that she did not do anything with the MARs on a daily basis. No one informed her she was supposed to be checking the MARs. She stated that she gets the new orders and the 24 hour report in the morning and then gives them to the ADON or DON to take them to the morning meeting. She did not usually go to the morning meetings and was not aware of any plan to begin to go. She stated that no education or training was provided to be a Unit Manager. The ADON told her the things that needed to be done and she was " just helping them out not doing the whole position. " The regular Unit Manager (LPN) B on the Long Term Care unit was currently on medical leave and was unable to be contacted. During an interview on 4/29/15 at 10:13 a.m. and 4/30/15 at 10:43 a.m., The DON stated that the process of checking the MARs was an informal process that was implemented inconsistently and the ADON and Unit Manager assisted with the process. There was not a written policy or procedure. The DON stated that she had been in the role of DON for one year and the process of checking the MARs had been an expectation since her arrival and she had continued that process since then. The DON also stated, on 4/30/15 at 10:43 a.m., that she was unaware the ADON and Unit Managers were not checking MARs daily. During an interview with the DON, she was unable to present any information regarding her investigation, education or audits. No formal action plan had been put in place as of the time of the start of the survey on 4/27/15. 2) During an interview on 4/28/2015 at 10:30 a.m. Resident #6 stated she was diagnosed with [REDACTED]. She said it was not just a [MEDICAL CONDITION] it was an extensive [MEDICAL CONDITION]. The resident stated that " the doctor said it was from my knee to my foot and I think there was more than one ([MEDICAL CONDITION]). " The resident was asked if the nurse had spoken to her about her [MEDICAL CONDITION]. She said, " No, the doctor told me the nurses were not giving me my medication. He was really pissed. " They (the nurses) had to give me [MEDICATION NAME] two times a day for five days and I hate needles. " Resident #6 said that when she first had come to the facility she had a [MEDICAL CONDITION] in her left arm and " that is why I take the Xarelto every day. " The resident stated that she used to check her medications every day and now has to start checking them again. " It ' s not my job to have to ask if all my medications are there or not is it? " During a telephone interview on 4/28/2015 at 11:42 a.m., Resident #6 ' s attending physician stated; " the nurses did not give her medication Xarelto, the medication was only on hold for a few days for her dental surgery. " The physician was asked why the medication Xarleto was not restarted after her dental surgery. The physician stated he did not understand why the nurses did not restart the medication. " I gave the nurses the order and they should have restarted the Xarelto after the dental procedure was completed. The Xarelto is to prevent her from getting a [MEDICAL CONDITION]. If she would have received the medication she would not have gotten a ([MEDICAL CONDITION]). " During an interview on 4/30/15 at 12:20 p.m., the attending Physician confirmed he assessed the resident on 3/28/15 and documented the resident ' s leg was red and swollen. He also ordered a venous Doppler study. The physician stated that he was informed by Employee (LPN) A of the swollen leg and the lack of the Xarelto on 3/28/15. He verbally gave the order to Employee A. The attending physician confirmed the venous Doppler order was not completed until 03/31/2015 and also confirmed that no medication was started until 03/31/2015. He was unsure of why there would have been a delay in obtaining treatment, necessary tests or initiating the medication. Further review of the physician orders, dated on 2/11/2015, reflected " Stop blood thinners x 3 days prior to tooth extraction and resume one day post (3/4/2015) p.m. " A written telephone order, dated on 3/31/2015, referenced Venous Doppler STAT and a third order dated for the same day (3/31/2015), directed [MEDICATION NAME] 80 MG SQ ( subcutaneously) BID (two times) for 5 days. Review of the Medication Administration Record, dated March 2015, revealed a typed order dated 12/05/2014, for Xarelto 15 MG tablet one tablet by mouth once a day. Directly underneath the typed order a hand written entry stated resume 3-5-15. The Medication Administration Record (MAR) revealed the nurses documented for 03/01/2015, 3/2/2015, 3/3/2015 and 3/4/2015: " HOLD. " The Xarelto was to be restarted on 3/5/2015. The boxes, where an initial should have been written, were empty (indicating the dose was not administered). The remainder of the MAR from 3/6/2015 through 3/30/2015 was reviewed with no indication that the medication had been given and no indication as to why the medication was not given. A review of the Physician ' s Progress Notes revealed on 3/28/15, the Attending Physician assessed Resident #6 and diagnosed her with an acute [MEDICAL CONDITION]. The physician documented: " Redness and swelling left leg, 4+ [MEDICAL CONDITION] L > R, Tender left leg. " The physician also documented that the resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error. " Further review of the Attending Physician ' s progress note revealed he documented " Venous Doppler was ordered. " There was no corresponding physician ' s order for the Doppler Studies until 3/31/15, three days after the physician assessed the resident. Further review of Resident #6 ' s medical record revealed that she had resided in the facility for approximately fifteen months and was fifty three years old. Resident #6 ' s medical history included [MEDICAL CONDITION] and a history of [MEDICAL CONDITION]. On 12/22/2014, a Brief Interview for Mental Status (BIMS) revealed a Score of 15 indicating no cognitive impairment. Review of the Nurses ' Notes on 3/28/15 revealed no documentation of a red, swollen leg. There was no documentation of the omission of the medication, the physician visit or the new orders. On 3/30/15, employee (LPN) A documented: the resident complained of pain and redness to her leg and upon assessment the leg was warm to touch and was swollen. Painful, 2+ pitting. The doctor was paged and made aware and stated he saw her on Saturday. New orders for [MEDICATION NAME] BID were obtained. On 3/31/2015 at 3:25 a.m., the nurse documented at " 12:45 a.m. patient states she thinks she has a [MEDICAL CONDITION] to her LLE. Area of slight redness noted to inner calf to LLE, [MEDICAL CONDITION] to bilateral LE. Skin temp within normal limits. Capillary refill is brisk bilaterally. Unable to assess pulse related to [MEDICAL CONDITION]. Patient rates pain level #1 at this time on a scale of 1-10 with 10 being the worst. Patient states she has had multiple [MEDICAL CONDITION] in the past and knows what it feels like. Notified resident physician of above and new orders were received for a STAT venous Doppler of the LLE to rule out [MEDICAL CONDITION]. At 0200 (2:00 a.m.) [MEDICATION NAME] 100mg was administered for c/o pain to LLE with a pain level of 9 out of 10. [MEDICATION NAME] was effective. At 0330 (3:30 a.m.), the mobile radiology service arrived to perform Doppler. Patient remained on bed rest. Patient remained alert and responding appropriately to verbal and tactile stimuli. No s/s of distress noted. Vitals 97.8-74-18-119/78. Patient received new order on 3/30/15 to restart Xarelto (Xarelto was not discontinued). " A review of the Ultra Sound Report, date of service: 3/31/2015 revealed: " Examination: Venous Doppler extremity/limb, left. Clinical Indications: Swelling of Limb, Findings: Real time color imaging shows no collateral and augmentation of post tibial vein, popliteal vein, deep femoral vein and common vein of left leg. There are no excessive collateral veins. Left lower Extremity Venous duplex Ultrasound: Impression: Extensive [MEDICAL CONDITION] seen. " The MAR indicated that six nurses assigned on the 3-11 p.m. shift failed to follow Resident #6 ' s Plan of Care and administer the Xarelto as ordered by the attending physician. During an interview on 4/29/15 at 4:10 p.m. Employee (RN) E, a nurse that cared for the resident on 12 of the 26 evening shifts, stated that she had been a nurse for a long time and worked in long term care. She stated that she was familiar with Resident #6. She stated that she was aware the resident needed Xarelto. The medication was not administered. She stated that she did not think the order was on going. She stated that it was on hold. She stated that she did not have the time to research the order and was aware that Resident #6 was at high risk for [MEDICAL CONDITION]. She stated that she questioned the medication to other staff; however, she did not recall who the staff member was. She stated that the doctor came in and then realized the medication should have been resumed. The nurse stated that when a medication was held, the nurse should write hold on the days that the medication is to be held and then indicate when the medication should be resumed. The nurse confirmed the MAR and confirmed that there was no indication the medication had been given. She stated that she did not recall the 3/5/15 resume date. The nurse stated that " my philosophy is if I don ' t see the medication and don ' t see a stop order, then I question with another nurse as to whether the medication is on hold or should be discontinued. " She stated that she would call the pharmacy. She stated that the medication card was not in the cart. The nurse also confirmed that she did not document any omissions in the chart. She stated that she did not look at the chart to find the original order. An interview was conducted on 4/29/15 at 4:30 p.m. with past Employee (LPN) D She stated that she worked at the facility 2/13/15-4/26/15. She said that she was a new LPN, graduated 2014, and it was her first job in a Skilled Nursing Facility. When asked about her training she stated she had trained for two to three days and was on her own by the fourth day. She said she had felt that it was " 50/50 " on her orientation process as far as knowing the processes and was able to always go back and ask questions. Employee (LPN) D stated that she recalled caring for Resident #6. She confirmed that she was on Xarelto and stated that she cared for her several times. The staff member was asked and visually confirmed the MAR and confirmed that she worked on 3/6/15, 3/9/15, 3/10/15, 3/13/15, 3/19/15, 3/23/15, 3/24/15 and 3/29/15. The nurse next confirmed the order for Xarelto and then confirmed the order said to resume 3/5/15. The nurse stated that she would not have given a medication without signing the MAR. These dates were blank, with no initials. The Pharmacy Dispensing Record for Resident #6 ' s Xarelto from January 1-April 2015 was reviewed. The pharmacy sent 14 pills at a time. Review of the Dispensing Log revealed the facility last received 14 pills on 2/15/15. All of the medication would have been administered by 3/1/15. Therefore, there was no Xarelto available for administration. The medication was not a routinely stocked medication in the Emergency Drug Kit. Review of the Drug Manufacturer ' s Pharmaceutical Medication Guide for Xarelto revealed; " XARELTO® is a prescription medicine used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Do not stop taking XARELTO® without talking to your doctor first. Your doctor may stop XARELTO® for a short time before any surgery, medical or dental procedure. Your doctor will tell you when to start taking XARELTO® again after your surgery or procedure. " Review of Resident #6 ' s Care plan Focus on Anticoagulation Therapy reflected the resident had a " potential for abnormal bleeding. The date Initiated was 12/23/2014 and updated 3/12/2015. The goal included will be free from signs and symptoms of abnormal bleeding. Interventions: " Administer anticoagulant as MD ordered. " The Care Plan was not followed. 3) During an interview on 04/27/2015 at 3:45 p.m. the facility ' s Director of Nursing (DON) stated: " we have had another problem with an anticoagulant. It happened to Resident #2. " The DON said that Resident #2 was admitted on [DATE] and the nurse had written up the physician orders on one of our order sheets. The [MEDICATION NAME] was written on a regular sheet that did not have a carbon copy that is used for the medication administration record. We (DON and ADON) did not find out about the medication not being given until 04/17/2015. " The DON was asked what the process was on checking admission orders [REDACTED]. The DON was asked who would be responsible to verify the physician ordered medications were accurately transcribed into the Medication Administration Record (MAR). She said the ADON or me. The DON said " We checked the physician order sheet and they were written correctly, but, because the [MEDICATION NAME] order was not put on the physician order sheet that contained a carbon copy it did not show up on the MAR. " The DON confirmed she did not review the MAR to make sure all the physician orders were transcribed. The DON was asked how that had happened she stated; " I ' m still trying to figure out how it happened and then I do find it out it had unfortunately already occurred. " When asked if the facility uses a check off system for newly admitted residents she said " we used to but now it is computerized. The computer tells us what to do. " She stated she was there the day of the verbal teaching but she did not sign the in-service verifying that she had attended. A medical record review was conducted for Resident #2 and revealed he had resided in the facility for approximately three weeks. His [DIAGNOSES REDACTED]. The Medication Administration Record for Resident #2 ' s orders were to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. The MAR indicated that on; 4/8, 4/9, 4/12, 4/13, 4/14, and on 4/16/2015 both orders were initialed/signed as being administered resulting in a total of 6 mg of [MEDICATION NAME]. On 4/17/2015, the order was discontinued and rewritten to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. On 4/28/2015 at 11:45 a.m. a telephone interview was conducted with Resident #2 ' s attending physician. He confirmed he was notified that the resident had been receiving double doses of his [MEDICATION NAME] and confirmed that his International Ratio was 3.2 and not critical (supra-therapeutic) . The physician confirmed the facility did not follow his orders and should have administered the proper dosages of [MEDICATION NAME] on the proper days as ordered. " The DON provided a copy of an in-service that was conducted on 4/20/2015 (three days after the medication omission was found). The documentation included " Teaching Method: Verbal Topic: Anticoagulant and [MEDICATION NAME] Protocol. Make sure PT/INR is done, Call MD with results before giving medication, check orders daily and make sure [MEDICATION NAME] log is accurate. " The DON was asked about any in-servicing that was provided to the licensed staff on physician orders not being transcribed accurately in the residents MAR or not being transcribed at all. She did not respond. When asked if there was any other information that she had on training her nursing staff she stated " We were going to bring it into our QA meeting on Tuesday (4/21/2015). " The DON and NHA on 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #2 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of Resident #2 ' s medication error on 4/17/15, however, no negative outcomes occurred. It was unclear, due to the lack of the investigation, of how and why the medication error was found. On 4/29/2015 the DON stated, She " checks the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit Manger check every MAR daily for accuracy and completeness. 4) The facility admitted Resident #10 on 4/3/15 with [DIAGNOSES REDACTED]. Review of the Admission Physician Orders dated 4/3/2015, revealed the resident was prescribed [MEDICATION NAME] 40 unit subcutaneously daily at 9 a.m. Review of the April Medication Administration Record revealed Resident #10 did not receive [MEDICATION NAME] on 4/9 or 4/12/15. There was no documentation on the back side of the MAR as to why the medication was omitted. Review of the Care Plan, dated 4/22/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information was provided related to why the medication would not have been given to Resident #10. 5) The facility admitted Resident #14 on 1/23/15 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #14 was transferred to a Hospice House for end of life care. Further review of the medical record revealed a physician ' s telephone order dated 2/16/2015, for [MEDICATION NAME] 30 units subcutaneously twice daily. The resident was placed on [MEDICATION NAME] due to sub-therapeutic INR (International Normalizing Ratio) levels and she was at risk for developing additional blood clots. Review of the Laboratory results revealed on 2/16/15, Resident #14s INR was 1.1. On 2/19/2015, the [MEDICATION NAME] was discontinued. The resident remained sub-therapeutic and the physician was attempting to adjust her [MEDICATION NAME]. Review of the Medication Administration Record for February 2015 revealed Resident #14 did not receive [MEDICATION NAME] for 4 out of the 6 available doses. She did not receive any [MEDICATION NAME] on 2/16/15. The resident did not receive [MEDICATION NAME] on 2/17/15 at 9 a.m., 2/18/15 at 9 a.m., or 2/19/15 at 9 a.m. There was no documentation in the nurses ' notes or the back of the Medication Administration Record as to why the medication was not given. On 2/26/15 the resident was noted to have redness and swelling to her right leg. An ultrasound was ordered and the resident was diagnosed with [REDACTED]. Review of the Care Plan, dated 2/11/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " During an interview on 4/29/15 at 2:30 pm, the Nurse Consultant confirmed the missed doses of [MEDICATION NAME]. He stated that the medication should have been available from pharmacy and was unable to determine why the nurses would not have given the medication. He stated that at least one dose of the [MEDICATION NAME] should have been given on 2/16/15. 6) The facility admitted Resident #15 on 4/15/15 with [DIAGNOSES REDACTED]. Review of the April 2015 Physician Orders revealed Resident #15 was prescribed [MEDICATION NAME] 40 unit subcutaneously daily for two weeks. Review of the Medication Administration Record for April 2015 revealed Resident #15 did not receive her [MEDICATION NAME] on 4/17/15 and 4/22/15. Review of the Care Plan, dated 4/29/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11:00 a.m. No additional information as provided related to why the medication would not have been given to Resident #15. 7) The facility admitted Resident #16 on 3/19/15 with [DIAGNOSES REDACTED]. Review of the Physician ' s Orders revealed, on 3/23/15, Resident #16 was prescribed " [MEDICATION NAME] 60 units every 12 hours, D/C (discontinue) when INR (international normalizing ratio) above 2. " Review of the Laboratory Data revealed an INR was collected on 2/13/15 that was 2.5. Review of the Medication Administration Record for March 2015 revealed Resident #16 was given [MEDICATION NAME] on 4/13, 4/14, 4/15 and 4/16/15. He received four doses of [MEDICATION NAME] after the medication should have been discontinued per the INR value of 2.5. Further review of the Laboratory Data revealed an INR was collected on 4/16/15 and the resident was supra-therapeutic at 3.9. Record review revealed no indication of abnormal bleeding was noted. Review of the Care Plan, dated 4/8/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information as provi

Based on a review of the facility ' s Medical Director Service Agreement , interviews with the facility staff, the Attending Physician, facility Administration, and the facility ' s policy and procedures on medication administration, the Medical Director failed to assure resident care policies were implemented related to medication administration. Based on a review of all current residents receiving anticoagulants, ten of thirty residents did not receive their anticoagulants per the physician ' s orders. Residents ' #2, #6, #10, #14, #15, #16, #17, #18, #19 and #20 were identified as not receiving anticoagulants that were necessary to prevent blood clots or [MEDICAL CONDITION]. Resident #6 was not administered Xarelto for twenty six days. The medication was placed on hold for three days for a dental procedure. The facility staff failed to implement the order and resume the medication on March 5, 2015. Resident #6 reported pain to the nursing staff and reported that the pain was consistent with a [MEDICAL CONDITION]. The physician was notified on 3/28/15 and ordered the necessary tests. The facility failed to implement those orders for three days, delaying treatment to the resident until 3/31/15. Resident #6 required injections of [MEDICATION NAME] to dissolve the clot. Resident #2 was administered a double dose of [MEDICATION NAME] on 4/8, 9, 12, 13, 14 and 16/2015. His INR was supra-therapeutic on 4/20/2015 at 3.2. Resident #10 was not administered her prescribed [MEDICATION NAME] on 4/9 and 12/2015. Resident #14 was not administered four of six available doses of [MEDICATION NAME]. Resident #15 was not administered her [MEDICATION NAME] on 4/1/2015 and on 4/22/2015. Resident #16 ' s [MEDICATION NAME] was to be discontinued when the International Normalizing Ratio (INR) was greater than 2. On 4/13/2015, the laboratory results indicated that her INR was 2.5 and the [MEDICATION NAME] was continued for four additional doses. Resident #17 was not administered five doses of [MEDICATION NAME] on 3/7, 10, 13, 15, 19/2015. Resident #18 was not administered four doses of [MEDICATION NAME] on 4/2, 11, 13 and 15/2015. Resident #19 missed four doses of [MEDICATION NAME] from 4/3-4/5/15. Resident #20 was not administered seven doses of [MEDICATION NAME] from 4/9/15-4/22/15. The facility ' s Licensed Nursing staff failed to administer medications in accordance with physician ' s orders. The failure of the nurses to administer anticoagulants resulted in significant medication errors that subsequently caused Resident #6 to develop an avoidable blood clot ([MEDICAL CONDITION]). Based on record review and interview, the facility ' s Medical Director failed to assure policies and procedures related to medication administration were followed in two (#2, #8) out of forty-eight (48) residents reviewed for medication accuracy. Resident #2 ' s physician ordered [MEDICATION NAME] and [MEDICATION NAME] that were omitted for 10 days. There was a three day delay in starting a physician ordered antibiotic for Resident #8 and two doses were admitted . The facility ' s Medical Director failed to assure medication administration policies and procedures were implemented. The facility ' s medical director also failed to assure policies and procedures were implemented to systematically identify, investigate and report medication errors. The failure of the Medical Director facility resulted in the findings of Immediate Jeopardy existing in the facility as of 3/5/2015. The facility Administration was informed on 5/1/2015 at 9:50 a.m. The Immediate Jeopardy was removed on 5/1/15 at 5:30 p.m. and the scope and severity was reduced to a " E. " Findings include: 1. Review of the Medical Director Services Exhibit A; (1) " Assume the administrative authority, responsibility, and accountability of implementing Facility ' s medical services, policies and procedures. (2) Coordinate medical care, maintain effective liaison with attending physicians and implement methods to keep the quality of care under constant monitoring. (3) Participate in the development of written policies, rules, and regulations to govern the nursing care and related medical and other health services provided. Medical Director is responsible for seeing that these policies reflect an awareness of and have provisions for meeting the total needs of the residents. (4) Ensure that Facility ' s resident ' s receive adequate services appropriate to their needs. " Review of the facility policy entitled " Medication Administration General Guidelines for the Administration of Medications " policy 6.2 (page one of three) (not dated) was reviewed and it was expected that the nurses administer medications per the physician ' s orders. During an interview on 4/29/15 at 2:45 p.m., the Medical Director stated that he had been the Medical Director of the facility since 2012. He stated that he participated in the QA monthly meetings and the facility followed a set agenda. He stated that he was made aware of incidents for his patients and that the attending physician for the other residents would be notified of incidents. He stated that he would expect to be notified of incidents, including medication errors, specifically, for system failures that could affect all residents. He stated that he was here at the facility every Wednesday and Friday. However, someone from his physician group was present daily and should be notified. He expected that the nurses notify the physician of any incident. He confirmed again that he was not made aware of any medication errors for Resident #6. He was not aware of any issues in QA related to medication administration. He stated that he was aware that the facility used a lot of agency staff and had a lot of turnover. The Medical Director stated that there was no action plan identified or implemented related to staffing or staff procedures. He also stated that he was aware of a concern with nurses not implementing physician orders timely. He stated that the nurse would pass off the order to the oncoming shifts and the medication would not be started. He stated that he provided education to the staff " within the year " related to medication implementation. The education was to have a second nurse initial the order to assure implementation. He confirmed that there was nothing in Quality Assurance (QA) related to the medication administration and order implementation process. The Medical Director stated that if the facility had a good system in place, then any staff member should be able to come in and care for the resident with no breaks in the system. He stated that the " system was not perfect and should not have failed. " The Medical Director was asked if it was expected that the facility notify him of negative outcomes; he stated, " I would love to. " When referring to the incident for Resident #6, the Medical Director stated that it was a " negative outcome and that he was afraid for his patients. " He stated that " there was not a plan in place. " 2. During an interview on 4/30/15, at 10:15 a.m., the Administrator stated that she was informed of Resident #6 ' s medication error on April 1, 2015. She was informed that the Unit Manager had educated the staff involved. The DON informed her that she was assembling her investigation and would bring the information to the next QA meeting on 4/28/15. The QA meeting was initially scheduled on 4/21/15 and it was delayed due to a trial. The Nursing Home Administrator (NHA) said usually the QA is scheduled every third Tuesday of the month. The facility had done Ad Hoc meetings in the past but the DON wanted to make sure everything was done before hand and an Ad Hoc meeting was not scheduled. The DON informed her that the physician had been notified. The DON also, informed her that the facility was still working the concern. The Administrator stated that she was aware the process was in place. The four point process was not completed and had not been presented. 3. An interview was conducted with the facility ' s Director of Nursing (DON), on 4/27/2015, at 3:00 p.m. A list of medication errors for the month of March 2015 was provided by the DON. The DON stated that she was aware of the medication error for Resident #6. She stated that a nurse found the error after performing a " medication review. " The DON stated that she was unsure of why the error occurred. She stated that the facility ' s intervention was the Venous Ultrasound and the physician and the resident were notified of the error. The DON confirmed that no audits or education was provided to the staff following the medication error. The DON also confirmed that there was no evidence of an investigation. The DON stated that her conclusion of the omitted medication for Resident #6 was " we performed an ultrasound, and started giving her [MEDICATION NAME] injections and elevated her left leg. " During an interview with the DON at approximately 2:30 p.m., she was unable to present any information regarding her investigation, education or audits. No formal action plan had been put in place as of the time of the start of the survey on 4/27/15. On 5/1/2015 at 9:50 a.m. the Nursing Home Administrator, DON and the facility ' s corporate nurse confirmed that an in service was not conducted related to Resident #6 ' s omissions of her scheduled medications. The DON and NHA ON 4/27/2015 at 3:30 p.m. confirmed that they were aware of Resident #6 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of the medication errors for Resident #6 only after the Doppler confirmed the positive [MEDICAL CONDITION]. It was unclear, due to the lack of the investigation, of how and why the medication error was found. During an interview on 4/29/2015, at 3:30 p.m., the DON stated " she checks the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. During an interview on 4/30/15, at 8:50 a.m., The Assistant Director of Nurses stated that she randomly checked the MARs on a daily basis for accuracy and completeness. She stated that she checked new admissions and " maybe two others. " She stated that the Unit Manager was responsible for checking at least five residents on each cart on a daily basis. The ADON stated that there was not a definite system of checking the MARs. 4. An interview was conducted on 4/30/15 at 9:30 a.m., Employee (LPN) A Interim Unit Manager (started on Monday 4/20/15). She stated that she checked all new admissions for accuracy of orders and double checks with the MAR for accuracy. She stated that she did not do anything with the MARs on a daily basis. No one informed her she was supposed to be checking the MARs. She stated that she gets the new orders and the 24 hour report in the morning and then gives them to the ADON or DON to take them to the morning meeting. She did not usually go to the morning meetings and was not aware of any plan to begin to go. She stated that no education or training was provided to be a Unit Manager. The ADON told her the things that needed to be done and she was " just helping them out not doing the whole position. " 5. The regular Unit Manager (LPN) B, on the Long Term Care unit was currently on medical leave and was unable to be contacted. 6. During an interview on 4/29/15 at 10:13 a.m. and 4/30/15 at 10:43 a.m., The DON stated that the process of checking the MARs was an informal process that is implemented inconsistently and the ADON and Unit Manager assist with the process. There was not a written policy or procedure. The DON stated that she had been in the role of DON for one year and the process of checking the MARs had been an expectation since her arrival and she had continued that process since then. The DON also stated on 4/30/15 at 10:43 am that she was unaware the ADON and Unit Managers were not checking MARs daily. 7. During an interview on 4/28/2015 at 10:30 a.m. Resident #6 stated she was diagnosed with [REDACTED]. She said it was not just a [MEDICAL CONDITION] it was an extensive [MEDICAL CONDITION]. The resident stated that " the doctor said it was from my knee to my foot and I think there was more than one ([MEDICAL CONDITION]). " The resident was asked if the nurse had spoken to her about her [MEDICAL CONDITION]. She said, " No, the doctor told me the nurses were not giving me my medication, he was really pissed. " They (the nurses) had to give me [MEDICATION NAME] two times a day for five days and I hate needles. " Resident #6 said that when she first had come to the facility she had a [MEDICAL CONDITION] in her left arm and, " that is why I take the Xarelto every day. " The resident stated that she used to check her medications every day and now has to start checking them again. " It ' s not my job to have to ask if all my medications are there or not is it? " During a telephone interview on 4/28/2015 at 11:42 a.m., Resident #6 ' s attending physician stated; " the nurses did not give her medication Xarelto. The medication was only on hold for a few days for her dental surgery. " The physician was asked why the medication Xarleto was not restarted after her dental surgery. The physician stated he did not understand why the nurses did not restart the medication. " I gave the nurses the order they should have restarted the Xarelto after the dental procedure was completed. The Xarelto is to prevent her from getting a [MEDICAL CONDITION], if she would have received the medication she would not have gotten a ([MEDICAL CONDITION]). " During an interview on 4/30/15 at 12:20 p.m., the attending Physician confirmed he assessed the resident on 3/28/15 and documented the resident ' s leg was red and swollen. He also ordered a venous Doppler study. The physician stated that he was informed by Employee (LPN) A of the swollen leg and the lack of the Xarelto on 3/28/15. He verbally gave the order to Employee A. The attending physician confirmed the venous Doppler order was not completed until 03/31/2015 and also confirmed that no medication was started until 03/31/2015. He was unsure of why there would have been a delay in obtaining treatment, necessary tests or initiating the medication. Further review of the physician orders dated on 2/11/2015; " Stop blood thinners x 3 days prior to tooth extraction and resume one day post (3/4/2015) p.m. " The order did not contain a nursing signature. The next order that was written; Clarification Xarelto 15 mg orally every HS- [MEDICAL CONDITION] (this order was not dated). A hand written telephone order, dated 3/31/2015, reflected Venous Doppler STAT and a third order dated for the same day (3/31/2015), [MEDICATION NAME] 80 MG SQ ( subcutaneously) BID (two times) for 5 days. Review of the Medication Administration Record, dated March 2015, revealed a typed order dated 12/05/2014; Xarelto 15 MG tablet one tablet by mouth once a day. Directly underneath the typed order, a hand written entry stated resume 3-5-15. The Medication Administration Record (MAR) revealed the nurses documented for 03/01/2015, 3/2/2015, 3/3/2015 and 3/4/2015: " HOLD. " The MAR for 3/5/2015, when the Xarelto was to be restarted was reviewed. The boxes, where an initial should have been written, were empty (indicating the dose was not administered). The remainder of the MAR from 3/6/2015 through 3/30/2015 was reviewed with no indication that the medication had been given and no indication as to why the medication was not given. The medical record in Resident #6 ' s chart contained a Progress note/Monthly Evaluation " dated: 3/28/2015 Listed under current complaints was " Redness and swelling left leg. " Documented (under extremities) was 4+ [MEDICAL CONDITION] L > R, Tender left leg (new finding). The Resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error. " Further review of the attending physician ' s progress note indicated that Resident #6 had a Recurrent [MEDICAL CONDITION] to her left leg that was new and had worsened. Hand written next to the word worsened " Venous Doppler was ordered. " A review of the Physician ' s Progress Notes revealed on 3/28/15, the Attending Physician assessed Resident #6 and diagnosed her with an acute [MEDICAL CONDITION]. The physician documented: " Redness and swelling left leg, 4+ [MEDICAL CONDITION] L > R, Tender left leg. " The physician also documented that the resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error. " Further review of the Attending Physician ' s progress note revealed he documented " Venous Doppler was ordered. " There was no corresponding physician ' s order for the Doppler Studies until 3/31/15, three days after the physician assessed the resident. Further review of Resident #6 ' s medical record revealed that she had resided in the facility for approximately fifteen months and was fifty three years old. Resident #6 ' s medical history included [MEDICAL CONDITION] and a history of [MEDICAL CONDITION]. On 12/22/2014, a Brief Interview for Mental Status (BIMS) revealed a Score of 15 indicating no cognitive impairment. Review of the Nurses ' Notes on 3/28/15 revealed no documentation of a red, swollen leg. There was no documentation of the omission of the medication, the physician visit or the new orders. On 3/30/15, employee (LPN) A documented: the resident complained of pain and redness to her leg, upon assessment the leg was warm to touch and was swollen. Painful, 2+ pitting. The doctor was paged and made aware and stated he saw her on Saturday. New orders for [MEDICATION NAME] BID were obtained. On 3/31/2015 at 3:25 a.m. the nurse documented at " 12:45 a.m. patient states she thinks she has a [MEDICAL CONDITION] to her LLE. Area of slight redness noted to inner calf to LLE, [MEDICAL CONDITION] to bilateral LE. Skin temp within normal limits. Capillary refill is brisk bilaterally. Unable to assess pulse related to [MEDICAL CONDITION]. Patient rates pain level #1 at this time on a scale of 1-10 with 10 being the worst. Patient states she has had multiple [MEDICAL CONDITION] in the past and knows what it feels like. Notified resident physicians of above and new orders were received for a STAT venous Doppler of the LLE to rule out [MEDICAL CONDITION]. At 0200 (2:00 a.m.) [MEDICATION NAME] 100mg was administered for c/o pain to LLE with a pain level of 9 out of 10. [MEDICATION NAME] was effective. At 0330 (3:30 a.m.), the mobile radiology service arrived to perform Doppler. Patient remained on bed rest. Patient remained alert and responding appropriately to verbal and tactile stimuli. No s/s of distress noted. Vitals 97.8-74-18-119/78. Patient received new order on 3/30/15 to restart Xarelto. " Xarelto was not discontinued. " A review of the Ultra Sound Report, date of service: 3/31/2015 revealed: Examination: Venous Doppler extremity/limb, left. Clinical Indications: Swelling of Limb, Findings: Real time color imaging shows no collateral and augmentation of post tibial vein, popliteal vein, deep femoral vein and common vein of left leg. There are no excessive collateral veins. Left lower Extremity Venous duplex Ultrasound: Impression: Extensive [MEDICAL CONDITION] seen. The MAR indicated that six nurses, assigned on the 3-11 p.m. shift, failed to administer the Xarelto as ordered by the attending physician. During an interview on 4/29/15 at 4:10 p.m. Employee (RN) E, a nurse that cared for the resident on 12 of the 26 evening shifts, stated that she had been a nurse for a long time and worked in long term care. She stated that she was familiar with Resident #6. She stated that she was aware the resident needed Xarelto. The medication was not administered. She stated that she did not think the order was on going. She stated that it was on hold. She stated that she did not have the time to research the order and was aware that Resident #6 was at high risk for [MEDICAL CONDITION]. She stated that she questioned the medication to other staff; however, she did not recall who the staff member was. She stated that the doctor came in and then realized the medication should have been resumed. The nurse stated that when a medication was held, the nurse should write hold on the days that the medication is to be held and then indicate when the medication should be resumed. The nurse confirmed the MAR and confirmed that there was no indication the medication had been given. She stated that she did not recall the 3/5/15 resume date. The nurse stated that " my philosophy is if I don ' t see the medication and don ' t see a stop order, then I question with another nurse as to whether the medication is on hold or should be discontinued. " She stated that she would call the pharmacy. She stated that the medication card was not in the cart. The nurse also confirmed that she did not document any omissions in the chart. She stated that she did not look at the chart to find the original order. An interview was conducted on 4/29/15 at 4:30 p.m. with past Employee (LPN) D. She stated that she worked at the facility 2/13/15-4/26/15. When asked about her training she stated she had trained for two to 3 days and was on her own by the fourth day. She said she had felt that it was " 50/50 " on her orientation process as far as knowing the processes and was able to always go back and ask questions. Employee (LPN) D, stated that she recalled caring for Resident #6. She confirmed that she was on Xarelto and stated that she cared for her several times. The staff member was asked and visually confirmed the MAR and confirmed that she worked on 3/6/15, 3/9/15, 3/10/15, 3/13/15, 3/19/15, 3/23/15, 3/24/15 and 3/29/15. The nurse next confirmed the order for Xarelto and then confirmed the order said to resume 3/5/15. The nurse stated that she would not have given a medication without signing the MAR. These dates were blank, with no initials. A review was conducted of the Pharmacy Dispensing Record for Resident #6 ' s Xarelto from January 1-April 2015. The pharmacy sent 14 pills at a time. Review of the Dispensing Log revealed the facility last received 14 pills on 2/15/15. All of the medication would have been administered by 3/1/15. Therefore, there was no Xarelto available for administration. The medication was not a routinely stocked medication in the Emergency Drug Kit. Review of the Drug Manufacturer ' s Pharmaceutical Medication Guide for Xarelto revealed; " XARELTO® is a prescription medicine used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Do not stop taking XARELTO® without talking to your doctor first. Your doctor may stop XARELTO® for a short time before any surgery, medical or dental procedure. Your doctor will tell you when to start taking XARELTO® again after your surgery or procedure. " Review of Resident #6 ' s Care plan Focus on Anticoagulation Therapy reflected the resident had a " potential for abnormal bleeding. " Date Initiated; 12/23/2014 updated: 3/12/2015. Goal will be free from signs and symptoms of abnormal bleeding. Interventions: Administer anticoagulant as MD ordered. " The Care Plan was not followed. 8. During an interview on 04/27/2015 at 3:45 p.m. the facility ' s Director of Nursing (DON) stated: " we have had another problem with an anticoagulant. It happened to Resident #2. " The DON said that when Resident #2 was admitted on [DATE] and the nurse had written up the physician orders on one of our order sheets, the [MEDICATION NAME] was written on a regular sheet that did not have a carbon copy that is used for the medication administration record. We (DON and ADON) did not find out about the medication not being given until 04/17/2015." The DON was asked what the process was on checking admission orders [REDACTED]. The DON was asked who would be responsible to verify the physician ordered medications were accurately transcribed into the Medication Administration Record (MAR), she said the ADON or me. The DON said, " We checked the physician order sheet and they were written correctly but because the [MEDICATION NAME] order was not put on the physician order sheet that contained a carbon copy it did not show up on the MAR. " The DON confirmed she did not review the MAR to make sure all the physician orders were transcribed. The DON was asked how that had happened and stated; " I ' m still trying to figure out how it happened and then I do find it out it has unfortunately already occurred. " When asked if the facility used a check off system for newly admitted residents she said, " we used to but now it is computerized. The computer tells us what to do. " She stated she was there the day of the verbal teaching but she did not sign the in-service verifying that she had attended. A medical record review was conducted for Resident #2 and revealed he had resided in the facility for approximately three weeks. His [DIAGNOSES REDACTED]. Review of resident #2's April admission orders [REDACTED]. The MAR indicated that on; 4/8, 4/9, 4/12, 4/13, 4/14, and on 4/16/2015 both orders were initialed/signed as being administered resulting in a total of 6 mg of [MEDICATION NAME]. On 4/17/2015 the order was discontinued and rewritten to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. (The same identical order, this time the initial boxes were outlined indicating which day of the week the medication needed to be given). A Medical record review of admission orders [REDACTED]. The MAR did not reflect this order until 4/17/2015 (ten days after he was admitted ). The facility failed to administer [MEDICATION NAME] 70/30 15 units in the morning and 5 units at night time until 4/17/2015, ten days after being admitted to the facility. This order was also missed on admission. The facility also failed to ensure Resident #2, with a [DIAGNOSES REDACTED]. On 4/28/2015 at 11:45 a.m. a telephone interview was conducted with Resident #2 ' s attending physician. He confirmed he was notified that the resident had been receiving double doses of his [MEDICATION NAME] and confirmed that his International Ratio was 3.2 and not critical (supra-therapeutic) . The physician confirmed the facility did not follow his orders and should have administered the proper dosages of [MEDICATION NAME] on the proper days as ordered. The attending physician also confirmed that he was notified that resident did not receive his ordered [MEDICATION NAME] for eleven days after being admitted and he did not receive his insulin for eleven days after being admitted to the facility. The attending physician was asked if a resident had a [DIAGNOSES REDACTED].? The attending physician stated " yes, he needs his blood sugars monitored, he could have went into [MEDICAL CONDITION] or [DIAGNOSES REDACTED] and worse yet into ketoacidosis. " The physician stated " they need to fix it, I don ' t know if it ' s the DON or the corporation they have to fix these things so it doesn ' t happen again. " The DON provided a copy of an in-service that was conducted on 4/20/2015 (three days after the medication omission was found) Teaching Method: Verbal Topic: Anticoagulant and [MEDICATION NAME] Protocol. Make sure PT/INR is done, Call MD with results before giving medication, check orders daily and make sure [MEDICATION NAME] log is accurate. The DON was asked about any in-servicing that was provided to the licensed staff on physician orders not being transcribed accurately in the residents MAR or not being transcribed at all, she did not respond. The DON was asked if the nurse that had not transcribed the [MEDICATION NAME] and Insulin in Resident #2 ' s MAR had attended the in-service that she had on 4/20/2015. The DON stated, " The nurse was there but she did not sign on the sign in sheet. " When asked if there was any other information that she had on training her nursing staff she stated, " We were going to bring it into our QA meeting on Tuesday (4/21/2015). " On 4/27/2015, the DON and NHA confirmed that they were aware of Resident #2's medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of Resident #2 ' s medication error on 4/17/15, however, no negative outcomes occurred. It was unclear due to the lack of the investigation of how and why the medication error was found. On 4/29/2015, the DON stated she " checks the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. 9. The facility admitted Resident #10 on 4/3/15 with [DIAGNOSES REDACTED]. Review of the Admission Physician Orders, dated 4/3/2015, revealed the resident was prescribed [MEDICATION NAME] 40 unit subcutaneously daily at 9 a.m. Review of the April Medication Administration Record revealed Resident #10 did not receive [MEDICATION NAME] on 4/9 or 4/12/15. There was no documentation on the back side of the MAR as to why the medication was omitted. Review of the Care Plan, dated 4/22/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information was provided related to why the medication would not have been given to Resident #10. 10. The facility admitted Resident #14 on 1/23/15 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #14 was transferred to a Hospice House for end of life care. Further review of the medical record revealed a physician ' s telephone order, dated 2/16/2015, for [MEDICATION NAME] 30 units subcutaneously twice daily. The resident was placed on [MEDICATION NAME] due to sub-therapeutic INR (International Normalizing Ratio) levels and she was at risk for developing additional blood clots. Review of the Laboratory results revealed, on 2/16/15, Resident #8 ' s INR was 1.1. On 2/19/2015, the [MEDICATION NAME] was discontinued. The resident remained sub-therapeutic and the physician was attempting to adjust her [MEDICATION NAME]. 11. Review of the Medication Administration Record for February 2015 revealed Resident #14 did not receive [MEDICATION NAME] for 4 out of the 6 available doses. She did not receive any [MEDICATION NAME] on 2/16/15. The resident did not receive [MEDICATION NAME] on 2/17/15 at 9 a.m., 2/18/15 at 9 a.m. or 2/19/15 at 9 a.m. There was no documentation in the nurses ' notes or the back of the Medication Administration Record as to why the medication was not given. On 2/26/15 the resident was noted to have redness and swelling to her right leg. An ultrasound was ordered and the resident was diagnosed with [REDACTED]. Review of the Care Plan, dated 2/11/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " During an interview on 4/29/15 at 2:30 pm, the Nurse Consultant confirmed the missed doses of [MEDICATION NAME]. He stated that the medication should have been available from pharmacy and was

Based on resident record review, interviews with the facility staff, the Attending Physician, the Medical Director, and facility Administration, the facility failed to ensure care planning interventions/approaches were implemented to assure residents were free of significant medication errors. Based on a review of all current residents receiving anticoagulants, ten of thirty residents care plans were not followed and residents did not receive their anticoagulants per the physician's order [REDACTED].#2, #6, #10, #14, #15, #16, #17, #18, #19 and #20 were identified as not receiving anticoagulants that were necessary to prevent blood clots or [MEDICAL CONDITION]. Resident #6 was not administered Xarelto for twenty six days. The medication was placed on hold for three days for a dental procedure. The facility staff failed to implement the order and resume the medication on March 5, 2015. Resident #6 reported pain to the nursing staff and reported that the pain was consistent with a [MEDICAL CONDITION]. The physician was notified on 3/28/15 and ordered the necessary tests. The facility failed to implement those orders for three days, further delaying treatment to the resident until 3/31/15. Resident #6 required injections of [MEDICATION NAME] to dissolve the clot. Resident #2 was administered a double dose of [MEDICATION NAME] on 4/8, 9, 12, 13, 14 and 16/2015. His INR was supra-therapeutic on 4/20/2015 at 3.2. Resident #10 was not administered her prescribed [MEDICATION NAME] on 4/9 and 12/2015. Resident #14 was not administered four of six available doses of [MEDICATION NAME]. Resident #15 was not administered her [MEDICATION NAME] on 4/1/2015 and on 4/22/2015. Resident #16 ' s [MEDICATION NAME] was to be discontinued when the International Normalizing Ratio (INR) was greater than 2. On 4/13/2015 the laboratory results indicated that her INR was 2.5 and the [MEDICATION NAME] was continued for four additional doses. Resident #17 was not administered five doses of [MEDICATION NAME] on 3/7, 10, 13, 15, 19/2015. Resident #18 was not administered four doses of [MEDICATION NAME] on 4/2, 11, 13 and 15/2015. Resident #19 missed four doses of [MEDICATION NAME] from 4/3-4/5/15. Resident #20 was not administered seven doses of [MEDICATION NAME] from 4/9/15-4/22/15. The facility ' s Licensed Nurse ' s failed to administer medications in accordance with physician's order [REDACTED]. The failure to follow the resident ' s plan of care and administer their anticoagulants resulted in significant medication errors that subsequently caused Resident #6 to develop an avoidable blood clot ([MEDICAL CONDITION]). Based on record review and interview, the facility failed to administer medication timely and accurately in two (#2, #8) out of forty-eight (48) residents reviewed for medication accuracy. Resident #2 ' s physician ordered [MEDICATION NAME] and [MEDICATION NAME]were omitted for 10 days. There was a three day delay in starting a physician ordered antibiotic for Resident #8 and two days were omitted. The facility failed to follow the individualized care plans and monitor the administration of medications on a routine basis. The facility failed to systematically identify, investigate and report medication errors. The failure of the facility resulted in the findings of Immediate Jeopardy existing in the facility as of 3/5/2015. The facility Administration was informed on 5/1/2015 at 9:50 a.m. The Immediate Jeopardy was removed on 5/1/15 at 5:30 pm and the scope and severity was reduced to a " E. " Findings include: 1. Review of Resident #6 ' s medical record revealed that she had resided in the facility for approximately fifteen months and was fifty three years old. Resident #6 ' s medical history included [MEDICAL CONDITION] and a history of [MEDICAL CONDITION] per the recorded admission information. On 12/22/2014, a Brief Interview for Mental Status (BIMS) revealed a Score of 15 indicating no cognitive impairment. Resident #6 ' s Plan of Care included administer the Xarelto as ordered by the attending physician. Review of Resident #6 ' s Care plan Focus on Anticoagulation Therapy reflected the resident had a " potential for abnormal bleeding. " The date Initiated was 12/23/2014 and it was updated 3/12/2015. Goal " will be free from signs and symptoms of abnormal bleeding. Interventions: Administer anticoagulant as MD ordered. " The Care Plan was not followed. Resident #6 was not administered Xarelto for 26 days. The MAR indicated that six nurses, assigned on the 3-11 p.m. shift, failed to follow Resident #6 ' s plan of care and administer the Xarleto as ordered by the attending physician. Review of the Medication Administration Record (MAR), dated March 2015, revealed a typed order dated 12/05/2014; Xarelto 15 MG tablet one tablet by mouth once a day. Directly underneath the typed order was a hand written entry; resume 3-5-15. The Medication Administration Record (MAR) revealed the nurses documented for 03/01/2015, 3/2/2015, 3/3/2015 and 3/4/2015 the word " HOLD. " On 3/5/2015, the MAR indicated to resume Xarleto. The boxes, where an initial should have been written, were empty (indicating the dose was not administered). The remainder of the MAR from 3/6/2015 through 3/30/2015 was reviewed with no indication that the medication had been given and no indication as to why the medication was not given. Further review of the physician orders, dated on 2/11/2015, found directions to " Stop blood thinners x 3 days prior to tooth extraction and resume one day post (3/4/2015) p.m. " A telephone order was dated on 3/31/2015 ordering a Venous Doppler STAT and a third order was dated for the same day (3/31/2015,) [MEDICATION NAME] 80 MG SQ ( subcutaneously), BID (two times), was ordered for 5 days. During an interview on 4/28/2015 at 10:30 a.m., Resident #6 stated she was diagnosed with [REDACTED]. She said it was not just a [MEDICAL CONDITION] it was an extensive [MEDICAL CONDITION]. The resident stated that " the doctor said it was from my knee to my foot and I think there was more than one ([MEDICAL CONDITION]). " The resident was asked if the nurse had spoken to her about her [MEDICAL CONDITION]. She said, " No, the doctor told me the nurses were not giving me my medication, he was really pissed. They (the nurses) had to give me [MEDICATION NAME] two times a day for five days and I hate needles. " Resident #6 said that when she first came to the facility, she had a [MEDICAL CONDITION] in her left arm and " that is why I take the Xarelto every day. " The resident stated that she used to check her medications every day and now has to start checking them again. " It ' s not my job to have to ask if all my medications are there or not is it? " During an interview on 4/29/15 at 4:10 p.m. Employee (RN) E, a nurse that cared for the resident on 12 of the 26 evening shifts, stated that she had been a nurse for a long time and worked in long term care. She stated that she was familiar with Resident #6. She stated that she was aware the resident needed Xarelto. The medication was not administered. She stated that she did not think the order was on going. She stated that it was on hold. She stated that she did not have the time to research the order and was aware that Resident #6 was at high risk for [MEDICAL CONDITION]. She stated that she questioned the medication to other staff; however, she did not recall who the staff member was. She stated that the doctor came in and then realized the medication should have been resumed. The nurse stated that when a medication was held, the nurse should write hold on the days that the medication is to be held and then indicate when the medication should be resumed. The nurse confirmed the MAR and confirmed that there was no indication the medication had been given. She stated that she did not recall the 3/5/15 resume date. The nurse stated that " my philosophy is if I don ' t see the medication and don ' t see a stop order, then I question with another nurse as to whether the medication is on hold or should be discontinued. " She stated that she would call the pharmacy. She stated that the medication card was not in the cart. The nurse also confirmed that she did not document any omissions in the chart. She stated that she did not look at the chart to find the original order. An interview was conducted on 4/29/15 at 4:30 p.m. with Employee (LPN) D. She stated that she worked at the facility 2/13/15-4/26/15. When asked about her training, she stated she had trained for two to three days and was on her own by the fourth day. She said she had felt that it was " 50/50 " on her orientation process as far as knowing the processes and was able to always go back and ask questions. Employee (LPN) D. stated that she recalled caring for Resident #6. She confirmed that she was on Xarelto and stated that she cared for her several times. The staff member reviewed the MAR and confirmed that she worked on 3/6/15, 3/9/15, 3/10/15, 3/13/15, 3/19/15, 3/23/15, 3/24/15 and 3/29/15. The nurse next confirmed the order for Xarelto and then confirmed the order said to resume 3/5/15. The nurse stated that she would not have given a medication without signing the MAR. These dates were blank, with no initials. During a telephone interview on 4/28/2015 at 11:42 a.m., Resident #6 ' s Attending Physician stated; " the nurses did not give her medication Xarelto, the medication was only on hold for a few days for her dental surgery. The physician was asked why the medication Xarleto was not restarted after her dental surgery. The physician stated he did not understand why the nurses did not restart the medication. " I gave the nurses the order, they should have restarted the Xarelto after the dental procedure was completed. The Xarelto is to prevent her from getting a [MEDICAL CONDITION]. If she would have received the medication, she would not have gotten a ([MEDICAL CONDITION]). " During an interview on 4/30/15 at 12:20 p.m., the Attending Physician confirmed he assessed the resident on 3/28/15 and documented the resident ' s leg was red and swollen. He also ordered a venous Doppler study. The physician stated that he was informed by Employee (LPN) A of the swollen leg and the lack of the Xarelto on 3/28/15. He verbally gave the order to Employee A. The Attending Physician confirmed the venous Doppler order was not completed until 03/31/2015 and also confirmed that no medication was started until 03/31/2015. He was unsure of why there would have been a delay in obtaining treatment, necessary tests or initiating the medication. A review of the Physician ' s Progress Notes revealed on 3/28/15, the Attending Physician assessed Resident #6 and diagnosed her with an acute [MEDICAL CONDITION]. The physician documented: " Redness and swelling left leg, 4+ [MEDICAL CONDITION] L > R, Tender left leg. " The physician also documented that the resident had been " Off Xarelto 15 MG for 3 weeks by nurse ' s error. " Further review of the Attending Physician ' s progress note revealed he documented " Venous Doppler was ordered. " There was no corresponding physician's order [REDACTED]. Review of the Nurses ' Notes on 3/28/15 revealed no documentation of a red, swollen leg. There was no documentation of the omission of the medication, the physician visit or the new orders. On 3/30/15, employee (LPN) A documented: " the resident complained of pain and redness to her leg, upon assessment the leg was warm to touch and was swollen. Painful, 2+ pitting. The doctor was paged and made aware and stated he saw her on Saturday. New orders for [MEDICATION NAME] BID were obtained. " On 3/31/2015 at 3:25 a.m., the nurse documented at " 12:45 a.m. patient states she thinks she has a [MEDICAL CONDITION] to her LLE. Area of slight redness noted to inner calf to LLE, [MEDICAL CONDITION] to bilateral LE. Skin temp within normal limits. Capillary refill is brisk bilaterally. Unable to assess pulse related to [MEDICAL CONDITION]. Patient rates pain level #1 at this time on a scale of 1-10 with 10 being the worst. Patient states she has had multiple [MEDICAL CONDITION]'s in the past and knows what it feels like. Notified resident physicians of above and new orders were received for a STAT venous Doppler of the LLE to rule out [MEDICAL CONDITION]. At 0200 (2:00 a.m.) [MEDICATION NAME] 100mg was administered for c/o pain to LLE with a pain level of 9 out of 10. [MEDICATION NAME] was effective. At 0330 (3:30 a.m.), the mobile radiology service arrived to perform Doppler. Patient remained on bed rest. Patient remained alert and responding appropriately to verbal and tactile stimuli. No s/s of distress noted. Vitals 97.8-74-18-119/78. Patient received new order on 3/30/15 to restart Xarelto (Xarelto was not discontinued). " A review of the Ultra Sound Report, date of service: 3/31/2015 revealed: Examination: Venous Doppler extremity/limb, left. Clinical Indications: Swelling of Limb, Findings: Real time color imaging shows no collateral and augmentation of post tibial vein, popliteal vein, deep femoral vein and common vein of left leg. There are no excessive collateral veins. Left lower Extremity Venous duplex Ultrasound: Impression: Extensive [MEDICAL CONDITION] seen. An interview was conducted with the facility ' s Director of Nursing (DON), on 4/27/2015, at 3:00 p.m. A list of medication errors for the month of March 2015 was provided by the DON. The DON stated that she was aware of the medication error for Resident #6. She stated that a nurse found the error after performing a " medication review. " The DON stated that she was unsure of why the error occurred. She stated that the facility ' s intervention was the Venous Ultrasound and the physician and the resident were notified of the error. The DON confirmed that no audits or education were provided to the staff following the medication error. The DON also confirmed that there was no evidence of an investigation. The DON stated that her conclusion of the omitted medication for Resident #6 was " we performed an ultrasound, and started giving her [MEDICATION NAME] injections and elevated her left leg. " On 4/27/2015 at 3:30 p.m., the Nursing Home Administrator and D.O.N. confirmed that they were aware of Resident #6 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of the medication errors for Resident #6 only after the Doppler confirmed the positive [MEDICAL CONDITION]. It was unclear, due to the lack of the investigation of how and why, the medication error was found. During an interview on 4/29/2015, at 3:30 p.m., the DON stated, " she checks the MARs two times a week by flipping through all of the MARs. " She confirmed there is no documentation related to this process. The DON said that the ADON and Unit manger check every MAR daily for accuracy and completeness. During an interview on 4/30/15, at 8:50 a.m., The Assistant Director of Nurses stated that she randomly checked the MARs on a daily basis for accuracy and completeness. She stated that she checked new admissions and " maybe two others. " She stated that the Unit Manager was responsible for checking at least five residents on each cart on a daily basis. The ADON stated that there was not a definite system of checking the MARs. An interview was conducted on 4/30/15 at 9:30 a.m. with Employee (LPN) A, Interim Unit Manager (started on Monday 4/20/15). She stated that she checked all new admissions for accuracy of orders and double checked the MAR for accuracy. She stated that she did not do anything with the MARs on a daily basis. No one informed her she was supposed to be checking the MARs. She stated that she gets the new orders and the 24 hour report in the morning and then gives them to the ADON or DON to take them to the morning meeting. She did not usually go to the morning meetings and was not aware of any plan to begin to go. She stated that no education or training was provided to be a Unit Manager. The ADON told her the things that needed to be done and she was " just helping them out not doing the whole position. " The regular Unit Manager (LPN) B on the Long Term Care unit was currently on medical leave and was unable to be contacted. During an interview on 4/29/15 at 10:13 a.m. and 4/30/15 at 10:43 a.m., The DON stated that the process of checking the MARs was an informal process that was implemented inconsistently and the ADON and Unit Manager assist with the process. There was not a written policy or procedure. The DON stated that she had been in the role of DON for one year and the process of checking the MARs had been an expectation since her arrival and she had continued that process since then. The DON also stated, on 4/30/15 at 10:43 a.m., that she was unaware the ADON and Unit Managers were not checking MARs daily. During an interview on 4/29/15 at 2:45 pm, the Medical Director stated that he had been the Medical Director of the facility since 2012. He stated that he participated in the QA monthly meetings and the facility followed a set agenda. He stated that he was made aware of incidents for his patients and that the attending physician for the other residents would be notified of incidents. He stated that he would expect to be notified of incidents, including medication errors and, specifically, for system failures that could affect all residents. He stated that he was here at the facility every Wednesday and Friday. However, someone from his physician group was present daily and should be notified. He expected that the nurses notify the physician of any incident. He confirmed, again, that he was not made aware of any medication errors for Resident #6. He was not aware of any issues in QA related to medication administration. He stated that he was aware that the facility used a lot of agency staff and had a lot of turnover. The Medical Director stated that there was no action plan identified or implemented related to staffing or staff procedures. He also stated that he was aware of a concern with nurses not implementing physician orders [REDACTED]. He stated that he provided education to the staff " within the year " related to medication implementation. The education was to have a second nurse initial the order to assure implementation. He confirmed that there was nothing in Quality Assurance (QA) related to the medication administration and order implementation process. The Medical Director stated that if the facility had a good system in place, then any staff member should be able to come in and care for the resident with no breaks in the system. He stated that the " system was not perfect and should not have failed. " The Medical Director was asked if it was expected that the facility notify him of negative outcomes; he stated, " I would love to. " When referring to the incident for Resident #6, the Medical Director stated that it was a " negative outcome and that he was afraid for his patients. " He stated that " there was not a plan in place. " During an interview on 4/30/15, at 10:15 a.m., the Administrator stated that she was informed of Resident #6 ' s med error on April 1st. The DON stated that the Unit Manager had educated the staff involved. The DON information her that she was assembling her investigation and would bring the information to the next QA meeting on 4/28/15. The meeting was initially scheduled on 4/21/15 and it was delayed due to a trial. The Nursing Home Administrator (NHA) said, usually, the QA is scheduled every third Tuesday of the month. The facility had done Ad Hoc meetings in the past but the DON wanted to make sure everything was done before hand and the AD Hoc meeting was not scheduled. The DON informed her that the physician had been notified. The DON also informed her that the facility was still working the concern. The Administrator stated that she was aware the process was in place. The four point process was not completed and had not been presented. A review was conducted of the Pharmacy Dispensing Record for Resident #6 ' s Xarelto from January 1-April 2015. The pharmacy sent 14 pills at a time. Review of the Dispensing Log revealed the facility last received 14 pills on 2/15/15. All of the medication would have been administered by 3/1/15. Therefore, there was no Xarelto available for administration. The medication was not a routinely stocked medication in the Emergency Drug Kit. Review of the Drug Manufacturer ' s Pharmaceutical Medication Guide for Xarelto revealed; " XARELTO® is a prescription medicine used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Do not stop taking XARELTO® without talking to your doctor first. Your doctor may stop XARELTO® for a short time before any surgery, medical or dental procedure. Your doctor will tell you when to start taking XARELTO® again after your surgery or procedure. " 2. Review of Resident #2 ' s Care plan Focus on Anticoagulation Therapy reflected the resident had a " potential for abnormal bleeding. " The goal reflected " will be free from signs and symptoms of abnormal bleeding. Interventions: Administer anticoagulant as MD ordered. " The Care Plan was not followed. Review of the Medication Administration Record for Resident #2 included orders to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. The MAR indicated that on; 4/8, 4/9, 4/12, 4/13, 4/14, and on 4/16/2015 both orders were initialed/signed as being administered resulting in a total of 6 mg of [MEDICATION NAME]. On 4/17/2015, the order was discontinued and rewritten to give [MEDICATION NAME] 4 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday and to administer [MEDICATION NAME] 2 mg on Monday and Friday. This was the same identical order, however, this time the initial boxes were outlined indicating which day of the week the medication needed to be given. A medical record review was conducted for Resident #2 and revealed he had resided in the facility for approximately three weeks. His [DIAGNOSES REDACTED]. During an interview on 04/27/2015 at 3:45 p.m., the facility ' s Director of Nursing (DON) stated: " we have had another problem with an anticoagulant, it happened to Resident #2. " The DON said that when Resident #2 was admitted on [DATE], the nurse had written up the physician orders [REDACTED]. The [MEDICATION NAME] was written on a regular sheet that did not have a carbon copy that is used for the medication administration record. We (DON and ADON) did not find out about the medication not being given until 04/17/2015. " The DON was asked what the process was on checking admission orders [REDACTED]. The DON was asked who would be responsible to verify the physician ordered medications were accurately transcribed into the Medication Administration Record (MAR) and she said the ADON or me. The DON said, " We checked the physician order [REDACTED]. " The DON confirmed she did not review the MAR to make sure all the physician orders [REDACTED]. She stated; " I ' m still trying to figure out how it happened and then I do find it out it has unfortunately already occurred. " When asked if the facility used a check off system for newly admitted residents she said, " we used to but now it is computerized. The computer tells us what to do. " She stated she was there the day of the verbal teaching but she did not sign the in-service verifying that she had attended. On 4/28/2015 at 11:45 a.m., a telephone interview was conducted with Resident #2 ' s attending physician. He confirmed he was notified that the resident had been receiving double doses of his [MEDICATION NAME] and confirmed that his International Ratio was 3.2 and not critical (supra-therapeutic) . The physician confirmed the facility did not follow his orders and should have administered the proper dosages of [MEDICATION NAME] on the proper days as ordered. The DON provided a copy of an in-service that was conducted on 4/20/2015 (three days after the medication omission was found) Teaching Method: Verbal Topic: Anticoagulant and [MEDICATION NAME] Protocol. Make sure PT/INR is done, call MD with results before giving medication, check orders daily and make sure [MEDICATION NAME] log is accurate. The DON was asked about any in-servicing that was provided to the licensed staff on physician orders [REDACTED]. The DON and NHA ON 4/27/2015 confirmed that they were aware of Resident #2 ' s medication errors and provided a facility document that indicated a medication error had occurred. The facility was aware of Resident #2 ' s medication error on 4/17/2015; however, no negative outcomes occurred. It was unclear, due to the lack of the investigation, of how and why the medication error was found. On 4/29/2015 the DON stated " I check the MARs two times a week by flipping through all of the MARs. " She confirmed there was no documentation related to this process. The DON said that the ADON and Unit Manager check every MAR daily for accuracy and completeness. 3. The facility admitted Resident #10 on 4/3/15 with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 4/22/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The resident was not administered [MEDICATION NAME] as ordered. Review of the Admission Physician Orders, dated 4/3/2015, revealed the resident was prescribed [MEDICATION NAME] 40 unit subcutaneously daily at 9 a.m. Review of the April, 2015, Medication Administration Record revealed Resident #10 did not receive [MEDICATION NAME] on 4/9 or 4/12/15. There was no documentation on the back side of the MAR as to why the medication was omitted. The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information was provided related to why the medication would not have been given to Resident #10. 4. The facility admitted Resident #14 on 1/23/15 with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 2/11/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The resident was not administered [MEDICATION NAME] as ordered. Review of the Medication Administration Record for February 2015 revealed Resident #14 did not receive [MEDICATION NAME] for 4 out of the 6 available doses. She did not receive any [MEDICATION NAME] on 2/16/15. The resident did not receive [MEDICATION NAME] on 2/17/15 at 9 a.m., 2/18/15 at 9 a.m., or 2/19/15 at 9 a.m. There was no documentation in the nurses ' notes or the back of the Medication Administration Record as to why the medication was not given. Further review of the medical record revealed a physician ' s telephone order, dated 2/16/2015, for [MEDICATION NAME] 30 units subcutaneously twice daily. The resident was placed on [MEDICATION NAME] due to sub-therapeutic INR (International Normalizing Ratio) levels and she was at risk for developing additional blood clots. Review of the Laboratory results revealed on 2/16/15, Resident #14 ' s INR was 1.1. On 2/19/2015, the [MEDICATION NAME] was discontinued. The resident remained sub-therapeutic and the physician was attempting to adjust her [MEDICATION NAME]. On 2/26/15 the resident was noted to have redness and swelling to her right leg. An ultrasound was ordered and the resident was diagnosed with [REDACTED]. During an interview on 4/29/15 at 2:30 pm, the Nurse Consultant confirmed the missed doses of [MEDICATION NAME]. He stated that the medication should have been available from pharmacy and was unable to determine why the nurses would not have given the medication. He stated that the at least one dose of the [MEDICATION NAME] should have been given on 2/16/15. Review of the medical record revealed Resident #14 was transferred to a Hospice House for end of life care. 5. The facility admitted Resident #15 on 4/15/15 with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 4/29/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The resident was not administered [MEDICATION NAME] as ordered. Review of the April 2015 Physician order [REDACTED]. Review of the Medication Administration Record for April 2015 revealed Resident #15 did not receive her [MEDICATION NAME] on 4/17/15 and 4/22/15. The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11:00 a.m. No additional information as provided related to why the medication would not have been given to Resident #15. 6. The facility admitted Resident #16 on 3/19/15 with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 4/8/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The resident was not administered [MEDICATION NAME] as ordered. Review of the Medication Administration Record for March 2015 revealed Resident #16 was given [MEDICATION NAME] on 4/13, 4/14, 4/15 and 4/16/15. He received four doses of [MEDICATION NAME] after the medication should have been discontinued per the INR value of 2.5. Review of the physician's order [REDACTED].#16 was prescribed " [MEDICATION NAME] 60 units every 12 hours, D/C (discontinue) when INR (international normalizing ratio) above 2. " Review of the Laboratory Data revealed an INR was collected on 2/13/15 that was 2.5. Further review of the Laboratory Data revealed an INR was collected on 4/16/15 and the resident was supra-therapeutic at 3.9. Record review revealed no indication of abnormal bleeding was noted. The findings were confirmed by the Nurse Consultant, Administrator and Director of Nurses on 4/30/15 at 11 am. No additional information as provided related to why the resident received the [MEDICATION NAME] when the medication should have been discontinued. 7. The facility admitted Resident #17 on 2/6/15 with [DIAGNOSES REDACTED]. Review of the Care Plan, dated 2/25/15, revealed a problem area was identified for " anticoagulant therapy, potential for abnormal bleeding. " The approaches included " administer anticoagulant as MD ordered. " The resident was not administered [MEDICATION NAME] as ordered. Review of the April 2015 Medication Administration Record revealed Resident #17 did not receive the prescribed [MEDICATION NAME] for 5 doses; 4/7, 4/10, 4/13, 4/15 and 4/19/15. There was no documentation in the nurses ' notes or on the back of the MAR as to why the medication was omitted. Review of the physician's order [REDACTED]. The findings were confirmed by the Nurse Consultant, Administrat