Every finding on record at Healdsburg Hospital D/P SNF

Based on interview and record review, the facility failed to develop activity care plans for the residents when three of five residents sampled for activities (Residents 7, 9, 13) did not have an activities care plan. This failure had the potential to result in activities that do not meet the needs of the residents.During a record review and concurrent interview on 7/8/26 at 10:52 a.m., when asked for the location of the activity care plan in the electronic medical record, Nurse Manager navigated to a flow sheet in Resident 13's chart for documentation of activities and stated the flow sheet was considered the care plan for activities. Review of Resident 13's flow sheet for activities indicated several general one-word categories of activities, such as music, but did not indicate what the resident's preferred activities were or how the resident's personal activities needs would be met. During an interview on 7/8/26 at 2:07 p.m. with Nurse Manager and Quality Manager, Nurse Manager stated the electronic medical record (eMR) was not set up to have care plans for activities. Nurse Manager stated they would have to put in a request to the eMR company for them to make a customized activity care plan for the residents. Nurse Manager verified the flow sheet where activities were documented was not individualized with the residents' preferred activities. Nurse Manager verified the social worker's progress notes with the residents' preferred activities did not replace a care plan. Nurse Manager stated having a personalized activities plan for their resident population was very important. Quality Manager stated an activity care plan was important so that anyone can see in the medical record what the resident's preferences were, such as whether a resident liked Mexican music or country music, or liked action movies or liked to watch football, so staff knew to put the game on when they came in the room. Review of Resident 7's face sheet (demographics) indicated Resident 7 was admitted on [DATE] with a primary diagnosis of traumatic brain dysfunction (disruption of normal brain function caused by an outside force-such as a bump, jolt, or penetrating object). Resident 7's MDS (minimum data set, an assessment tool) dated 5/5/26 indicated Resident 7 was not able to complete a cognitive assessment. Review of Resident 9's face sheet indicated Resident 9 was admitted on [DATE] with a primary diagnosis of stroke (a disruption of blood flow to the brain caused by a blocked or a ruptured blood vessel). Resident 9's MDS dated [DATE] indicated Resident 9 was not able to complete a cognitive assessment. Review of Resident 13's face sheet indicated Resident 13 was admitted on [DATE] with a primary diagnosis of persistent vegetative state (a condition where a person with severe brain damage appears to be awake but has no conscious awareness of themselves or their environment). Review of Resident 13's MDS dated [DATE] indicated Resident 13 was not able to complete a cognitive assessment. Review of facility policy and procedure Person-Centered Care Plan, last revised 10/2024, indicated, [Facility named] will establish a Multidisciplinary, Person-Centered Care Plan (Plan) for each resident who is admitted for care and treatment. The Plan will be comprehensive based on the medical, functional and psychosocial needs of the resident with time limited goals. The following elements must be present in every Care Plan: . Person-Centered care that focuses on resident choice, such as choosing activities . Each resident's person-centered care will be implemented based on their Plan of Care.

Based on observation, interview and record review, the facility did not ensure the posted daily staffing information included the required elements: 1. Facility name 2. The current date 3. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. 4. Resident census. This failure resulted in residents, visitors and staff not having access to the required information and had the potential for the facility not to meet the required daily nurse staffing hours per patient day. During an observation on 7/7/26 at 11:35 a.m., the staffing assignment sheets were observed posted at the nursing station and contained licensed and unlicensed staff assigned to specific resident rooms. During an interview on 7/7/26 at 11:50 a.m., the Nurse Manager stated they did not publicly post the required hours per resident, only the staffing assignment. The Nurse Manager stated she did not know what the Hours Per Resident Day (HPRD) was.

Based on interview and record review, the facility's staff failed to complete comprehensive assessments of residents when two of five residents sampled for activities (Residents 9 and 13) did not have completed activity assessments through family interview. This failure had the potential to result in activities that are not personalized for residents who are no longer able to communicate their preferences.During a record review and concurrent interview on 7/8/26 at 1:30 p.m., MDS Coordinator reviewed Resident 9's activity assessments dated 3/23/26 and 3/22/25 and verified they had not been completed. MDS Coordinator also reviewed Resident 9's activity assessment at the time of her admission in March of 2024 and verified it had not been completed, which meant Resident 9 had never had an activity assessment completed at this facility. MDS Coordinator stated the social worker was responsible for conducting the activity assessment with the residents' family since their resident population were unable to communicate for the most part. MDS Coordinator stated Resident 9 had two sons who were involved in Resident 9's care and that Resident 9's activity assessments should have been completed. Continuing the record review and concurrent interview on 7/8/26 at 1:30 p.m., MDS Coordinator reviewed Resident 13's activity assessments dated 1/29/26 and 1/28/26 and verified they had not been completed. MDS Coordinator stated Resident 13 had family that were involved in her care and the activity assessments should have been completed. MDS Coordinator stated the facility had a social worker at the time that Residents 9 and 13's activity assessments were due to be completed. During an interview on 7/8/26 at 2:07 p.m., Nurse Manager stated having a personalized activities plan for their resident population was very important. Review of facility policy and procedure Minimum Data Set (MDS) Assessments, last revised 4/2026, indicated, [Facility named] will submit . all required Minimum Data Set (MDS) assessments, according to the MDS guidelines. The MDS Assessment is divided into sections and Interdisciplinary team members other than nursing may complete their sections, as coordinated by an MDS nurse. Each discipline is responsible for completion of their section by the specified due date.

Based on observation and interview and facility policy review, the facility failed to ensure food items were stored in a manner that complied with food handling practices to prevent food-borne illness (illness caused by the ingestion of contaminated food or beverages), when two bowls of prepared food were in the walk-in refrigerator without any labeling and several food items were opened and without labels in the dry storage area. This failure had the potential to result in the rapid growth of pathogenic (capable of causing disease) microorganisms (e. g. bacteria, virus etc.) that could cause food-borne illnesses and could affect the residents of the facility. Findings: During an observation on 8/12/24 at 9:15 a.m., food items in the freezers were labeled with the arrival date. Food items in the refrigerators had the arrival date. Food items in dry storage were labeled with the arrival date. On 8/14/24 at 9:30 a.m., during an observation in the dry storage area, several open food packages were found without a label, starting with a large open box that contained the oatmeal in plastic bag, but no label. An open box of Nilla wafers, 1 bag of tortilla chips, an 8-ounce box of pasta and a box of pancake mix had been opened and partially used but were without labels to show an opened date or use by date. During an interview on 8/14/24 at 9:45 a.m., Kitchen Staff E stated that upon delivery, the items were labeled with a Received Date. The boxes and bags of the food products taken out of the shipping boxes also get the Received Date. When the food packages are opened, they should have a new label that showed the date received, date opened and a use by date. During an observation on 8/14/24 at 9:50 a.m., the walk-in refrigerator was found to have open items unlabeled. One item was a bowl of cooked and cut up chicken, covered with plastic wrap. No label was found. The second item was a dark colored sauce in a bowl, covered in plastic wrap and not labeled. During an observation and concurrent interview on 8/14/24 at 9:53 a.m., Kitchen Staff D removed the items and stated there should be labels that include the received date, open date, and use by date. Kitchen Staff D stated staff could generate labels electronically. Kitchen Staff D stated he would need to talk with staff. The facilities policy and procedure titled Food and Supply Storage, dated 6/2023, indicated: Cover, label and date unused portions and open packages. Complete all sections of the [NAME] orange label or other approved labeling system. The policy is to store food items and supplies in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice when two of three residents (Resident 16 and Resident 5) did not have their enteral tube (a soft, flexible tube which enters a surgically created opening in the abdominal wall and is used to administer food, fluids, and medications to a person that cannot receive food, fluid, or medications through their mouth) flushed (the process of gently pushing water through the tube to clean it) before and after medication administration. This failure had the potential to cause a blockage in the enteral tube and delay the administration of critical medications (priority medications that should not be omitted or delayed). Findings: Record review of a document titled, Face Sheet (resident demographics) for Resident 16, indicated Resident 16 was admitted to the facility on [DATE]. Record review of a document titled, Problem List for Resident 16, indicated Resident 16 had the following diagnoses: traumatic brain injury with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level, encounter for PEG (percutaneous endoscopic gastrostomy [the procedure to insert an enteral tube into the abdomen]), fecal incontinence (loss of conscious control over bowel movements), and gastroesophageal reflux disease (GERD - a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus). During an observation on 8/14/24 at 10:32 AM, Licensed Nurse A prepared and administered the following medications through an enteral tube to Resident 16: Docusate 100 Milligrams (mg - a unit of weight measure), three liquid packets of 10 milliliters (ml - a unit of liquid measure) each (a medication used to prevent or treat constipation [a blockage and/or hardening of stool in the intestinal tract]). Senna 8.6 mg, one tablet (a medication used to prevent constipation). Famotidine 20 mg, one tablet (a medication used to treat stomach ulcers, heartburn, acid indigestion, and gastroesophageal reflux disease). Gabapentin 300 mg, one capsule (a medication used to treat or prevent seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in muscle tone, behavior, sensations, or awareness] or to treat nerve pain). Potassium Chloride 1.5 grams (gm - a unit of weight measure), mixed with 15 ml of water (a medication used in the management and treatment of hypokalemia [a condition where potassium [an important chemical in the body] levels are too low in the blood]). Polyethylene Glycol (PEG) 17 gm, mixed with enough water to dissolve the powder (a medication used to prevent constipation). Licensed Nurse A administered each medication separately and flushed Resident 16's enteral tube with a small amount of water (approximately 5 ml) between each medication. Licensed Nurse A did not flush the enteral tube before administering medications to Resident 16. Licensed Nurse A did not flush the enteral tube after administering medications to Resident 16. During an interview on 8/14/24 at 11:25 AM, Licensed Nurse A stated she flushed Resident 16's enteral tube with approximately 5 ml of water between each medication administered through the enteral tube. Record review of a document titled, Face Sheet (resident demographics) for Resident 5, indicated Resident 5 was admitted to the facility on [DATE]. Record review of a document titled, Problem List for Resident 5, indicated Resident 5 had the following diagnoses: traumatic brain injury (TBI - A traumatic brain injury refers to a brain injury that is caused by an outside force. TBI can be caused by a forceful bump, blow, or jolt to the head or body, or from an object entering the brain), seizure disorder, encounter for PEG, abdominal distension (abdomen is measurably swollen beyond its normal size, often due to trapped gas), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid.) During an observation on 8/14/24 at 12:39 PM, Licensed Nurse A prepared and administered the following medications through an enteral tube for Resident 5: Simethicone 125 mg, one tablet (a medication used to treat excessive gas in the digestive tract). Clonazepam 0.5 mg, four tablets (a medication used to treat seizure disorders and anxiety disorders [A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]). Oxycodone 5 mg, one tablet (a medication used to treat pain). Milk of Magnesia (MOM) 5ml (a medication used as a dietary supplement of magnesium [an important chemical in the body]). Levetiracetam, 1500ml (a medication used to treat seizure disorders). Licensed Nurse A administered each medication separately and flushed Resident 5's enteral tube with a small amount of water (approximately 5 ml) between each medication. Licensed Nurse A did not flush the enteral tube before administering medications to Resident 5. Licensed Nurse A did not flush the enteral tube after administering medications to Resident 5. During an interview on 8/14/24 at 4:03 PM, the Director of Nursing (DON) stated the facility policy was to always flush before and after enteral tube medication administration. The DON further stated the policy specified a minimum flush of 15 ml of water before and after medication administration through an enteral tube. Record review of a Policy and Procedure titled, Medication Administration Through a Feeding Tube, last approved on 3/2021, indicated flush feeding tube with 15-30 ml of warm water before administering medications. The Policy and Procedure further indicated flush the feeding tube with at least 15 - 30 ml of warm water after the completion of the medication administration.

Based on observation, interviews and records review, the facility failed to develop a person-centered individualized care plan for 1 of 8 sampled residents (Resident 7.) This failure had the potential for facility staff to not provide adequate care to Resident 7's eyes which could cause further damage to his eyes and/or blindness. Findings: During on observation on 8/13/24 at 10:25 a.m., in Resident 7's room, Resident 7 had his right eye covered with a gauze dressing. Resident 7's left eye was open and seemed to be looking at the HFEN. During an interview on 8/13/24 at 2:57 p.m., Licensed Nurse C stated Resident 7 has his eye covered because his medical condition causes the eye to be swollen preventing the eye lids from closing. He got eye drops and the dressing to prevent his eye from drying out. During an interview and concurrent record review on 8/14/24 at 3:35 p.m., Licensed Nurse C reviewed the electronic care plan for Resident 7, and it was determined that an individualized care plan concerning Resident 7's vision had not been written. The facilities policy Person-Centered Care Plan, dated 8/2024, indicated a Person-Centered Care Plan will be written for each resident. The plan will be based on the medical, functional, and psychosocial needs of the resident and will include instructions for providing effective and person-centered care that meets the professional standards of quality care.

Based on observation, interview and record review, the facility failed to provide respiratory care for 1 of 8 residents (Resident 7), when Resident 7's corrugated aerosol tubing was disconnected from the oxygen source. This failure had the potential to result in respiratory distress for Resident 7. Findings: During an observation on 12/10/18, at 9:05 a.m. Resident 7 had a [MEDICAL CONDITION] (an opening in the neck used to deliver oxygen to the lungs). Resident 7's corrugated aerosol tubing was disconnected from the oxygen source and humidifier (medical devices used to humidify supplemental oxygen to provide long-[MEDICATION NAME] moisture for patients' comfort during oxygen therapy, especially in drier climates). During an observation and concurrent interview on 12/10/18, at 9:12 a.m., Licensed Staff B noticed Resident 7's corrugated aerosol tubing was disconnected from the oxygen source. Licensed Staff B stated the aerosol tubing came off. Licensed Staff B stated if the Respiratory Therapists from Night and Day shift did a walking round (giving reports at resident bedside); the disconnected aerosol tubing would have been noticed. Licensed Staff B stated he would replace the corrugated aerosol tubing and reconnect it to Resident 7. The facility policy and procedure titled, Respiratory Care Equipment, dated 7/18, indicated, The Respiratory Care Service is responsible for providing respiratory equipment in conjunction with respiratory care modalities and to assure safe and effective services to the patient.

Based on observation, interview, and record review, the facility failed to follow medication administration policy for 1 of 8 residents (Resident 9), when the nurse did not hold the feeding tube before administering [MEDICATION NAME] (medication used to treat and control [MEDICAL CONDITION]/[MEDICAL CONDITION].). This failure had the potential to result in [MEDICATION NAME] subtherapeutic blood levels (a dosage less than the amount required for a therapeutic effect), which could put Resident 9 at risk for [MEDICAL CONDITION]. Findings: During a medication administration observation and concurrent interview on 12/12/18, at 10:30 a.m. for Resident 9, Licensed Staff C was preparing to administer medications that would go into the J-tube (Jejunostomy tube - a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Resident 9's nutritional supplement, via the feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, unable to swallow safely, or need nutritional supplementation), was running at 45 milliliter per hour (ml/hr). At 10:45 a.m., Licensed Staff C verified the feeding tube was running. Licensed Staff C stated staff held the feeding tube at 8 a.m., and restarted it at 10:30 a.m. At 10:48 a.m., Licensed Staff C turned off the feeding tube machine. At 10:55 a.m., Licensed Staff C administered the medications, including [MEDICATION NAME] 350 mg via the J-tube. At 11:21 a.m., Licensed Staff C turned on the feeding tube machine. Licensed Staff C stated the feeding tube would be held for 50 minutes before it restarted running at 45 ml/hr, automatically. During an interview on 12/12/18, at 2:57 p.m., Administrator A stated the feeding tubes were held before administering [MEDICATION NAME]. The facility policy and procedure titled, Medication Administration through a Feeding Tube, dated 11/16, indicated, [MEDICATION NAME]. Administration with continuous tube feeding may result in subtherapeutic blood levels. Discontinue tube feeding 2 hours before and after [MEDICATION NAME] administration.

Based on observation, interview, and record review, the facility failed to follow infection control practices when: 1. The staff did not dispose of the suction catheter right away after suctioning Resident 1's airway; and 2. Condensation collected from Resident 7's corrugated aerosol tubing was touching the floor. These failures had the potential to spread infection among residents and staff. Findings: 1. During an observation and concurrent interview on 12/10/18, at 10:19 a.m., Resident 1 was sitting in his wheelchair by the nurse station with a suction catheter laying on top of his pillow. When the suction catheter was pointed out, Licensed Staff D stated, I think it's suction. Licensed Staff D disposed of the suction catheter. Review of the Resident 1's Minimum Data Set (an assessment tool) dated 9/9/18, indicated the facility was providing oxygen therapy, suctioning and [MEDICAL CONDITION] care (an opening in the neck in order to place a tube into a person's windpipe, requiring care to keep the tube clean to prevent a clogged and decreased risk of infection.). During an interview on 12/13/18, at 4:15 p.m., Licensed Staff E stated the suction catheter was to be thrown away after use. The facility policy and procedure titled, Tracheal Suctioning and Sterile Technique, dated 4/17, indicated, Disconnect the catheter and fold it inside your gloves while removing them. Discard the catheter, gloves, rinsing solution and container into a waster container. 2. During an observation on 12/10/18, at 9:05 a.m., the condensation collector of the corrugated aerosol tubing connected to Resident 7, was touching floor. Review of the Resident 7's Minimum Data Set (an assessment tool) dated 10/17/18, indicated the facility was providing oxygen therapy. During an observation on 12/11/18, at 1:05 p.m., the condensation collector of the aerosol tubing connected to Resident 7, was touching the floor. During an observation on 12/13/18 at 3:36 p.m., the condensation collector of the aerosol tubing connected to Resident 7, was touching the floor. When pointed out, Licensed Staff C stated the condensation collector was not supposed to touch the floor. Licensed Staff C stated she fixed the aerosol tubing that morning but it moved. During an interview on 12/13/18, at 3:15 a.m., when asked about the condensation collector of the aerosol tubing touching the floor, Administrator F stated, Totally unacceptable, nothing should be on the floor.

Based on observation, interview and record review, the facility failed to ensure patient care reusable equipment was sorted to identify clean from dirty equipment. This had the potential for patient care equipment to go unsanitized between patient use and to spread infections. Findings: During an observation on 11/8/16, at 2:45 p.m., a cart in the kitchen area contained feeding pumps (pump used to regulate feeding through a tube) and compression stocking pumps (used to aid circulation in extremities of bedridden patients). The pumps had no indication if they were clean or dirty after patient use. During an interview with the Unit Manager on 11/8/16 at 2:45 p.m., she stated the pumps were not labeled clean or dirty. When asked how staff would know if the pumps were ready for use, she stated they just know. The Unit Manager stated the staff are inserviced when they first start working at the facility. The facility policy titled Infection Prevention, dated 1/16, indicated 2. Equipment left in the room for longer procedures, .will be completely cleaned and disinfected prior to use on another patient. Generally, the equipment is moved to the dirty utility room when no longer needed by either EVS (Environmental Service) or patient care staff. The list on the policy included Intravenous (IV) or feeding pumps, sequential compression device machine, monitor and cables, IV poles, K-Pad (used to warm patients), bed alarm equipment, bedside commodes and infant scale.

Based on observations, interviews and facility policy, the facility failed to ensure 4 of 5 Unlicensed staff could correctly answer emergency and disaster preparedness questions. These failures had the potential to endanger residents, family members, visitors and staff during an emergency or disaster situations. Findings: 1) During an interview and concurrent observation on 10/11/16, at 11:20 a.m., when asked: a) Where is the Disaster Manual located, Unlicensed Staff F stated she did not know. b) Where is the gas-shut off value located and how to shut if off, Unlicensed Staff F stated it is behind the cafeteria and it needs a key; when asked to get the key and explain how to shut off the gas, she took the surveyor to the nursing station in the emergency room got the key to the Sprinkler Room and could not see any gas valve in there. c) Where is the water-shut off value located and how to shut it off, Unlicensed Staff F stated it is located in the engineering shop; when asked where is the engineering shop, Unlicensed stated she did not know. 2) During an interview and concurrent observation on 11/7/16, at 1:15p.m.,When asked: a) what would you do if you discovered a fire in a Residents room?. Unlicensed Staff G stated he will call the charge nurse who would make an over page announcement. b) Where the fire alarms and the fire extinguishers located at? Unlicensed Staff G stated he was not sure, he would ask his supervisor. c) where is the water off value and how would you shut off the value? Unlicensed Staff G stated he did not know. 3) During an interview and concurrent observation on 11/8/16, at 11:30.a.m.,When asked: a) What would you do if the fire alarm goes off?, Unlicensed Staff H stated he would alert the nurse. b) What would do if you discovered fire in the Resident's room?, Unlicensed Staff H stated would call the nurse. c) How do use the fire extinguisher?, Unlicensed Staff H did not know. d) How do you access the emergency power if the electricity goes out?, Unlicensed Staff H did not know. 4) During an interview and concurrent observation on 11/8/16, at 11:30.a.m.,When asked: a) Where is the disaster manual located?, Unlicensed Staff I stated it was in the lobby. b) Where is the gas shut off value located?, Unlicensed Staff I stated she was new and did not know it. c) Where is the wrench located to turn the gas valve on and off?, Unlicensed Staff I stated she did not know. d) Where is the water shut off valve and how would you shut off the value?, Unlicensed Staff I stated she did not know.

Based on observation, interview and record review, the facility failed to ensure there was a safe supply of emergency water. This had the potential to sicken the residents or alter the tast of the water in the event of the need for emergency water. Findings: During a concurrent observation and interview with Maintenance Staff C, on 11/8/16 at 2:50 p.m., he stated the facility had two 250 gallon tanks that the emergency water was stored in. An observation of the two water tanks revealed two tanks in a locked room. When Maintenance Staff C was asked how the water was maintained he stated the water was checked every week with chemical strips that are used to test pool water. He stated the test strips do not show exactly the parts per million (ppm) in the water, but only indicate if more chlorine needs to be added. Maintenance Staff C stated the chlorine chemical used had been purchased from the local pool store. Maintenance Staff C was asked if the facility had obtained information on emergency water storage from CDC (Center for Disease Control) or FEMA (Federal Emergency Management Agency) and he stated no. Staff C stated the tanks are drained every year, but if the chemical strips do not indicate adequate chlorine, the tanks are drained. Maintenance Staff C was asked if there was a policy on maintaining the emergency water supply, he stated no. Record review provided by the facility of the chemical used in the emergency water indicated the chemical was 12.5% sodium hypochlorite (Chlorine). The information provided by the facility titled Hasachlor, undated, on the chemical also indicated Bacteriological sampling must be conducted at a frequency no less that that prescribed by the National Interim Primary Drinking Water Regulations. The facility did not provide a policy on Emergency Water storage.

Based on observation, interview and record review, the facility failed to accurately assess one of eight sampled residents, Resident 3, range of motion on the MDS (Minimum Data Set - assessment used as baseline information of residents). This had the potential for an inaccurate assessment of the resident and how he was able to move his lower extremities. Findings: Resident 3 was a resident who had experienced a [MEDICAL CONDITION]. Resident 3 was unable to get out of bed and was totally dependent on staff for all movements. The MDS for Resident 3, dated 3/8/16, indicated, ROM limitation: lower extremity: Impairment on both sides. The MDS for Resident 3, dated 6/8/16, indicated his ROM limitation: lower extremity: indicated no impairment. The MDS for Resident 3, dated 9/7/16, indicated, ROM limitation: Lower extremity: No impairment. During an interview with Licensed Staff B, the MDS nurse, on 11/7/16, at 2 p.m., she stated no impairment meant full use of extremities. Licensed Staff B stated the accuracy of the MDS from 6/8/16 and 9/7/16 indicating no impairment, needed to be corrected. Licensed Staff B stated there had been no improvement in Resident 3's range of motion of the lower extremities.

Based on interview and record review, the facility failed to ensure 1. the weekly assessment for Resident 2 was accurate and complete, 2. alert charting was done for one sampled resident, Resident 2. This had the potential for patient information to be communicated accurately to other staff. Findings: Record review of the facility document titled Nursing Weekly/Discharge Summary for Resident 2 was not complete. The weekly assessment document had missing information such as who completed it, the date of completion and title. Also missing on the Nursing Weekly/Discharge Summary was information from several dates about the enteral (feeding through a tube in the resident's stomach) feeding solution and the rate of the tube feeding. Record review of Resident 3's Nursing Weekly/Discharge Summary also had missing documentation that included missing rate of flow, rate not documented in increments of ounces of milliliters (a measure of liquid), and missing signature, title and date that the document was created. During an interview with Licensed Staff A on 11/8/16 at 10 a.m., she stated the milliliters and signatures should have been included on the document as a part of best practice.

Based on observation, interview and record review, the facility failed to ensure an air purifier in a patient room had been through a biomedical check. This had the potential for faulty equipment to be used in a patient room. Findings: During an observation on 11/7/16 at 9:45 a.m., an air purifier being used in a patient's room did not have a sticker on it to indicate it had been checked by biomedical. During an interview with Unit Manager on 11/7/16 at 9:45 a.m., when asked about the sticker to indicate that the air purifier had been checked, she stated she did not know.

Based on observations, staff interviews, and document review, the facility failed to ensure: 1. Two of five staff members (Licensed Staff B and Licensed Staff I) performed hand hygiene (by either washing hands with soap and water or using an alcohol-based hand gel) before and after donning/doffing (putting on/taking off) gloves; 2. Work surfaces were disinfected before and after use; 3. A communal (used for several patients) plastic medication container was disinfected after patient use; 4. A communal pill crushed was disinfected after patient use; 5. Two of three staff members (Licensed Staff B and Licensed Staff C) prepared and/or administered [MEDICATION NAME] (administered with a sterile needle and syringe) medications using aseptic (sterile) technique; 6. Staff (Licensed Staff B) changed face shields in between patients' care; 7. One of five licensed staff members (Licensed Staff B) changed gloves in between different patient procedures/treatments; and 8. Four of 15 suction canisters and/or suction tubing in use were changed in a timely manner according to facility protocol. These failures had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) and spread of infection between patients and/or staff. Findings: 1. During an observation on 10/19/15 at 10:50 a.m., Licensed Staff B was performing tracheostomy care on Unsampled Resident 9 (a tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube). Licensed Staff B did not change gloves or perform hand hygiene in between removal of the existing inner cannula and replacement with a new cannula. After the cannula was replaced, Licensed Staff B changed gloves but did not perform hand hygiene. Wearing the same gloves, he opened the bathroom door to get tap water for irrigation (flushing of the feeding tube with a small amount of water before and/or following medication administration) of the feeding tube. During an observation of medication preparation and administration on 10/19/15 at 11:17 a.m. for Unsampled Resident 9, Licensed Staff B did not change gloves following medication administration and again opened the bathroom door using the same gloves. Wearing the same gloves, Licensed Staff B then touched the computer mouse and keyboard. After another medication administration, using the same gloves, Licensed Staff B touched the computer table to move it to a different position in the room. During an observation on 10/19/15 at 11:35 a.m., Licensed Staff B administered a medication to Unsampled Resident 9 via subcutaneous (into the fatty tissue just under the skin) injection. He then changed his gloves but did not perform any hand hygiene before donning new gloves and performing the resident's mouth care. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B stated he should have performed hand hygiene between patient procedures, i.e. trach care and medication administration. During an observation of mouth care for Unsampled Resident 10 on 10/20/15 at 9:40 a.m., Licensed Staff I donned new gloves, but did not perform hand hygiene before doing so. He then gave mouth care to the resident, changed gloves without performing hand hygiene then proceeded to prepare and administer medications to Unsampled Resident 10. After administration of eye drops to Unsampled Resident 10, Licensed Staff I changed his gloves but did not perform any hand hygiene. He then applied lotion to the resident's arms and legs, again changed gloves without performing any hand hygiene. During an interview on 10/20/15 at 10:06 a.m., Licensed Staff I was asked about performing hand hygiene when donning/doffing gloves. He stated he was told as long as he was administering care to the same resident, he did not have to perform hand hygiene in between donning/doffing gloves. He added he was instructed to perform hand hygiene before and after contact with a resident. The policy titled, Hand Hygiene and Glove Use, revised 5/2013, indicated to either wash hands with soap and water or use an alcohol-based hand gel before and after donning/doffing gloves. According to Perry, A. G., Potter, P. A., & Ostendorf, W. R., (2014). Clinical Nursing Skills & Techniques (8th ed.)., section Medical Asepsis: The most important and basic technique in preventing and controlling transmission of infection is hand hygiene (p. 168). 2. During an observation on 10/19/15 at 10:50 a.m., Licensed Staff B prepared to administer medication via Unsampled Resident 9's feeding tube. After obtaining tap water from the bathroom in the resident's room, Licensed Staff B placed the irrigation syringe directly on the computer table without a barrier. After irrigating the feeding tube with a small amount of water and administering 30 ml. of Milk of Magnesia, Licensed Staff B again placed the irrigation syringe directly on the computer table. Using the same gloves, Licensed Staff B touched the computer mouse to check the dose of the next medication. Throughout the medication pass, Licensed Staff B wore the same gloves and repeatedly touched the computer tabletop, mouse, keyboard, and the bathroom door handle. Following administration of all the medications, Licensed Staff B removed his gloves and performed hand hygiene using alcohol gel. He then wheeled the computer cart out of the patient's room and to the nurses' station. Neither the work table in Unsampled Resident 9's room, the door handle to the patient's bathroom, nor the computer table, mouse or keyboard were disinfected after use. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B acknowledged he placed the irrigation syringe directly on the computer table and stated he should have disinfected the work surfaces following use. During an interview on 10/20/15 at 1:13 p.m., Administrative Staff A stated the computer table, mouse, and keyboard would be considered contaminated if they were not disinfected following direct placement of an irrigation syringe on the table top. 3. During an observation on 10/19/15 at 10:50 a.m., Licensed Staff B prepared to administer medication via Unsampled Resident 9's feeding tube. After gathering the medications from the medication cart at the nurses' station, Licensed Staff B placed them in a square, plastic container which he carried into the resident's room and placed it directly on the bedside working table. Following administration of the medications, Licensed Staff B placed the plastic container directly on Unsampled Resident 9's roommate's bedside table. The plastic container was not disinfected prior to or after patient use. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B acknowledged he did not disinfect the communal plastic medication container after bringing it into Unsampled Resident 9's room and stated he should have done so before returning it to the medication cart at the nurses' station. During an interview on 10/21/15 at 9 a.m., Infection Control Nurse H stated it was not acceptable practice to change gloves without performing hand hygiene, use communal patient supplies without proper disinfection following use, nor to fail to disinfect contaminated work surfaces following use. The policy titled, Standard Precautions, reviewed 3/2015, indicated: Be sure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. 4. During an observation on 10/19/15 at 10:50 a.m., Licensed Staff B prepared to administer medication via Unsampled Resident 9's feeding tube. A communal pill crusher was observed to be directly on Unsampled Resident 9's roommate's bedside table. Licensed Staff B picked up the pill crusher and moved it to a fixed counter in the room and crushed the necessary pills. The pill crusher was not disinfected before or after patient use. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B acknowledged he did not disinfect the communal pill crusher after placing it directly on two work surfaces in Unsampled Resident 9's room and stated he should have done so before taking it into another resident's room. The policy titled, Standard Precautions, reviewed 3/2015, indicated: Be sure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. 5. During observation of preparation of 5000 units of injectable ([MEDICATION NAME]) [MEDICATION NAME] for Unsampled Resident 9, on 10/19/15 at 11:32 a.m., Licensed Staff B touched the sterile plunger of the syringe with his non-sterile gloved hand/fingers while drawing up the medication from the vial. He then carried the syringe by the now contaminated plunger over to the resident's bedside for administration. Licensed Staff B then injected the [MEDICATION NAME] subcutaneously into the resident's abdomen. During observation of preparation of 5000 units of injectable ([MEDICATION NAME]) [MEDICATION NAME] for Unsampled Resident 9, on 10/20/15 at 9:15 a.m., Licensed Staff C touched the sterile plunger of the syringe with her non-sterile gloved hand/fingers of both hands while expelling air from the syringe. During a concurrent interview with Administrative Staff A and review of the facility's nursing reference manual (Lippincott Manual of Nursing Practice) on 10/22/15 at 3:55 p.m., found no mention of preparation/administration of [MEDICATION NAME] medications using aseptic technique. According to Perry, A. G., Potter, P. A., & Ostendorf, W. R., (2014). Clinical Nursing Skills & Techniques (8th ed.)., Chapter 22, [MEDICATION NAME] Medications, Preventing Infection During an Injection, Avoid touching the length of the plunger or inner part of the barrel (p. 539). 6. During care for Unsampled Resident 9 (tracheostomy care and medication administration via feeding tube) on 10/19/15 from 10:50 to 11:42 a.m., Licensed Staff B was observed wearing a clear plastic face shield. Following care, Licensed Staff B removed his face shield and hung it on the back of the computer cart. He then pushed the cart to the nurses' station. A minute or two later, Licensed Staff B removed the face shield from the back of the computer cart and carried it into Resident 6's room where he placed it on the bedside work table. At 11:46 a.m., Licensed Staff B put on the same face shield and proceeded to care for Resident 6. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B acknowledged he wore the same face shield while caring for Unsampled Resident 9 and then while immediately caring for Resident 6. During a concurrent interview on 10/20/15 at 1:30 p.m., and observation of the box containing clean face shields, Administrative Staff A corroborated the manufacturer's instructions for use indicated: Intended use: This product is a non-sterile, single-use disposable medical device and is intended to protect the wearer's face from splashing liquids and bodily fluid. The policy titled, N-95 Masks, Redonning During Epidemics, reviewed 3/2015, included face shields as eye protection and recommended they be removed upon leaving a room. 7. During an observation of care for Unsampled Resident 9 on 10/19/15 from 10:50 to 11:42 a.m., Licensed Staff B did not change gloves or perform hand hygiene following tracheostomy care and before proceeding to administer medications through the resident's feeding tube. During an interview on 10/19/15 at 1:30 p.m., Licensed Staff B stated he should have changed gloves and performed hand hygiene in between the tasks of tracheostomy care and medication administration while caring for Unsampled Resident 9. The policy titled, Standard Precautions, reviewed 3/2015, indicated: Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments. 8. Observations of in use, wall-mounted suction canisters and tubing on 10/19/15 at 1:15 p.m. and 10/20/15 at 10:45 a.m. indicated: room [ROOM NUMBER]-1: Canister dated 10/4/15 room [ROOM NUMBER]-2: Tubing dated 10/11/15 room [ROOM NUMBER]-1: Tubing dated 10/11/15 room [ROOM NUMBER]-2: Tubing dated 10/11/15 Observation of a sign posted on a bulletin board above the sink at the nurses' station on 10/19/15 at 3:50 p.m. indicated: Suction canisters and suction tubing must be changed and dated every Sunday. You are responsible for canisters and tubing of each patient that gets up into a chair on your shift. During an interview on 10/21/15 at 1:20 p.m., Administrative Staff A corroborated the above dates on the suction canisters and/or tubing and verified they should have been changed prior to 10/19/15. She stated the sign posted at the nurses' station reflected the facility's policy regarding changing suction canisters and tubing in a timely manner.

Based on observation and staff interviews, the facility failed to ensure: 1. The emergency water supply was chlorinated with food-grade bleach; 2. Potable hoses were available for water removal; and 3. Maintenance logs were kept for the emergency water supply. This had the potential to sicken residents consuming stored water in the event of an emergency. Findings: During an observation with concurrent interviews on 10/21/15 at 3:20 p.m., Management Staff F stated the water in each of the two 250 gallon water tanks is chlorinated and changed one time per year. The first tank had a sticker on it with a date of 7/14 (July 2014) with the sticker on the second tank indicating 8/15 (August 2015). When asked if there were any maintenance logs for tracking when the water is replaced and chlorinated, Management Staff F stated, No, adding that he or his assistant just put a new dated sticker on the tank when changed. Lying on the floor near the water tanks was a green hose, identified by the Engineering Staff G as a garden hose. When asked if staff used the green hose to remove water from the tanks, the Engineering Staff G stated, Yes, adding the facility did not have a potable (food safe) hose. When asked to see the bottle of bleach solution used to chlorinate the emergency drinking water, the label did not indicate it was food grade, thus making it safe to use on surfaces coming in contact with food or water. When asked if there was a policy and procedure for chlorination and replacing the emergency water supply, Management Staff F stated there was not. According to www.ready.gov/water (accessed 11/2/15), Water that has not been commercially bottled should be replaced every six months. According to the Food and Agricultural Products Research and Technology Center at Oklahoma State University (www.fapc.okstate.edu; accessed 11/2/15), Any chlorine bleach that is used for making a sanitizing solution, whether for equipment or raw produce, must be of sufficient purity to be categorized as a 'food grade' substance.

Based on staff interview and record review, the facility failed to ensure care plans were complete for four of eight sampled residents (Residents 4, 5, 7, and 8). This had the potential for staff to provide inadequate care to meet the residents' needs. Findings: Review of Resident 5's care plans on 10/19/15 at 2 p.m., indicated 9 of 19 care plans were incomplete. The Altered Cardiovascular care plan, dated 9/13/15, listed no indication of the cause of the altered cardiovascular status and did not include any treatment goals. The care plan was also not signed by the Licensed Nurse. The Altered Coagulation care plan, dated 9/13/15, listed no treatment goals. The undated Diabetes/Metabolic Disease care plan was blank. The undated Discharge Planning care plan did not include any goals or approaches. The undated Altered Neurological care plan did not include any approaches. The Pain/Comfort care plan was not dated. The undated Patient Rights/Advanced Directives care plan was blank. The Physical Restraints care plan was undated. The Visual Function care plan was undated and blank. Review of Resident 4's care plans on 10/21/15 at 10:55 a.m. indicated 3 of 22 care plans were incomplete. The short-term care plan dated 9/22/15 under Change of Condition gave no indication what the change of condition was. The Communication Impairment care plan dated 8/31/15, indicated the impairment was due to PVS (persistent vegetative state), but no goals or approaches were indicated. The undated Visual Function care plan was blank. Review of Resident 7's care plans on 10/23/15 at 12 p.m. indicated 5 of 5 care plans were incomplete. The following care plans were undated and blank: Visual Function, Psychosocial/Mood/Behavior, Patient Rights/Advance Directives, and Diabetes/Metabolic Disease. The Discharge Planning care plan did not indicate any treatment goals or approaches. Review of Resident 8's care plans on 10/23/15 at 12:15 p.m. indicated 13 of 14 care plans were incomplete. The following care plans were undated and blank: Altered Cardiovascular, Altered Coagulation, Diabetes/Metabolic Disease, Discharge Planning, Fall Risks, Feeding Tube, Infection, Altered Neurological, Nutrition Risk, Altered Oral Health, Physical Restraints, and Visual Function. The Cognitive Loss care plan was undated and not signed by the Licensed Nurse. During an interview and concurrent record review on 10/22/15 at 2:05 p.m., Licensed Staff E corroborated the incomplete care plans for Resident 5. During an interview and concurrent record review on 10/22/15 at 3:15 p.m., Licensed Staff E corroborated the incomplete care plans for Resident 4. During an interview and concurrent record review on 10/23/15 at 12:07 a.m., Licensed Staff E corroborated the incomplete care plans for Resident 7. Review of the policy titled, Multidisciplinary Plan of Care, revised 11/2014, indicated: The following key elements must be present in every Care Plan: a. Problem identification; b. Measurable short and long-term goals; c. Plan of action or intervention; d. Date the problem was identified; e. Date the problem was resolved; f. Professional discipline responsible for each element of care. Each resident's care will be implemented based on this plan.

Based on observations, staff interviews, and document review, the facility failed to ensure: 1. Staff (Licensed Staff C) administered [MEDICATION NAME] (an anti-coagulant) according to facility policy; 2. Staff (Licensed Staff C) identified residents prior to medication administration; and 3. A policy was in place directing staff what to do in the event of computer downtime prior to the institution of the new electronic computer system. These failures had the potential to contribute to medication errors which could jeopardize patient safety and well-being. Findings: 1. During an observation on 10/20/15 at 9:15 a.m., Licensed Staff C drew up 5000 units of [MEDICATION NAME] into a syringe then administered it to Unsampled Resident 9. Even though another Licensed Nurse was present in the room (Licensed Staff D), Licensed Staff C did not check the dose with the other nurse prior to its administration. During an interview on 10/20/15 at 11:05 a.m., Licensed Staff C was asked what the facility policy was regarding checking [MEDICATION NAME] with another nurse prior to it being administered. She stated insulin was the only medication that needed to be double-checked with another nurse prior to administration. Licensed Staff C added that the new electronic computer system did not prompt the nurse to check [MEDICATION NAME] with another nurse, only for insulin. During an interview on 10/21/15 at 9:40 a.m., Administrative Staff A corroborated that the new computer system does not prompt the nurse to get a second check with [MEDICATION NAME] and stated since the residents are on such low doses of [MEDICATION NAME], double-checking with another nurse was not necessary and that the policy needed to be changed. Review of the policy titled, Medication System Ordering, Transcribing & Administering, revised 9/2015, indicated: The following drug doses must be checked with another RN: Insulin, [MEDICATION NAME], PCA (Patient Controlled [MEDICATION NAME])--including dosage changes, and Potassium . 2. During an observation of a medication pass on 10/20/15 at 9 a.m., Licensed Staff C prepared medications for Unsampled Resident 9. Prior to administering 5000 units of [MEDICATION NAME], Licensed Staff C scanned the resident's barcode on the identification bracelet. Even though the resident's identification card (with photo and name) was brought into the room in the plastic medication container, Licensed Staff C did not compare the identification card to the identification bracelet. During an interview at 9:20 a.m., Licensed Staff C acknowledged she did not identify the resident prior to medication administration and stated she thought with the new electronic computer system, scanning the barcode was sufficient. During an interview on 10/20/15 at 9:21 a.m., Administrative Staff A stated she instructed staff to first compare the identification card to the resident's identification bracelet, then scan the barcode. Review of the policy titled, Medication System Ordering, Transcribing & Administering, revised 9/2015, indicated: When the dose of medication is given, the nurse will: Verify the 2 patient identifiers; Barcode scan the patient id bracelet . According to Perry, A. G., Potter, P. A., & Ostendorf, W. R., (2014). Clinical Nursing Skills & Techniques (8th ed.)., Before giving a medication to a patient, always use at least two patient identifiers (TJC, 2012a). Acceptable patient identifiers include the patient's name, an identification number assigned by a health care agency, or date of birth .TJC (2012b) requires use of two patient identifiers when nurses administer medications (p. 483). 3. During concurrent interviews on 10/19/15 at 10:25 a.m, Administrative Staff A stated the mobile wireless computer system used by nurses to verify medication orders and document medication administration was down and that it went down approximately 10 minutes prior (10:15 a.m.). Licensed Staff B was standing next to one of the computers and stated he was just about to start his medication pass, but was unable due to the computer failure. He stated he was not sure how many minutes to wait before reverting back to a paper system. Administrative Staff A stated there were not any downtime policies yet. We're working on them. The computers were functional again at 10:40 a.m.

Based on observation, interviews, and record review, the facility failed to ensure a medication error rate of less than five percent when staff (Licensed Staff B ) administered five medications 90 to 120 minutes late. This failure resulted in a medication error rate of 17 percent and had the potential to adversely affect a resident's (Unsampled Resident 9) health. Findings: During an observation of medication administration on 10/19/15 from 11:00-11:32 a.m., Licensed Staff B administered five medications to Unsampled Resident 9. The medications included: Milk of Magnesia (a laxative) 30 milliliters (ml); [MEDICATION NAME] (for anxiety) 10 milligrams (mg); [MEDICATION NAME] (an antibiotic) 100 mg; [MEDICATION NAME] (an [MEDICATION NAME]) 10 mg; and [MEDICATION NAME] (an anti-coagulant) 5000 units. During an interview on 10/19/15 at 11:35 a.m., Licensed Staff B was asked what time the medications were scheduled to be given. He stated nine and ten o'clock. During a second interview that day at 1:30 p.m., Licensed Staff B was asked what the allowable window of time was when medications could be administered and he stated 30 minutes before or after the scheduled time. He acknowledged the medications he administered to Unsampled Resident 9 from 11:00-11:30 a.m. were late. During an interview on 10/20/15 at 4:30 p.m., Administrative Staff A stated the allowable time frame for the administration of non-critical medications was one hour on either side of the scheduled time. She acknowledged medications scheduled for 9 or 10 a.m., but given from 11:00 to 11:30 a.m. were considered late. Concurrent interview and medication policy and procedure review on 10/21/15 at 11:20 a.m., found no mention of an acceptable time frame for the administration of medications. Administrative Staff A stated there was no policy which addressed the acceptable time frames, but that is the practice staff are oriented to. Review of physician MEDICATION ORDERS FOR [REDACTED] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5000 units subcutaneously every eight hours (0100, 0900, 1700); [MEDICATION NAME] 10 mg. JT (via feeding tube) give daily at 1000; [MEDICATION NAME] Hcl 100 mg. JT twice daily (0900, 2100); Milk of Magnesia 7.75% 30 ml. JT daily (1000); [MEDICATION NAME] 10 mg. JT every eight hours (0100, 0900, 1700). According to Perry, A. G., Potter, P. A., & Ostendorf, W. R., (2014). Clinical Nursing Skills & Techniques (8th ed.)., section, Safe Medication Administration: Standards are those actions that ensure safe nursing practice .Professional standards such as Nursing: Scope and Standards of Practice (ANA, 2010) apply to the activity of safe medication administration. To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication; 2. The right dose; 3. The right patient; 4. The right route; 5. The right time; 6. The right documentation (p. 480).

The facility failed to ensure that, Resident 9 (one of the three abbreviated survey sample), who was fed by a gastric tube (G tube: a tube inserted directly into the stomach through an abdominal incision for the administration of food, fluids, and medications), received appropriate treatment and services to prevent gastric tube replacement complications; failed to identify signs and symptoms [MEDICAL CONDITION] (sepsis is a serious medical condition caused by an overwhelming immune response to infection); and failed to ensure that all staff were trained to replace feeding tubes. This presented imminent danger to Resident 9, as a result of the misplacement of the gastric tube outside of the stomach, which led [MEDICAL CONDITION], kidney failure and death. During a review of the clinical record, on [DATE] at 11 a.m., Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9 had a gastric tube for feeding, fluids, and medications. Resident 9's Minimum Data Set (MDS), an evaluation tool, revealed that Resident 9 could not understand others or be understood and was totally dependent for all activities of daily living. (Merck Manual - persistent vegetative state is a chronic condition that preserves the ability to maintain blood pressure, respiration, and cardiac function, but not cognitive function. The patient has no awareness of self and interacts with the environment only via reflexes and cannot interact with people. Purposeful responses to external stimuli are absent, as are language comprehension and expression. Treatment is supportive only). Nurses notes, dated [DATE], as a late entry for [DATE], revealed that at 10 a.m., Licensed Nurse (LN) D went into Resident 9's room to turn on the tube feeding after it had been turned off for one hour after medication was administered. The gastric tube was lying on Resident 9's stomach with the balloon deflated. A moist Q-tip was inserted to keep the tract open and another gastric tube was inserted, with some difficulty. Placement was checked by injecting air into the gastric tube and listening for air. The notes indicated that air was heard to the left of the gastric tube insertion site, and that there was no residual fluid, as the tube feeding had been off for one hour following a medication. A second nurse checked placement. Further record review revealed that there were no notations on the care plan about the reinsertion. During an interview, on [DATE] at 11:30 a.m., when asked to explain the note of passing the gastric tube with difficulty, LN D stated that she could not get it to, "follow the line," and tried three or four attempts to get it in, then finally felt a pop as the gastric tube was placed and felt that the pop meant that it was in the tract of the stomach. LN D did inject air into the tube to listen for air in the stomach and heard it to the left, not where it had normally been heard before (on the right). LN D asked another nurse to check placement but was not in the room when this occurred. LN D stated that the second nurse, who checked placement, reported that Resident 9's color was gray two hours after the gastric tube was replaced. Resident 9 was suctioned through the [MEDICAL CONDITION], and there was no sputum, and it was decided to just continue monitoring. LN D stated that this resident could not tell you what was wrong, so observation skills were critical. LN D stated that the physician was not notified at the time, as she felt the tube pop into the tract. LN D also stated that an X-ray should have been done, to check placement, after the difficult placement and that it was standard orders when something did not seem right. During an interview, on [DATE] at 11 a.m., LN H stated that LN D had requested that he check placement of the gastric tube after it was reinserted. LN H was not in the room when LN D reinserted the tube. LN H stated that the tube feeding had been held for one hour after medication so there was only a small amount of residual fluid in the tube when checked for fluid, and that air was heard on the left side and none on the right side, where it had been previously heard. LN H stated that he had not attended any in-services for gastric tubes. During an interview, on [DATE] at 10:20 a.m., LN G, the nurse who cared for Resident 9 during the evening (3 p.m. to 11 p.m.) shift, was asked if gastric tube residual and placement had been verified. LN G stated that it had been reported that the gastric tube was replaced, but the report had not indicated that it was a difficult replacement. LN G did state that air was heard when the gastric tube placement was checked. When asked if there was residual fluid, and where the residual was recorded, LN G stated that residuals were not recorded, and could not remember if there was any residual fluid in the tube or stomach, and that residuals were never recorded. LN G stated that as the evening progressed Resident 9's condition worsened. The nursing assistants had reported that Resident 9 was very diaphoretic (profuse sweating) while sitting up in a chair. LN G asked the nursing assistants to put Resident 9 back to bed and turn on a fan. Later the nursing assistants reported that Resident 9 was again very diaphoretic and asked LN G to re-evaluate. LN G stated that Resident 9's blood pressure was low, and it seemed like something was going on, and thought that Resident 9 was possibly getting a urinary tract infection. Resident 9's temperature and pulse were not taken. When asked what the policy was for reporting a low blood pressure or for required nursing documentation, LN G did not know, and stated that the policy manuals that were at the nursing station, and were not very user friendly, so they were not used very often. LN G also stated that the above findings were not recorded in the record, but should have been. Record review, on [DATE] at 11 a.m., revealed nurses notes for the night shift (11 p.m. to 7 a.m.), with a time recorded as 3 a.m., that Resident 9's blood pressure was ,[DATE]: "Gave patient rest of water via G tube, stopped feeding for 30 minutes, re-checked BP (blood pressure), it had gone up to ,[DATE], restarted feeding." A second note, timed also as 3 a.m., indicated, "Second time BP was checked, it was ,[DATE]. After giving rest of water and elevating feet re-checked, it was ,[DATE]." During an interview, on [DATE] at 11:35 a.m., LN I stated that the concern on the night shift was the low blood pressure. LN I also stated that sometime during the night Resident 9 was shaking, so a warm blanket was applied. When asked what the pulse was when the blood pressure was checked, LN I did not know. When asked if a temperature was taken when Resident 9 was shaking, LN I replied, "no." LN I stated that the other Licensed Nurse on that night (LN P) and she had been concerned with the low blood pressure. LN I did check gastric tube placement, but did not recall if there was any residual, did hear air, but was not sure which side it was heard. When asked about the no urine output for the entire night shift, LN I responded that sometimes the residents did not have urine output on the night shift and would make up for it on the day shift. When asked to list the symptoms [MEDICAL CONDITION], LN I did not know them. During an interview, on [DATE] at 11 a.m.., when asked what the signs and symptoms [MEDICAL CONDITION] were, LN P, the second nurse on the night shift caring for Resident 9, indicated she did not know them that night. (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms [MEDICAL CONDITION] are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. [MEDICAL CONDITION] is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. [MEDICAL CONDITION] does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.) Record review, on [DATE] at 10 a.m., of the [DATE], day shift nurses notes (7 a.m. to 3 p.m.), revealed that at 8 a.m. the vital signs were: Temperature 38.2 axillary, Pulse 132, Respirations 43, Blood Pressure ,[DATE]. Resident 9 was diaphoretic and cold, his toes and feet were gray, his hands were cold, and he was cyanotic (a bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished). The notes indicated that the physician was notified immediately, and laboratory studies, EKG and chest x-ray were ordered. At 9 a.m. Resident 9's heart rate was in the 40's, his blood pressure was ,[DATE], his oxygen saturations were in the 70's (normal = ,[DATE]), and the hospital Rapid Response Team was called. During an interview, on [DATE] at 3:15 p.m., LN E, the hospital intensive care nurse who responded to the rapid response team page, stated that Resident 9's abdomen was very distended, his color was gray, his skin was cold, and that it was obvious that Resident 9 was in full-blown septic shock. LN E stated that the rapid response team should have been called much earlier. Resident 9 was transferred to the hospital intensive care unit with a [DIAGNOSES REDACTED]. Record review, on [DATE] at 10 a.m., revealed a CT scan of the abdomen/pelvis, dated [DATE], with the conclusion: "The gastrostomy tube is outside the stomach. Fluid and air are present in the abdominal wall." Resident 9 was transferred to another local hospital intensive care unit on [DATE], for consideration of [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a special machine. [MEDICAL TREATMENT] is necessary when the kidneys are not able to filter the blood) due to [MEDICAL CONDITION] (kidney function failure) with anuria (failure of the kidneys to produce urine). A CT scan of the abdomen/pelvis, dated [DATE], was done with the impression: Feeding tube in musculature of the left abdominal wall, air in the left anterior abdominal wall crossing the midline to the right, intra-abdominal air also present, primarily against the left anterior abdominal wall, with associated fluid. Resident 9 died on [DATE], with final discharge [DIAGNOSES REDACTED]. Review, on [DATE] at 1 p.m., of the facility policy titled: Gastrostomy Tube Changing or Reinsertion of (excluding Jejunostomy tubes), dated ,[DATE], included the policy statement: "...if a gastrostomy tube falls out, a replacement tube should be inserted as soon as possible, within a few minutes at most..." Documentation required: "1. 24 hour nursing assessment notes, 2. Nurse's progress notes, 3. Kardex, and 4. Care Plan." Review of the facility policy titled: Notification of Resident Changes, dated ,[DATE], included: "Procedure: The physician shall be notified promptly of: a. Any sudden and marked change in signs, symptoms or behavior exhibited by a resident, b. Any unusual occurrence involving a resident,... d. Any untoward response or reaction by a resident to a medication or treatment..." During a review, on [DATE] at 5 p.m., the facility policy Titled: Contacting the physician for changes in patient's condition, revised ,[DATE], included: "1. The nurse will notify the attending physician when the following circumstances arise, unless otherwise modified by the physician: a. Systolic B/P below 80 or above 180 mm Mercury - new onset, b. Pulse below 50 or above 110, new onset....2. When any of the above conditions occur, the Lead Nurse or Staff nurse will: 1. Contact the physician by office phone, Tiger Text or overhead paging if in the hospital. B. Contact the ICU for possible admission to that unit (consider calling a Rapid Response Team to evaluate the patient) ..." During a review, on [DATE] at 11 a.m., the manufacturer instructions (BARD) for the gastric tube, included in Warnings "...Be certain that the balloon has passed through the fistulous tract and is completely in the stomach prior to inflation of the balloon. Placement or slippage of the device into the peritoneal cavity will result in serious consequences including peritonitis,[MEDICAL CONDITION] and potentially, death..." During an interview, on [DATE] at 10 a.m., when asked about the specific staff training for gastric tubes, Administrative Staff C stated that there was no formal training. Nursing staff, who had previous experience, trained new staff who, after inserting a G tube, could then train the next nurse. There were no skills competency evaluations, and the yearly Licensed Nurse performance evaluations were not specific to skills with gastric tubes. Administrative Staff C stated that all 13 residents in the distinct part skilled nursing unit had gastric tubes, and that all residents had traumatic brain injuries requiring feeding, fluids, and medications through gastric tubes. During a review, on [DATE] at 11 a.m., the performance evaluation for LN D indicated that all criteria were met, but that there was a need to strengthen critical thinking skills. The licensed nurse performance evaluation did not include an evaluation of skills with gastric tubes. Safe Practices in Patient Care: Enteral Nutrition and Hydration in Long-Term Care (Continuing Education for Nurses), indicated...Tube Displacement...The auscultation method of listening for insufflative air over the epigastrium to check for tube placement is not always reliable...If there is any question of tube migration or displacement or if the nurse is unable to determine tube placement, an X-ray should be requested..." http://emedicene.medscape.com/article/ -overview: [DEVICE] replacements:..."If [DEVICE] replacement does not occur easily, abort the procedure and contact the provider who placed the tube..." American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN) Standards of Practice: Standard 11: 11.1 Appropriate access devices (tubes placed for the delivery of nutrients or drugs) shall be placed by or under the supervision of a physician, nurse or specially trained healthcare professional who is competent and knowledgeable in recognizing and managing complications associated with the placement and management of the device...11.3 Proper placement of vascular (into a blood vessel) and enteral devices (into the gastrointestinal tract) shall be appropriately confirmed and documented before use...11.4 complications related to an access device and outcome of actions to manage the complication shall be clearly documented in the medical record. The facility violated the regulation by failing to ensure that all staff were trained and competent to replace gastrostomy tubes, failed to obtain an x-ray to check placement of the gastric tube after difficulty in passing the tube, and failed to recognize signs and symptoms [MEDICAL CONDITION]. These failures resulted in Resident 9's gastric tube placement outside of the stomach which resulted in septic shock with kidney failure and was the direct proximate cause of death. The above violation presented an imminent danger to the patient and was a direct proximate cause of the death of the patient.

Based upon observations, interviews, and record reviews, the facility failed to implement and maintain an infection control program when the facility: 1. Failed to have an Infection Control Committee; which resulted in the inability to investigate, control, and prevent infections; 2. Failed to implement an infection control log, which resulted in the inability to provide surveillance, tracking, trending, and monitoring of infections; 3. Failed to identify the signs and symptoms of sepsis for two of the nine sampled residents (Resident's 9 and 3); which resulted in septic shock and death for Resident 9 and an intensive care admission for sepsis for Resident 3; PubMed Health: Sepsis is an illness in which the body has a severe response to bacteria. 4. Failed to update or change the Infection Care Plan's for residents with repeated infections, for four of nine sampled residents (Resident's 2, 3, 5, and 8); which resulted in repeated urinary tract infections with bacteria normally found in stool, urinary tract infections that led to [MEDICATION NAME] (inflammation of the bladder), pyelonephritis (infection of the kidneys) or bacteremia (infection of the blood), pneumonia, and intensive care admissions for infections and sepsis; 5. Failed to identify educational requirements and provide in-services for signs and symptoms of sepsis, how to assess for signs and symptoms of infections in a medically compromised population of residents who could not communicate or make their needs known, and how to prevent cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another, or from one part of the body to another) for five of nine sampled residents (Resident's 2, 3, 5, 8, and 9), which resulted in repeated infections and intensive care admissions for infections. 6. Failed to implement a monitoring system to evaluate the compliance of hand washing, which has the potential for cross-contamination by bacteria that can spread to susceptible persons by person-to-person contact or contact with contaminated surfaces; and 7. Licensed Nursing staff failed to disinfect the plastic plates used to deliver medications, to four of nine sampled Resident's (1, 2, 3 and 5) and 3 random residents, during medication administration, when plates were placed on resident's bedside tables and then re-used without disinfection, which has the potential for cross-contamination to all residents by spreading bacteria that had contact with potentially contaminated surfaces. Findings: 1. During an interview on [DATE] at 10:50 a.m. Administrative Staff B, Performance Improvement and Quality staff member, stated that there was no functioning infection control committee and no data for infections or infection control monitoring for the last year. During an interview, on [DATE] at 1 p.m., Administrative Staff B, the performance improvement nurse for the hospital and skilled nursing unit, stated that there was no way to track or trend infections in the skilled nursing unit. Administrative Staff B stated that routine data for infections for the residents in the skilled nursing unit was not captured, as none of the residents had Foley catheters, central intravenous lines, or surgeries, which was the focus for the hospital. During an interview, on [DATE] at 1 p.m., Administrative Staff C stated that there was no functioning infection control committee and that the need for this committee had just been identified, and that this committee should report information to a Quality Council, that also needed to be implemented. Administrative Staff C also stated that the Interdisciplinary Team (IDT), during the monthly meetings for each resident, did not address infections, repeat infections, trend infections, nor recommend changes to the residents' Infection Care Plans or treatment plans. During an interview, on [DATE] at 1:20 p.m., the Medical Director, also the attending physician for all residents in the skilled nursing unit, concurred that: a) There was a very high rate of urinary tract infections, primarily caused by E. Coli; b) Urinary tract infections had led to sepsis (illness in which the body has a severe response to bacteria), bacteremia (infection of blood) and pyelonephritis (infection of kidney); c) The entire population in the skilled nursing facility is at a very high risk for infections; d) The Interdisciplinary Team (IDT) needed to revise the format of the monthly meetings and address infections, trends in infections, and recommend changes to the Infection Care Plans and treatment plans, which should include preventative measures; and e) There was no data available to determine baseline data for the infection rate of the facility, or to determine if the facility's infection rate was above or below standards. The Agency for Healthcare Research and Quality, Guidelines for Common Infections, revised 2011, in the long term care setting included: "Management/Treatment/Prevention...6. Implementation of a facility-wide infection control program including hygiene practices, employee health, employee education, and environmental decontamination, 7. Monitoring the management of infections in the facility using an effective infection control program... Step 10: Implement a facility-wide infection control program that conforms to federal and state regulations and current standards of practice, Step 11: Monitor the management of infections in the facility: Long Term Care Facilities should maintain records of patients treated for [REDACTED]. Aggregate data analysis that provides information about patterns of specific infections is much more useful..." 2. During an interview, on [DATE] at 12:15 p.m., when asked for the infection control log, Infection Control Staff (IC) J stated that there was none for the skilled nursing facility since the last infection control staff person left in October of 2011. During an interview, on [DATE] at 11:20 a.m., IC J stated that there was no system in place to identify trends, patterns, or cases for investigation, and was not sure if any infection data was being sent to the hospital committees for the skilled nursing unit. During an interview, on [DATE] at 12:25 p.m., IC J stated that culture and sensitivity reports of all infections were reviewed weekly, but not trended by resident. The main focus for reviewing these reports was to identify those infections where contact precautions would need to be instituted. During an interview, on [DATE] at 1 p.m., Administrative Staff C stated that infections had not been logged, tracked or trended. Administrative Staff C stated that she had just started to note the type of infection and the bacteria in the residents Infection Care Plan records, starting with infections in [DATE], but did not have prior data. 3. Record review, on [DATE] at 11 a.m., revealed that Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 9 had a gastric tube for feeding, fluids, and medications. Resident 9's Minimum Data Set (MD'S), an evaluation tool, revealed that Resident 9 could not understand others or be understood and was totally dependent for all activities of daily living. (Merck Manual--Persistent vegetative state is a chronic condition that preserves the ability to maintain blood pressure, respiration, and cardiac function, but not cognitive function. The patient has no awareness of self and interacts with the environment only via reflexes and cannot interact with people. Purposeful responses to external stimuli are absent, as are language comprehension and expression. Treatment is supportive only). A multidisciplinary care plan, dated [DATE], and updated ,[DATE], under Infection, indicated Resident 9 was at high risk for infection and had the goal to be free from infection for 90 days. Approaches included assessing for signs and symptoms of infection daily, monitoring vital signs per physician order, notifying infection control, utilizing proper precautions, and if temperature was greater then 38.4 C, ordering, as soon as possible (ASAP), blood cultures times two, Complete Blood Count (CBC), urinalysis, and culture and sensitivity, if indicated. Nurses notes, noted dated [DATE], as a late entry for [DATE], revealed that at 10 a.m., Licensed Nurse (LN) D went into the room to turn on the tube feeding after it had been turned off for one hour after a medication. Resident 9's gastric tube was lying on his stomach with the balloon deflated. The notes indicated that another gastric tube was inserted with some difficulty. During an interview on [DATE] at 11:30 a.m., LN D stated that another nurse reported that Resident 9's color was gray two hours after the gastric tube was replaced, that Resident 9 was suctioned through the tracheostomy and that there was no sputum, and it was decided to continue monitoring. LN D added that Resident 9 could not tell staff what was wrong, so observation skills were critical. During an interview, on [DATE] at 10:20 a.m., LN G, the nurse who cared for Resident 9 during the evening (3 p.m. to 11 p.m.) shift, stated that as the evening progressed, Resident 9's condition worsened. The nursing assistants had reported that Resident 9 was very diaphoretic (profuse sweating) while sitting up in a chair. LN G asked the nursing assistants to put Resident 9 back to bed and turn on a fan. Later the nursing assistants reported that Resident 9 was again very diaphoretic and asked LN G to re-evaluate. LN G stated that Resident 9's blood pressure was low and it seemed like something was going on, and thought that Resident 9 was possibly getting a urinary tract infection. When asked, LN G stated that a temperature and pulse were not taken. When asked what the low blood pressure meant, LN G could not recall, and did not document the result. LN G also confirmed that the above findings were not recorded in the record, but should have been. Record review, on [DATE] at 11 a.m., revealed nurses notes for the night shift (11 p.m. to 7 a.m.), with a time recorded of 3 a.m., that Resident 9's blood pressure: "Second time BP was checked it was ,[DATE]. After giving rest of water and elevating feet re-checked, it was ,[DATE]." The intake and output record revealed no urine output for the 11 p.m., to 7 a.m. shift. During an interview, on [DATE] at 11:35 p.m., LN I stated that the concern on the night shift was the low blood pressure. LN I also stated that sometime during the night Resident 9 was shaking, so a warm blanket was applied. When asked what the pulse was when the blood pressure was checked LN I did not know. When asked if a temperature was taken when Resident 9 was shaking, LN I replied no. LN I stated that the other Licensed Nurse on that night (LN P) and she had been concerned with the low blood pressure. When asked about the no urine output for the entire night shift, LN I responded that sometimes the residents did not have urine output on the night shift and would make up for it on the day shift. When asked to list the symptoms of sepsis, LN I did not know them. When asked if the physician had been notified of the low blood pressure and lack of urine output, LN I responded no. During an interview, on [DATE] at 11 a.m., LN P, the second nurse on the night shift caring for Resident 9, was asked what the signs and symptoms of sepsis were, and stated that she did not know them that night. (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms of sepsis are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. Sepsis does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.) (Lippincott 9th edition, 2010: Chapter 35 - Emergent conditions: Primary Assessment: 3. Septic shock: Occurs as the result of bacteria and/or their toxins circulating in the blood...Rapid recognition and prompt intervention is essential....Subsequent Assessment: 3. Monitor arterial blood pressure...c. Fall in the systolic blood pressure...It is generally accepted that a systolic pressure below 80 mm Hg (millimeters of mercury) is indicative of shock...5. Assess urine output...b. Ideally for an adult, the urine output should be 50 milliliters (ml) per hour. An output of less then 25 ml/hour may indicate shock.) Record review, on [DATE] at 10 a.m., of the [DATE], day shift nurses notes (7 a.m. to 3 p.m.), revealed that at 8 a.m. Resident 9's vital signs were: Temperature 38.2 axillary, Pulse 132, Respirations 43, blood pressure ,[DATE], Resident 9 was diaphoretic and cold, toes and feet gray, hands were cold and was cyanotic (a bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished). The nurses notes indicated the physician was notified immediately and laboratory studies, EKG, and a chest x-ray, were ordered. At 9 a.m. Resident 9's heart rate was in the 40's, his blood pressure was ,[DATE], his oxygen saturations were in the 70's (normal = ,[DATE]), and the hospital Rapid Response Team was called. During an interview, on [DATE] at 3:15 p.m., LN E, the hospital intensive care nurse who responded to the rapid response team page, stated that Resident 9's abdomen was very distended, his color was gray, his skin was cold, and that it was obvious that Resident 9 was in full-blown septic shock. LN E stated that the rapid response team should have been called much earlier. Resident 9 was transferred to the hospital intensive care unit with a [DIAGNOSES REDACTED]. Record review, on [DATE] at 10 a.m., revealed a CT scan of Resident 9's abdomen/pelvis dated [DATE], with conclusion: "The gastrostomy tube is outside the stomach. Fluid and air are present in the abdominal wall." Resident 9 was transferred to another local hospital intensive care unit on [DATE], for consideration of dialysis due to renal insufficiency (kidney function failure) with anuria (failure of the kidneys to produce urine). A CT scan of the abdomen/pelvis, dated [DATE], with Impression: Feeding tube in musculature of the left abdominal wall, air in the left anterior abdominal wall crossing the midline to the right, intra-abdominal air also present, primarily against the left anterior abdominal wall, with associated fluid. Resident 9 died on [DATE], with a final discharge [DIAGNOSES REDACTED]. During a review, on [DATE] at 11 a.m., the manufacturer instructions (BARD) for the gastric tube, included in Warnings "...Be certain that the balloon has passed through the fistulous tract and is completely in the stomach prior to inflation of the balloon. Placement or slippage of the device into the peritoneal cavity will result in serious consequences including peritonitis, sepsis and potentially, death..." For more detail reference F 322 Record review, on [DATE] at 11 a.m. revealed that Resident 3, a young adult, was admitted to the facility with [DIAGNOSES REDACTED]. Resident 3 required respiratory support of a ventilator (a device for giving artificial respiration) through a tracheostomy (surgical opening in the windpipe with a tube placed through this opening to provide an airway), and received food, fluids, and medications through a gastric tube. Minimum Data Set (MDS - an assessment tool) revealed unknown mental status, inability to communicate basic needs, total dependence in all activities of daily living, and incontinence of bowel and bladder. Nursing notes dated [DATE], for the 11 p.m. to 7 a.m. shift revealed that Resident 3's temperature at midnight was 37.4? C axillary with a pulse of 141. Temperature was re-checked at 4:15 a.m., and noted as 38.9? C (no route indicated). The temperature protocol was done at that time, which included blood cultures, complete blood count (CBC), chest x-ray, and urine for cultures. Resident 3's heart rate remained high at 150 (normal ,[DATE]) all night. Laboratory results revealed that his white blood cell (WBC) count was 17.85 high (range 4.0 to 11.5) and the result was reported to the nurse at 6:20 a.m. The physician was notified of the high WBC via voicemail message at 7:45 a.m. Resident 3 was admitted to the hospital intensive care unit on [DATE] at 1:45 p.m., with a [DIAGNOSES REDACTED]. During an interview, on [DATE] at 11 a.m., when asked to clarify what the nurses notes meant by temperature protocol, Licensed nurse (LN) P stated that if temperatures were greater than 38.4? C, staff were to request laboratory studies and notify the physician when the results came in or if symptoms worsened. LN P stated that she had left a message on the physician's cell phone at 7:45 a.m., of the temperature, pulse and laboratory findings. When asked to clarify the route of the temperature reading, LN P stated that it meant an axillary temperature. When asked when to report a high pulse rate, LN P stated that the pulse had been high at 150 all night. The elevated pulse was discussed with the hospital nursing supervisor and, since Resident 3 usually ran a pulse of 90 to 100, it might have meant a need to have a bowel movement. LN P indicated she continued monitoring Resident 3's pulse throughout the night. When asked what the signs and symptoms of sepsis were, LN P stated that she did not know them that night. (Mayo Clinic: An axillary (armpit) reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading, and an oral temperature is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower then a rectal temperature). Record review, on [DATE] at 11 a.m., revealed the Care Assessment Areas, dated [DATE], a part of the Minimum Data Set (MD'S), included, "Since the last yearly assessment, the patient has had several admissions to the intensive care unit for infections..." Resident 3 was admitted to the intensive care unit: [DATE], a with [DIAGNOSES REDACTED]. The Interdisciplinary Team (IDT) meeting notes, dated [DATE], did not include documentation of any of these recent intensive care admissions for infections. For more detail reference F281, F309 4. Clinical record reviews, conducted between [DATE] and [DATE], revealed: a) Resident 8 had four urinary tract infections (UTI's) with E. Coli; two episodes of bacteremia with E. Coli; and two episodes with E. Coli in sputum (one [DIAGNOSES REDACTED]. b) Resident 2 had two UTI's with bacteria of E Coli, one of which progressed to pyelonephritis; and another, a fourth, UTI with the bacteria identified as [DIAGNOSES REDACTED] pneumoniae which progressed to pyelonephritis; and one admission to intensive care unit for pneumonia, and c) Resident 5 had three UTI's with E. Coli and one episode with a sputum culture that contained pseudomonas, Acinetobacter baumanii (a bacteria that can live on skin and spread to susceptible persons by person to person contact or contact with contaminated surfaces) and E. Coli. d) Resident 3 was admitted to the intensive care unit: [DATE], a with [DIAGNOSES REDACTED]. During an interview, on [DATE] at 2 p.m., Administrative Staff C stated that the interdisciplinary team met monthly, that they did not identify trends over time, just what had happened since the last meeting. When asked if the Care Plans were changed or updated following these meetings, Administrative Staff C stated that they (interdisciplinary team) did not usually recommend changes to the residents' care plans. During an interview, on [DATE] at 1 p.m., Administrative Staff C acknowledged that the Infection Care Plans were not revised after each infection. All residents in the skilled facility had the same Multidisciplinary Infection Control Plan. The IDT did not look back over previous months to identify repeated infections or identify trends. Administrative Staff C also stated that short term care plans were implemented for each infection, but these were specific for treatment of [REDACTED]. The information from the short-term care plan was not used to update the Multidisciplinary Infection Care Plans. For more detail reference F 309 5. During an interview, on [DATE] at 12:15 p.m., when asked if there had been in-services for signs and symptoms of sepsis, or for how to assess for signs and symptoms of infections, or prevent cross contamination, for a population of residents who could not communicate or make their needs known, IC J stated that none had been done since her employment in [DATE]. IC J also stated that there was no question that the licensed nursing staff did not recognize the signs and symptoms of sepsis or impending sepsis for Residents 9 and 3. IC J stated that only one in-service had been conducted for the skilled facility unit, on the gastro-intestinal tract, which focused on the anatomical and structural system only. During an interview, on [DATE] at 1:15 p.m., with Administrative Staff F, the staff educator for the skilled nursing facility, when asked if there had been training for signs and symptoms of infection, including sepsis, Administrative Staff F stated that there had not been any done in the last year. Administrative Staff F stated that after the event with Resident 9 (sepsis and death) education was needed. During an interview, on [DATE] at 10 a.m., IC J stated that she worked three days per week, as the infection control nurse for the hospital and the skilled nursing unit, and one day per week as the educator for the skilled nursing unit. There were no classes for standard infection precautions or cross-contamination and no monitoring process in place for infection control, nor any system in place to identify trends or patterns of infections. During an interview, on [DATE] at 11 a.m., Administrative Staff F provided documentation that all licensed staff had attended classes, during August and September of 2012 (after Resident 9's death), on Sepsis, Handwashing, Change of Condition, Vital Signs, Infection Prevention and Control. When asked if monitoring of compliance had occurred, after the in-services, Administrative Staff F stated that no data had been collected. During an interview, on [DATE] at 1 p.m., when asked if the facility had implemented McGreer's "Definitions of Infection for Surveillance in Long-term Care Facilities", Administrative Staff C stated that these definitions were not used at this time. For more detail reference F 281, F 309 and F 322 6. During an interview, on [DATE] at 10 a.m., IC J stated that there were no classes for standard precautions or cross-contamination and no monitoring process in place for infection control. During an interview, on [DATE] at 11 a.m., Administrative Staff F, the staff educator, stated that hand-hygiene classes were held in August and September, but did not know if monitoring of compliance had occurred. During an interview, on [DATE] at 10:50 a.m. Administrative Staff B, Performance Improvement and Quality staff member, stated that the facility had provided training to all staff on hand-hygiene and glove use, and that a monitoring system had been developed that was to be implemented in October of 2012. Administrative Staff B and Administrative Staff C could not produce any data to validate that any monitoring of hand hygiene had taken place. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 http://www.cdc.gov/ncidod/dhqp/gl_isolation.html> Standard Precautions:... "1) Hand Hygiene: Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. When hands are visibly soiled with blood or other body fluids, wash hands with soap and water. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites..." 7. During concurrent observations, on [DATE], [DATE], and [DATE], during medication pass, Licensed Nurses H, R, and V, prepared each resident's medications by placing the medications on a plastic plate. This plate was then taken into the resident room and placed on a bedside surface or over-bed table. After medications were administered, the licensed nursing staff returned to the nursing station and washed these plastic plates with soap and water at the sink at the nursing station and then returned the plates to the medication cart, to prepare and deliver medications to another resident. During an observation, on [DATE] at 10 a.m., LN V administered medications to Resident 5 and then returned the plastic plate to the top of the medication cart, without washing or disinfecting the plate. LN V then used this same plate to transport medications to another resident and placed the plate on surfaces in that resident's room. During an interview, on [DATE] at 2:30 p.m., when asked if the soap used to wash the plastic plates contained a disinfectant, Administrative Staff C requested the product identification sheet for the soap from Material management and concurred that the soap did not contain a disinfectant. Review, on [DATE] at 3 p.m., of the Material Safety Data Sheet, revealed that the soap did not contain a disinfectant. Healthcare Infection Control Practices Advisory Committee (HICPAC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings IV.F. Care of the environment IV.F.2. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients' rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms) IV.F.3. Use EPA-registered disinfectants that have microbicidal (i.e., killing) activity against the pathogens most likely to contaminate the patient-care environment. Use in accordance with manufacturer's instructions.

Based on observation, interview, and record review the facility: 1. Failed to identify signs and symptoms of infection, per the care plan, for 1 of the 9 sampled residents (Resident 3) Resident 3, developed signs and symptoms [MEDICAL CONDITION] that were not identified by staff, which resulted in transfer to the intensive care unit for treatment of [REDACTED]. PubMed Health: [MEDICAL CONDITION] is an illness in which the body has a severe response to bacteria. 2. Failed to revise and individualize Infection Care Plans when residents exhibited infections, repeated and/or trends in infections, for 4 of the 9 sampled residents (Residents 1, 2, 5 and 8). This resulted in repeated urinary tract infections, with bacteria normally found in stool, urinary tract infections that led to [MEDICATION NAME] (inflammation of the bladder), [MEDICAL CONDITION] (infection of the kidneys) or bacteremia (infection of the blood), and intensive care admissions for infections. 3. Failed to notify Infection Control of infections, per Care Plan requirements. This resulted in the failure to identify trends or patterns of infections so that timely and appropriate interventions and revisions could be made. Findings: 1. Record review, on 8/31/12 at 11 a.m. revealed that Resident 3, a young adult, was admitted to the facility with [DIAGNOSES REDACTED]. Resident 3 required respiratory support of a ventilator through a [MEDICAL CONDITION] (surgical opening in the windpipe with a tube placed through this opening to provide an airway), and received food, fluids, and medications through a [MEDICAL CONDITION] tube (tube inserted directly into the stomach through an abdominal incision). Resident 3's MDS revealed an unknown mental status, an inability to communicate his basic needs, a total dependence in all activities of daily living, and that he was incontinent of bowel and bladder. A multidisciplinary care plan, dated 5/22/12, and updated 8/1/12, under Infection indicated: At high risk for infection, with the goal to be free from infection for 90 days. Approaches included: Assess for signs and symptoms of infection daily; monitor vital signs per physician order; notify infection control; utilize proper precautions; and if temperature is greater then 38.4 C, order as soon as possible blood cultures times two, complete blood count (CBC), urinalysis, and culture and sensitivity if indicated. Nursing notes dated 6/26/12, for the 11 p.m. to 7 a.m. shift revealed that Resident 3's temperature at midnight was 37.4? C axillary with a pulse of 141. Temperature was re-checked at 4:15 a.m., and noted as 38.9? C (no route indicated). The temperature protocol was done at that time, which included blood cultures, complete blood count (CBC), chest x-ray, and urine for cultures. Resident 3's heart rate remained high at 150 (normal 60-100) all night. Laboratory results revealed that his white blood cell (WBC) count was 17.85 high (range 4.0 to 11.5) and the result was reported to the nurse at 6:20 a.m. The physician was notified of the high WBC via voicemail message at 7:45 a.m. (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms [MEDICAL CONDITION] are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. [MEDICAL CONDITION] is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. [MEDICAL CONDITION] does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.) (Lippincott 9th edition, 2010: Chapter 35 - Emergent conditions: Primary Assessment: 3. Septic shock: Occurs as the result of bacteria and/or their toxins circulating in the blood...Rapid recognition and prompt intervention is essential....Subsequent Assessment: 4. Assess pulse quality and rate change, a. the rate is usually increased...). Resident 3 was admitted to the hospital intensive care unit on 6/26/12 at 1:45 p.m., with a [DIAGNOSES REDACTED]. During an interview, on 9/4/12 at 11 a.m., when asked to clarify what the nurses notes meant by temperature protocol, Licensed nurse (LN) P stated that if temperatures were greater than 38.4? C, staff were to request laboratory studies and notify the physician when the results came in or if symptoms worsened. LN P stated that a message was left on the physician's cell phone at 7:45 a.m., of the temperature, pulse and laboratory findings. When asked to clarify the route of the temperature reading, LN P stated that it meant an axillary temperature. When asked when to report a high pulse rate, LN P stated that the pulse had been high at 150 all night. The elevated pulse was discussed with the hospital nursing supervisor and, since Resident 3 usually ran a pulse of 90 to 100, it might have meant a need to have a bowel movement. LN P indicated she continued monitoring Resident 3's pulse throughout the night. When asked what the signs and symptoms [MEDICAL CONDITION] were, LN P stated that she did not know them that night. When queried, LN P did not know what signs and symptoms to monitor [MEDICAL CONDITION], per the Care Plan. During an interview, on 8/30/12 at 9 a.m., LN Q, when asked to clarify the Care Plan notation to monitor for signs and symptoms of infection, stated that there were no specific rules for signs or symptoms, and no rules for when they would require notification to the physician. Record review, on 8/31/12 at 11 a.m., revealed the Care Assessment Areas, dated 8/1/12, a part of the Minimum Data Set (MDS), included, "Since the last yearly assessment, the patient has had several admissions to the intensive care unit for infections..." Resident 3 was admitted to the intensive care unit: 5/2/12, a with [DIAGNOSES REDACTED]. The Interdisciplinary Team (IDT) meeting notes, dated 7/12/12, did not include documentation of any of these recent intensive care admissions for infections. (Care Assessment Area's (CAA's), part of the MDS, help the nursing staff gather definite information on a nursing home resident's strengths and needs, which must be addressed in an individual care plan. The CAA's also assist staff to evaluate goal achievement and revise care plans accordingly, by enabling the facility to track changes in the resident status.) During an interview, on 8/14/12 at 2 p.m., Administrative Staff C stated that the interdisciplinary team (IDT) met monthly, they did not identify trends over time, just what had happened since the last meeting. When asked if the Care Plans were changed or updated following these meetings, Administrative Staff C stated that they (interdisciplinary team) did not usually recommend changes to the residents' care plans. During an interview, on 8/3/12 at 12:15 p.m., with Infection Control Staff J (IC J), when asked if there had been in-services for signs and symptoms [MEDICAL CONDITION], or for how to assess for signs and symptoms of infections, IC J stated that none had been done since her employment in April 2012. IC J also stated that there was no question that the licensed nursing staff did not recognize the signs and symptoms [MEDICAL CONDITION] or [MEDICAL CONDITION]. IC J stated that she did not know what was meant by the care plan approach of, "notify infection control." During an interview, on 8/7/12 at 1:15 p.m., with Administrative Staff F, the staff educator for the skilled nursing facility, when asked if there had been training for signs and symptoms of infection, [MEDICAL CONDITION], Administrative Staff F stated that there had not been any done in the last year. Administrative Staff F stated that education was needed. 2. All nine of nine sampled residents had the same Multidisciplinary Care Plan, which included: "Infection R/T: At high risk for infection, with goals to be free from infection for 90 days; with approaches including: assess for signs and symptoms of infection daily, monitor vital signs per MD order, monitor lab values per MD order, notify Infection Control, utilize proper precautions, and If the temperatures were over 38.4, order as soon as possible, blood cultures times two, a complete blood count (CBC), chest x-ray, urinalysis and cultures and sensitivities, if indicated. 2 a. Record reviews, on 8/14/12 , 8/20/12, 8/22/12, and 1/28/13, revealed that Resident 8, a young female, was admitted to the facility 12/6/10, with a [DIAGNOSES REDACTED]. Resident 8 has a [MEDICAL CONDITION] and a Jejunostomy tube (J tube: a tube inserted into the small intestine, just below the stomach) for fluids, nutrition and medications. MDS revealed that Resident 8 was totally dependent in all activities of daily living and incontinent of bowel and bladder. (Merck Manual - persistent vegetative state is a chronic condition that preserves the ability to maintain blood pressure, respiration, and cardiac function, but not cognitive function. The patient has no awareness of self and interacts with the environment only via reflexes and cannot interact with people. Purposeful responses to external stimuli are absent, as are language comprehension and expression. Treatment is supportive only). The multidisciplinary care plan for Infection was updated on 9/19/12, to change the temperature to greater then 38.9 C, and on 1/3/13, to avoid constipation to decrease the likelihood of urinary tract infections and aspiration pneumonia. Resident 8 was diagnosed with [REDACTED]. a) Urinary tract infections with bacteria identified as Escherichia coli, (E. coli: is one of several types of bacteria that normally inhabit the intestine) on 4/17/12, 5/19/12, 7/16/12, and 12/27/12; b) Bacteremia (an invasion of the bloodstream by bacteria) with bacteria identified as E. coli on 7/14/12 and 12/25/12; c) Pilonidal cyst (abscess near or on the cleft of the buttocks) with bacteria identified as [DIAGNOSES REDACTED] pneumoniae (found in the normal flora of the mouth, skin, and intestines) on 7/18/12; and d) Pneumonia with sputum cultures with bacteria identified as E. coli, Providencia stuartii (a bacterium commonly found in soil, water, and sewage) and Proteus Mirabilis (a bacterium usually found in fecal matter) on 8/4/12. The record indicated that on 1/20/13, Resident 8 was transferred to the intensive care unit of the hospital for worsening respiratory status and a white blood cell of 15.26 (range 4.0 to 11.5). Sputum cultures revealed bacteria of E. coli, Proteus Mirabilis and Providencia. During an interview, on 8/14/12 at 2 p.m., Administrative Staff C stated that the interdisciplinary team (IDT) met monthly, they did not identify trends over time, just what had happened since the last meeting. When asked if the Care Plans were changed or updated following these meetings, Administrative Staff C stated that they (interdisciplinary team) did not usually recommend changes to the residents' care plans. During an interview, on 8/22/12 at 10 a.m., Administrative Staff F, the staff educator for the skilled nursing facility, stated that when E. coli was identified in the sputum on 8/4/12, a conversation was held at the nursing station where licensed nursing staff acknowledged that the E. coli pneumonia was probably caused by cross-contamination. Administrative Staff F stated that the care plan was not revised to include interventions to prevent cross-contamination. During an interview, on 1/29/13 at 10:30 a.m., Respiratory Therapist U, stated that when Resident 8 was identified as having pneumonia caused by E. coli, the staff had discussed that it was probably caused by cross-contamination, as Resident 8 was having frequent diarrhea at the time, and acknowledged that the care plan was not revised to include interventions to prevent cross-contamination. 2 b. Record review, on 1/23/13 at 10 a.m., revealed that Resident 1, was admitted with a [DIAGNOSES REDACTED]. MDS revealed that Resident 1 was totally dependent in all activities of daily living and incontinent of bowel and bladder. Resident 1 had a condom catheter for bladder incontinence (a condom-like device is placed over the penis. A tube leads from this device to a drainage bag). On 1/9/13 Resident 1 was diagnosed with [REDACTED]. Record review, on 1/24/13 at 10 a.m., revealed that Resident 2, in the room next to Resident 1, also had a condom catheter for incontinence and was also diagnosed with [REDACTED]. During an interview on 1/24/13 at 3:15 p.m., Administrative Staff C acknowledged that she was not aware that two residents were diagnosed with [REDACTED]. 2 c. Record review, on 1/24/13 at 10 a.m., revealed that Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. MDS revealed that Resident 2 was totally dependent in all activities of daily living and incontinent of bowel and bladder. Resident 2 had a condom catheter for bladder incontinence. Resident 2 was diagnosed with [REDACTED]. a) Urinary tract infection with bacteria identified as Escherichia coli (E. coli), on 10/28/12; Resident 2 was transferred to the intensive care unit from 11/1/12 through 11/08/12, with [DIAGNOSES REDACTED]. IDT notes, dated 11/1/12, revealed: Antibiotics secondary to urinary tract infection, will look for trend. b) Urinary tract infection with bacteria identified as E. coli, on 11/22/12; and A CT scan of the abdomen and pelvis, dated 11/23/12, revealed [MEDICATION NAME] (inflammation of the bladder) and right [MEDICAL CONDITION] (infection of the kidney). IDT notes, dated 12/6/12, revealed"...completed current antibiotic treatment on 12/7/12, concerns for development of resistance to response of antibiotics in the future..." A quarterly Care Plan review form, dated 12/28/12, revealed that all areas of the care plan were reviewed, with no changes for the calendar quarter other than a new medication for [MEDICAL CONDITION] and a brand change of tube feeding formula. c) Urinary tract infection and [MEDICAL CONDITION] with bacteria identified as [DIAGNOSES REDACTED] pneumoniae, on 1/9/13. IDT notes, dated 1/3/13, revealed no notations about infections. During an interview, on 1/24/13 at 3:15 p.m., Administrative Staff C stated that the infection care plans were not updated or revised, did not address trends, that the short term care plans did not update the infection care plan so no history of infections was evident, and the care plan for urinary incontinence did not include a goal to prevent urinary tract infections. 2 d. Record review, on 1/23/13 at 10 a.m. and 1/26/13 at 4 p.m., revealed that Resident 5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 5 had a [MEDICAL CONDITION] and a [MEDICAL CONDITION] (inserted through the nose into the stomach) tube for food, fluids, and medications. MDS revealed that Resident 5 was totally dependent in all activities of daily living and incontinent of bowel and bladder. Resident 5 had a condom catheter for bladder incontinence. Resident 5 was diagnosed with [REDACTED]. a) Urinary tract infections with bacteria identified as E. coli on 7/25/12, 9/11/12, and 12/10/12; b) Sputum culture, dated 9/9/12, with bacteria identified as Pseudomonas species (tiny gram-negative aerobic bacillus which produce nosocomial infections), Acinetobacter baumannii and E. coli. (Centers for Disease Control and Prevention: Acinetobacter are a group of bacteria found in soil and water...typically occur in intensive care units and healthcare settings housing very ill patients...causes a variety of diseases, ranging from pneumonia to serious blood or wound infections...can be spread to susceptible persons by person-to-person contact or contact with contaminated surfaces...can live on the skin and may survive in the environment for several days. Careful attention to infection control procedures, such as hand hygiene and environmental cleaning, can reduce the risk of transmission...typically occurs in ill patients and can either cause or contribute to death in these patients.) During an interview, on 1/25/13 at 1 p.m., Administrative Staff C acknowledged that the Infection Care Plans had not been revised after each infection. All residents in the skilled facility had the same Infection Care Plan, which was not individualized. The IDT did not look back over previous months to identify repeated infections or identify trends. Administrative Staff C also stated that short term care plans were implemented for each infection, but these were specific for treatment of [REDACTED]. The information from the short term care plan was not used to update the Multidisciplinary Infection Care Plans. During an interview, on 1/29/13 at 1:20 p.m., the Medical Director, also the attending physician for all residents in the skilled nursing unit, concurred that: a) There was a very high rate of urinary tract infections, primarily caused by E. coli; b) Urinary tract infections had led [MEDICAL CONDITION], bacteremia and [MEDICAL CONDITION]; c) The entire population in the skilled nursing facility is at a very high risk for infections; and d) The IDT needed to revise the format for the monthly meetings and address infections and trends in infections, and recommend changes to the Infection Care Plans which included preventative measures. 3. During an interview, on 8/3/12 at 12:15 p.m., Infection Control Staff J (IC) stated that she did not know what was meant by the care plan approach of "notify Infection Control." IC J stated that the nursing staff did not notify her of infections. During an interview, on 8/22/12 at 11:30 a.m., LN P stated that she did not know what the Care Plan approach of "notify Infection Control" meant and had not made any notifications of infections.

Based on observation, interviews, and record reviews, the facility failed to provide services that met professional standards of quality when: 1. Staff failed to: a) Follow and clarify the physician orders [REDACTED].? Fahrenheit), to include the route of temperature (axillary, oral or rectal); b) Notify the physician promptly for results of laboratory studies or earlier, if signs and symptoms warranted notification; and c) Notify the physician of a pulse greater than 110 degrees, for Resident 3. (Mayo Clinic: An axillary (armpit) reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading, and an oral temperature is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower then a rectal temperature). The failure to follow physician orders [REDACTED]. PubMed Health: [MEDICAL CONDITION] is an illness in which the body has a severe response to bacteria. 2. Staff failed to follow the physician standing order to check and record the residual (remaining liquid in the stomach) [MEDICAL CONDITION] contents for residents with [MEDICAL CONDITION] tubes (a tube inserted directly into the stomach through an abdominal incision for the administration of food, fluids, and medications), every eight hours, for Residents 3 and 9 (two of three residents in the abbreviated survey sample had [MEDICAL CONDITION] tubes). Findings: 1. Record review, on 8/31/12 at 11 a.m., revealed that Resident 3, a young adult, was admitted to the facility with [DIAGNOSES REDACTED]. Resident 3 required respiratory support of a ventilator (a device for giving artificial respiration) through a [MEDICAL CONDITION] (surgical opening in the windpipe with a tube placed through this opening to provide an airway), and received food, fluids, and medications through a [MEDICAL CONDITION] tube. Minimum Data Set (MDS - an assessment tool) revealed unknown mental status, inability to communicate basic needs, total dependence in all activities of daily living, and incontinence of bowel and bladder. Nursing notes, dated 6/26/12, for the 11 p.m. to 7 a.m. shift, revealed that temperature at midnight was 37.4? C axillary with a pulse of 141. The temperature was rechecked at 4:15 a.m., and noted as 38.9? C (no route indicated), and the temperature protocol was done at that time, which included blood cultures, complete blood count (CBC), chest X-ray and urine for cultures. Heart rate remained high at 150 all shift. Laboratory results indicated that the white blood cell (WBC) count was 17.85 (range 4.0 to 11.5), and the result was reported to the nurse at 6:20 a.m. The physician was notified of the high WBC via voicemail message at 7:45 a.m. Respiratory therapy notes, dated 6/26/12, revealed: "Patient has had fever all shift with elevated respiratory rate and low volumes (amount of air in the lungs). Patient was also [MEDICAL CONDITION] (elevated heart rate) into the 150's. Nurse aware and blood cultures drawn." Resident 3 was admitted to the hospital intensive care unit at 1:45 p.m. with [DIAGNOSES REDACTED]. During an interview, on 9/4/12 at 11 a.m., when asked to clarify the temperature order, Licensed nurse (LN) P stated that the standing physician orders [REDACTED].? C, staff were to request laboratory studies and notify the physician when the results came in or if symptoms worsen. LN P left a message on the physician's cell phone at 7:45 a.m., providing the information of the temperature, pulse, and laboratory findings. When asked to clarify the route of the temperature reading to initiate the temperature order, LN P stated that it meant an axillary temperature. When asked when temperatures would be converted to rectal reading, LN P stated that it would depend on other symptoms, but one degree would be added to the axillary reading. When asked to clarify the conversion, LN P stated that the chart on top of the Kardex indicated add one degree for rectal. When asked at what temperature the protocol/order was to be implemented, LN P stated that she had asked several nurses for clarification and they stated that the standard for the unit was to follow the order/protocol for axillary temperatures greater then 38.4? C. When asked when to report a high pulse rate, LN P stated that Resident 3's pulse had been high at 150 all night and that it was discussed with the hospital nursing supervisor. LN P stated that the nursing supervisor advised her that since Resident 3 usually ran a pulse of 90 to 100 it might mean that Resident 3 might need to have a bowel movement, and recommended continued monitoring of the pulse throughout the night. When asked to clarify the physician order [REDACTED]. During an interview, on 8/9/12 at 10:45 a.m., Administrative Staff C stated that it meant a rectal temperature. During another interview, on 8/14/12 at 10 a.m., Administrative Staff C stated that it meant an oral temperature. During an interview, on 8/30/12 at 9 a.m., LN Q stated it meant an oral temperature. During an interview, on 8/30/12 at 10 a.m., LN R stated it meant a rectal temperature, that the physician wanted a core (internal) body temperature. During an interview, on 8/22/12 at 9:40 a.m., Administrative Staff F, the facility educator, stated that the physician expected the temperature to be taken rectally in order to determine core (internal) body temperature before the temperature order/protocol was to be carried out, but that the standard practice of the skilled nursing unit was to take axillary temperatures, which were not a reliable reading for the population in the facility (all residents had severe brain injuries, all with tracheostomies and most with arm contractures--shortening of muscle or joint). Administrative Staff F further stated that the nursing assistants had all been instructed to report a temperature greater then 37? C axillary to the nursing staff for nursing evaluation and follow up. Administrative Staff F stated that the Medical Director had stated that this resident population was at great risk for infection, and that nursing observations and critical thinking skills were required. During an interview, on 8/7/12 at 10:20 a.m., LN D stated that if an axillary temperature was above 37? C, then a rectal temperature was obtained and if that was above 38.4? C, to follow the physician protocol/order. During an observation, on 8/14/12 at 10 a.m., there was a temperature conversion chart (from Celsius to Fahrenheit) taped to the top of the cabinet that housed the medical records. This chart included a hand written note which was taped to the top which read: "Add one degree for rectal." During an interview, on 8/14/12 at 2 p.m., Administrative Staff C stated that there was no specific policy for temperatures or vital signs, but that if vital signs were necessary, they would be mentioned in other policies. When asked what nursing standards of care were used, Administrative Staff C stated that they followed basic nursing standards of Lippincott. Other policies were not provided. During a review, on 8/14/12 at 5 p.m., the facility policy Title: Contacting the physician for changes in patient's condition, dated 1/11, included in the procedure: 1. The nurse will notify the attending physician when the following circumstances arise, unless otherwise modified by the physician: ...b. Pulse below 50 or above 110 - new onset..." During a review, on 8/14/12 at 5 p.m., the facility policy Titled: Notification of Resident Changes, revised 10/06, included..." The physician shall be notified promptly of : a. Any sudden and/or marked change in signs, symptoms or behavior ..." (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms [MEDICAL CONDITION] are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. [MEDICAL CONDITION] is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. [MEDICAL CONDITION] does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.) (Lippincott 9th edition, 2010: Chapter 35 - Emergent conditions: Primary Assessment: 3. Septic shock: Occurs as the result of bacteria and/or their toxins circulating in the blood...Rapid recognition and prompt intervention is essential...Subsequent Assessment: 4. Assess pulse quality and rate change, a. the rate is usually increased...)." 2. Record review, on 8/9/12 at 12:30 p.m., revealed that Resident 3 had a [MEDICAL CONDITION] tube and a recurring physician order [REDACTED]. No documentation of residual was found. Record review, on 8/3/12 at 11 a.m., revealed that Resident 9 had a [MEDICAL CONDITION] tube and a recurring physician order, dated 1/30/12, "check and chart residual every 8 hours, if greater than 200 milliliters, hold tube feeding for one hour and then recheck." No documentation of residual was found in Resident 9's record. During an interview, on 8/7/12 at 10:20 a.m., LN G was asked if [MEDICAL CONDITION] tube residual and placement had been verified for Resident 9 during the evening shift on 6/5/12. LN G stated that air was heard, and that residuals were never recorded and could not remember if there was any residual. During an interview, on 8/7/12 at 10:20 a.m., when asked where the [MEDICAL CONDITION] tube residual was recorded in Resident 9's clinical record, LN H responded that it had never been recorded, and that the clinical record did not have a space to record the amount. LN H was not aware of the physician order [REDACTED]. During an interview, on 8/9/12 at 9 a.m., LN K, when asked where the [MEDICAL CONDITION] tube residual was recorded for Resident 9, stated that residual had never been recorded. During an interview, on 8/7/12 at 2 p.m., when asked where the [MEDICAL CONDITION] tube residual was recorded when, checked every eight hours, for Resident's 3 and 9, Administrative Staff C stated that there was no space in the nurses notes or treatment records to record the residual [MEDICAL CONDITION] fluid, and concurred that the physician's orders [REDACTED]. During an interview, on 1/24/13 at 2 p.m., Administrative Staff C stated that a form had been created and implemented, following the Abbreviated Survey in August of 2013, to record residual [MEDICAL CONDITION] contents per the physician order.

Based on staff interview and resident and facility record review, the facility: 1. Failed to ensure that, Resident 9 (1 of the 3 abbreviated survey sample), who was fed by a [MEDICAL CONDITION] tube (G tube: a tube inserted directly into the stomach through an abdominal incision for the administration of food, fluids, and medications), received appropriate treatment and services to prevent [MEDICAL CONDITION] tube replacement complications and failed to identify signs and symptoms [MEDICAL CONDITION]. PubMed Health: [MEDICAL CONDITION] is an illness in which the body has a severe response to bacteria. This resulted in actual harm to Resident 9 by the misplacement of the [MEDICAL CONDITION] tube outside of the stomach which led [MEDICAL CONDITION], kidney failure and death; 2. Failed to ensure that all staff were trained to replace feeding tubes; and 3. Failed to ensure that [MEDICAL CONDITION] tubes were maintained, per the manufacturer's guidelines, of replacing the [MEDICAL CONDITION] tubes every 30 days and to check the patency (the state of being freely open) of the [MEDICAL CONDITION] tubes' balloons every seven to ten days. Six of the 8 sampled residents (1, 2, 3, 4, 6, and 7); had [MEDICAL CONDITION] tubes which were not replaced every thirty days and did not have the balloon patency checked every seven to ten days. These failures could result in a lack of nutrition, fluids, and required medications being administered and the potential for infection and/or death. Findings: 1. During a review of the clinical record, on [DATE] at 11 a.m., Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9 had a [MEDICAL CONDITION] tube for feeding, fluids and medications. Resident 9's Minimum data set (MDS), an evaluation tool, revealed that Resident 9 could not understand others or be understood and was totally dependent for all activities of daily living and was incontinent of bladder and bowel. (Merck Manual -persistent vegetative state is a chronic condition that preserves the ability to maintain blood pressure, respiration, and cardiac function, but not cognitive function. The patient has no awareness of self and interacts with the environment only via reflexes and cannot interact with people. Purposeful responses to external stimuli are absent, as are language comprehension and expression. Treatment is supportive only). Nurses notes, dated [DATE], as a late entry for [DATE], revealed that at 10 a.m., Licensed Nurse (LN) D went into Resident 9's room to turn on the tube feeding after it had been turned off for one hour after a medication. The [MEDICAL CONDITION] tube was lying on Resident 9's stomach with the balloon deflated. A moist Q-tip was inserted to keep the tract open and another [MEDICAL CONDITION] tube was inserted, with some difficulty. Placement was checked by injecting air into the [MEDICAL CONDITION] tube and listening for air. Air was heard to the left of the [MEDICAL CONDITION] tube insertion site. There was no residual (remaining) fluid, as the tube feeding had been off for one hour following a medication. A second nurse checked placement. Further record review revealed that there were no notations on the Care Plan about the reinsertion. During an interview on [DATE] at 11:30 a.m., when asked to explain the note of passing the [MEDICAL CONDITION] tube with difficulty, LN D stated that she could not get it to, "follow the line," and tried three or four attempts to get it in, then finally felt a pop as the tube was placed and felt that the pop meant that the tube was in the tract of the stomach. LN D did inject air into the tube to listen for air in the stomach and heard it to the left, not where it had normally been heard before, on the right. LN D asked another nurse to check placement but was not in the room when this occurred. LN D stated that the second nurse, who checked placement, reported that Resident 9's color was gray two hours after the [MEDICAL CONDITION] tube was replaced. Resident 9 was suctioned through the [MEDICAL CONDITION] (surgical opening in the windpipe with a tube placed through this opening to provide an airway) and there was no sputum, and it was decided to just continue monitoring. LN D stated that this resident could not tell you what was wrong, so observation skills were critical. LN D stated that the physician was not notified, at the time, as she felt the tube pop into the tract. LN D also stated that an X-ray to check placement should have been done after the difficult placement of the tube and that it was standard orders when something did not seem right. During an interview, on [DATE] at 11 a.m., LN H stated that LN D had requested that he check placement of the [MEDICAL CONDITION] tube after it was reinserted. LN H was not in the room when LN D reinserted the tube. LN H stated that the tube feeding had been held for one hour after medication so there was only a small amount of residual fluid in the tube when he checked for fluid, and that air was heard on the left side and none on the right side, where it had been previously heard. LN H stated that he had not attended any in-services for [MEDICAL CONDITION] tubes. During an interview, on [DATE] at 10:20 a.m., LN G, the nurse who cared for Resident 9 during the evening (3 p.m. to 11 p.m.) shift, was asked if tube residual and placement had been verified. LN G stated that it had been reported that the [MEDICAL CONDITION] tube was replaced, but the report had not indicated that it was a difficult replacement. LN G did state that air was heard when the [MEDICAL CONDITION] tube placement was checked. When asked if there was residual fluid, and where the residual was recorded, LN G stated that residuals were not recorded, and could not remember if there was any residual fluid in the tube or stomach, and that residuals were never recorded. LN G stated that as the evening progressed Resident 9's condition worsened. The nursing assistants had reported that Resident 9 was very diaphoretic (profuse sweating) while sitting up in a chair. LN G asked the nursing assistants to put Resident 9 back to bed and turn on a fan. Later the nursing assistants reported that Resident 9 was again very diaphoretic and asked LN G to re-evaluate. LN G stated that Resident 9's blood pressure was low and it seemed like something was going on, and thought that Resident 9 was possibly getting a urinary tract infection. Resident 9's temperature and pulse were not taken. When asked what the policy was for reporting a low blood pressure or for required nursing documentation, LN G did not know, and stated that the policy manuals were at the nursing station, were not very user friendly, so they were not used very often. LN G also stated that the above findings were not recorded in the record, but should have been. Record review, on [DATE] at 11 a.m., revealed nurses notes for the night shift (11 p.m. to 7 a.m.), with a time recorded as 3 a.m., that Resident 9's blood pressure was ,[DATE]: "Gave patient rest of water via G tube, stopped feeding for 30 minutes, re-checked BP (blood pressure), it had gone up to ,[DATE], restarted feeding." A second note, timed also as 3 a.m., indicated, "Second time BP was checked, it was ,[DATE]. After giving rest of water and elevating feet re-checked, it was ,[DATE]." During an interview, on [DATE] at 11:35 a.m., LN I stated that the concern on the night shift was the low blood pressure ([MEDICAL CONDITION], low blood pressure, is usually a reading of ,[DATE] mmHg (millimeters of mercury) or below). LN I also stated that sometime during the night Resident 9 was shaking, so a warm blanket was applied. When asked what the pulse was when the blood pressure was checked LN I did not know. When asked if a temperature was taken when Resident 9 was shaking, LN I replied no. LN I stated that the other Licensed Nurse on that night (LN P) and she had been concerned with the low blood pressure. LN I did check [MEDICAL CONDITION] tube placement, did not recall if there was any residual, did hear air, but was not sure which side it was heard. When asked about the no urine output for the entire night shift, LN I responded that sometimes the residents did not have urine output on the night shift and would make up for it on the day shift. When asked to list the symptoms [MEDICAL CONDITION], LN I did not know them. During an interview, on [DATE] at 11 a.m.., LN P, the second nurse on the night shift caring for Resident 9, was asked what the signs and symptoms [MEDICAL CONDITION] were and did not know them that night. (Sepsis Fact Sheet - National Institute of General Medical Sciences: Common symptoms [MEDICAL CONDITION] are fever, chills, rapid breathing and heart rate, rash, confusion and disorientation. [MEDICAL CONDITION] is a serious medical condition caused by an overwhelming immune response to infection. Immune chemicals released into the blood to combat the infection trigger widespread inflammation, which leads to blood clots and leaky vessels. This results in impaired blood flow, which damages the body's organs by depriving them of nutrients and blood. In the worst cases, blood pressure drops, the heart weakens and the patient spirals toward septic shock. Once this happens, multiple organs - lungs, kidneys, liver - may quickly fail and the patient can die. [MEDICAL CONDITION] does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen or other part of the body.) Record review, on [DATE] at 10 a.m., of the [DATE], day shift nurses notes (7 a.m. to 3 p.m.) revealed that at 8 a.m. the vital signs were: Temperature 38.2 axillary (armpit), Pulse 132, Respirations 43, Blood Pressure ,[DATE], Resident 9 was diaphoretic and cold, toes and feet were gray, hands were cold, and was cyanotic (a bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished). The physician was notified immediately, and laboratory studies, EKG and chest x-ray were ordered. At 9 a.m. Resident 9's heart rate was in the 40's, his blood pressure was ,[DATE], his oxygen saturations were in the 70's (normal = ,[DATE]), and the hospital Rapid Response Team was called. During an interview, on [DATE] at 3:15 p.m., LN E, the hospital intensive care nurse who responded to the rapid response team page, stated that Resident 9's abdomen was very distended, color was gray, skin was cold, and that it was obvious that Resident 9 was in full-blown septic shock. LN E stated that the rapid response team should have been called much earlier. Resident 9 was transferred to the hospital intensive care unit with a [DIAGNOSES REDACTED]. Record review, on [DATE] at 10 a.m., revealed a CT scan of the abdomen/pelvis, dated [DATE], with the conclusion: "The gastrostomy tube is outside the stomach. Fluid and air are present in the abdominal wall." Resident 9 was transferred to another local hospital intensive care unit on [DATE], for consideration of [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a special machine. [MEDICAL TREATMENT] is necessary when the kidneys are not able to filter the blood) due to [MEDICAL CONDITION] (kidney function failure) with anuria (failure of the kidneys to produce urine). A CT scan of the abdomen/pelvis, dated [DATE], with the impression: Feeding tube in musculature of the left abdominal wall, air in the left anterior abdominal wall crossing the midline to the right, intra-abdominal air also present, primarily against the left anterior abdominal wall, with associated fluid. Resident 9 died on [DATE], with final discharge [DIAGNOSES REDACTED]. Review, on [DATE] at 1 p.m., of the facility policy titled: Gastrostomy Tube Changing or Reinsertion of (excluding Jejunostomy tubes), dated ,[DATE], included the policy statement: "...if a gastrostomy tube falls out, a replacement tube should be inserted as soon as possible, within a few minutes at most..." Documentation required: "1. 24 hour nursing assessment notes, 2. Nurse's progress notes, 3. Kardex, and 4. Care Plan." Review of the facility policy titled: Notification of Resident Changes, dated ,[DATE], included: "Procedure: The physician shall be notified promptly of: a. Any sudden and marked change in signs, symptoms or behavior exhibited by a resident, b. Any unusual occurrence involving a resident,... d. Any untoward response or reaction by a resident to a medication or treatment..." During a review, on [DATE] at 5 p.m., the facility policy Titled: Contacting the physician for changes in patient's condition, revised ,[DATE], included: "1. The nurse will notify the attending physician when the following circumstances arise, unless otherwise modified by the physician: a. Systolic B/P below 80 or above 180 mm Mercury - new onset, b. Pulse below 50 or above 110, new onset....2. When any of the above conditions occur, the Lead Nurse or Staff nurse will: 1. Contact the physician by office phone, Tiger Text or overhead paging if in the hospital. B. contact the ICU for possible admission to that unit (consider calling a Rapid Response Team to evaluate the patient) ..." During a review, on [DATE] at 11 a.m., the manufacturer instructions (BARD) for the [MEDICAL CONDITION] tube, included in Warnings "...Be certain that the balloon has passed through the fistulous tract and is completely in the stomach prior to inflation of the balloon. Placement or slippage of the device into the peritoneal cavity will result in serious consequences including peritonitis,[MEDICAL CONDITION] and potentially, death..." 2. During an interview, on [DATE] at 10 a.m., when asked about the specific staff training for [MEDICAL CONDITION] tubes, Administrative Staff C stated that there was no formal training. Nursing staff, who had previous experience trained new staff, who, after inserting a [MEDICAL CONDITION] tube, could then train the next nurse. There were no skills competency evaluations, and the yearly Licensed Nurse performance evaluations were not specific to skills with [MEDICAL CONDITION] tubes. Administrative Staff C stated that all 13 residents in the distinct part skilled nursing unit had [MEDICAL CONDITION] tubes, and that all residents had traumatic brain injuries requiring feeding, fluids, and medications through [MEDICAL CONDITION] tubes. During a review, on [DATE] at 11 a.m., the performance evaluation for LN D indicated that all criteria were met, but that there was a need to strengthen critical thinking skills. The licensed nurse performance evaluation did not include an evaluation of skills with [MEDICAL CONDITION] tubes. Safe Practices in Patient Care: Enteral Nutrition and Hydration in Long-Term Care (Continuing Education for Nurses), indicates...Tube Displacement...The auscultation method of listening for insufflative air over the epigastrium to check for tube placement is not always reliable...If there is any question of tube migration or displacement or if the nurse is unable to determine tube placement, an X-ray should be requested..." http://emedicene.medscape.com/article/ -overview: [DEVICE] replacements:..."If [DEVICE] replacement does not occur easily, abort the procedure and contact the provider who placed the tube..." American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN) Standards of Practice: Standard 11: 11.1 Appropriate access devices (tubes placed for the delivery of nutrients or drugs) shall be placed by or under the supervision of a physician, nurse or specially trained healthcare professional who is competent and knowledgeable in recognizing and managing complications associated with the placement and management of the device...11.3 Proper placement of vascular (into a blood vessel) and enteral devices (into the gastrointestinal tract) shall be appropriately confirmed and documented before use...11.4 complications related to an access device and outcome of actions to manage the complication shall be clearly documented in the medical record. During an interview, on [DATE] at 10:40 a.m., Administrative Staff F, the facility educator, provided, "Balloon type Gastrostomy Tube Replacement Competency," not dated, with the policy statement that a [DEVICE] may be replaced by a licensed nurse who has been checked off. A sign-in sheet was provided which revealed that 12 of the 22 active staff listed, had been signed off as competent to replace [DEVICE]s. The sign off sheet for 2012 indicated that competencies checked for licensed nursing staff were: One in June, two in July, one in August, one in September, two in October, one in November, three in December and one in [DATE]. Administrative Staff F stated that competencies were done as tubes needed to be replaced for the residents. When asked if monitoring of competencies occurred following the initial sign off, Administrative Staff F replied no. During an interview, on [DATE] at 11:30 a.m., when asked what the facility process was if no staff, who had been signed off as competent, were on duty when a [MEDICAL CONDITION] tube required replacement, Administrative Staff C stated that staff could call the nursing supervisor or herself. 3. During a review on [DATE] at 11 a.m., the Manufacturer's insert for the BARD Tri-Funnel Replacement Gastrostomy Tube, revealed under tube care "...3. Check balloon volume every seven to ten days for correct inflation volume ...4. For optimal performance, the Bard Tri-Funnel tube should be replaced every 30 days, or as required to ensure balloon patency and an un-occluded tube lumen..." During an interview, on [DATE] at 11:15 a.m., Administrative Staff F, the facility educator, discussed the BARD manufacturer's insert, and stated that the facility was not following these Tube Care instructions; the facility did not check balloon patency at all and did not change the tube unless it fell out. Administrative Staff F stated that she wondered if the tubes popping out were caused by lack of checking the patency of the balloon, as required. Reviews of the clinical records, between [DATE] and [DATE], revealed that [MEDICAL CONDITION] tubes were replaced as follows: Resident 1 on [DATE]; Resident 2 on [DATE]; Resident 3 on [DATE] and [DATE]; Resident 4 on [DATE]; Resident 6 on [DATE]; and Resident 7 on [DATE] During an interview, on [DATE] at 11 a.m., Administrative Staff C stated that the facility was not currently following the Manufacturer's Tube Care Instructions to check the balloon patency every ten days and were not changing tubes every 30 days. During an interview, on [DATE] at 1:20 p.m., the Medical Director stated that the facility used to have a policy and procedure in place to follow the manufacturer's instructions, and was not aware, and did not know when, this process stopped.